Kohji Fujisawa

Hematopoietic stem cell transplantation for Diamond-Blackfan anemia: a report from the Aplastic Anemia Committee of the Japanese Society of Pediatric Hematology.

Abstract:  Transfusion‐dependent Diamond‐Blackfan anemia (DBA) patients opt for allogeneic hematopoietic stem cell transplantation (HSCT) as curative therapy. Clinical outcomes of 19 transplanted Japanese patients were analyzed. Prior to HSCT, 10 patients (53%) suffered hemosiderosis with organ dysfunction, and all eight with short stature (42%) had adverse effects of prednisolone. Median age at the time of HSCT was 56 months. Transplantation sources were 13 bone marrow [six human leukocyte antigen (HLA)‐matched siblings, and six HLA‐matched and one HLA‐mismatched unrelated donors], five cord blood (two HLA‐matched siblings and three HLA‐mismatched unrelated donors), and one peripheral blood from haploidentical mother. All 13 patients with bone marrow transplantation (BMT) and two with sibling cord blood transplantation (CBT) had successful engraftment. Of three patients who underwent unrelated CBT, one died after engraftment, and the other two had graft failure but succeeded in a second BMT from an HLA‐disparate father and unrelated donor, respectively. One died shortly after haploidentical PBSCT. The five‐yr failure‐free survival rate after BMT was higher than CBT (100%: 40%, p = 0.002). Platelet recovery was slower in seven unrelated BMT than in six sibling BMT (p = 0.030). No other factors were associated with engraftment and survival. These results suggest that allogeneic BMT, but not unrelated CBT, is an effective HSCT for refractory DBA.

Diamond-Blackfan Anemia in Japan: Clinical Outcomes of Prednisolone Therapy and Hematopoietic Stem Cell Transplantation

The epidemiology and treatment outcomes for Diamond-Blackfan anemia (DBA) were surveyed in a cohort of 54 children (M/F = 26:28) registered in Japan from 1988 to 1998. The annual incidence was 4.02 cases per million births, the median age at diagnosis was 60 days, and 59% of the cases presented by 3 months of age.Three patients had a familial occurrence. All patients received prednisolone (PSL), and cyclosporin A (CsA) was added to the therapy in 17 patients. Forty-seven patients received transfusions, and 13 underwent hematopoietic stem cell transplantation (HSCT).The cumulative probabilities of a medicationfree or a transfusion-free state prior to HSCT were 36% and 69%, respectively, at more than 5 years after diagnosis. Thirteen patients were weaned from PSL therapy without HSCT, and CsA was not associated with weaning from therapy. Transfusion and medication were stopped at 249 days and 933 days after diagnosis in 34 and 13 patients, respectively, who achieved a state of independence. No initial findings predicted the treatment dependence. More than 20% of patients experienced sustained hemosiderosis and/or adverse effects of PSL. The ages and reticulocyte counts at diagnosis of the patients who underwent HSCT were lower than in the patients who did not. HSCT led to the highest success (85%) of all previous reports, even though 5 alternative donors were included in our study. Two cord blood transplants from unrelated donors failed. These findings suggest the need for developing an integral treatment strategy including selective HSCT for refractory DBA.

Consensus guideline for diagnosis and treatment of childhood idiopathic thrombocytopenic purpura.

A practice guideline aimed at standardizing the treatment for childhood idiopathic thrombocytopenic purpura (ITP) is presented. This consensus guideline is based on a survey carried out via a questionnaire prepared by the ITP Committee of the Japanese Society of Pediatric Hematology and sent to society members. The survey questionnaire included questions on the diagnosis of ITP submitted for the purpose of revising the ITP diagnostic guideline prepared in 1990 by the Research Group for Intractable Hematopoietic Disorders; a revised diagnostic guideline also is presented.

Carbamazepine-induced thrombocytopenia defined by a challenge test

Carbamazepine (CBZ), a widely used anticonvulsant, occasionally causes serious hematologic disorders. A 12‐year‐old boy was admitted because of a diffuse petechial rash and profound thrombocytopenia (10 × 109 platelets/l), after having been treated for epilepsy with CBZ for 12 days. Seven days following withdrawal of CBZ and initiation of prednisolone therapy, the platelet count recovered. In a subsequent challenge test with CBZ, platelet counts again decreased, and the levels of platelet‐associated IgG and serum interleukin‐6 increased. No antibodies against platelet glycoprotein IIb/IIIa or Ib were detected in plasma. We believe that this is the first reported occasion when CBZ‐induced thrombocytopenia has been defined by a rechallenge test. Am. J. Hematol. 64:52–55, 1999.

A Nationwide Survey of Newly Diagnosed Childhood Idiopathic Thrombocytopenic Purpura in Japan

Background We evaluated the clinical pictures, outcome for childhood idiopathic thrombocytopenic purpura (ITP) and the trends of the choice of management for childhood ITP in Japan. Method Every year, questionnaires were sent to all institutions that employ the active members of the Japanese Society of Pediatric Hematology. The questionnaires included age, sex, date of diagnosis, platelet count at diagnosis, the presence or absence of antecedent infection, hemorrhagic symptoms, initial management, and the outcome of all patients newly diagnosed with ITP. Results A total of 986 newly diagnosed as ITP patients were reported between January 2000 and December 2005. The occurrence of ITP peaked in boys less than 1 year of age, and at 1 year of age in girls. The male-to-female ratio was 1.24:1. Wet purpura was observed in more than half of the patients with platelet counts of <10,000/μL. The initial treatment varied among the patients with different platelet counts at diagnosis; most of the patients with platelet counts <20,000/μL received intravenous immunoglobulin or oral corticosteroids. Conversely, cases without any aggressive treatment increased to a larger degree in patients with ≥20,000/μL of platelet. Conclusions These findings indicate that overall compliance to the Japanese guideline is considered to be relatively good in Japan.

Analysis of telomerase activity and RNA expression in a patient with acute promyelocytic leukemia treated with all-trans retinoic acid.

In this study, we show that all‐trans retinoic acid (ATRA) treatment leads to a rapid decrease in telomerase activity, which was associated with the reduction in myeloblasts and occurs before the appearance of myelocytes, in a patient with acute promyelocytic leukemia (APL). Microarray analysis by ATRA treatment for 48 hr in peripheral blood mononuclear cells (in vivo) and in cultured bone marrow mononuclear cells (in vitro) from a patient with APL revealed upregulation of CD11b, CD11c, CCAAT enhancer binding protein ε, Rb1, Mad, and tumor necrosis factor‐related genes; and downregulation of hTERT, c‐Myc, WT1, bcl‐2, and eukaryotic translation elongation factor 1α2. The results might offer the potential to define the molecular mechanism underlying ATRA‐induced granulocytic differentiation in patients with APL, and provide clues to identify novel molecular therapeutic targets. Pediatr Blood Cancer 2006,46:506–511.

Severe aplastic anaemia complicating Sjögren syndrome in a 2-year-old girl.

We report a 2.5-year-old Japanese girl with severe aplastic anaemia complicating Sjögren syndrome. The patient had been born at 39 weeks’ gestation via an uncomplicated vaginal delivery as the first child of non-consanguineous parents. Birth weight was 2865 g (-0.58 SD), length was 48.3 cm (-0.31 SD), and occipitofrontal circumference was 32.0 cm (-0.84 SD). A developmental delay in gross motor performance had been noted at 10 months of age; however, she could assume a sitting position at the age of 18 months and could walk well at the age of 27 months. At the age of 21 months, a CT scan showed intracranial calcifications bilaterally in the basal ganglia and the deep cortical white matter. Moreover, laboratory studies showed anaemia (haemoglobin 8.4 g/dl) and liver dysfunction (aspartate aminotransferase 102 IU/dl, and alanine aminotransferase 83 IU/dl). Immunoglobulin (Ig)G and IgM antibodies against cytomegalovirus (CMV) were positive and negative, respectively; however, CMV was not isolated from the peripheral blood, urine, or CSF. She had routinely been brought to us because of a developmental delay due to suspected congenital CMV infection. Her family history was remarkable for a maternal grandmother with Sjögren syndrome complicating idiopathic thrombocytopenic purpura. At the age of 30 months, the patient was admitted to our hospital because of febrile convulsions. Her mother noted that she had been pale with purpura on both legs for 1 month. Physical examination on admission showed no anomalies such as short stature, nail dystrophy, and bone or urogenital tract malformations. In addition, there was no rash, leukoplakia, or hyperpigmentation in the skin. Haematological investigations unexpectedly showed anaemia (haemoglobin 9.0 g/dl) and thrombocytopenia (platelet count, 1.6·10/ll). Bone marrow examination revealed hypocellularity (17·10/ll) without megakaryocytes or proliferation of blasts, leading to a diagnosis of aplastic anaemia. Analysis of surface markers of bone marrow cells with flow cytometry revealed the following: CD2 70.8%; CD3 66.8%; CD4 37.9%; CD5 70.7%; CD7 67.8%; CD8 29.8%; CD13 9.3%; CD14 6.3%; CD33 12.8%; and CD34 3.6%. At the age of 34 months, haematological studies showed severe aplastic anaemia; haemoglobin 5.6 g/dl; haematocrit 14.9%; red blood cell count 190·10/ll; reticulocyte count 1.9·10/ll; platelet count 1.7·10/ll; white blood cell count 3400/ll; and granulocyte count 34/ll. Bone marrow biopsy revealed markedly hypoplastic marrow (nucleated cell count 11·10/ll) consisting chiefly of fat and fibrous tissue, and lymphocytes without immature or differentiated myeloid cells or megakaryocytes (Fig. 1). There was no chromosomal abnormality. Analysis of surface markers with flow cytometry revealed increased numbers of bone marrow T-cells (CD2 89.0%; CD3 83.5%; CD4 40.6%; CD5 89.4%; CD7 87.3%; CD8 40.7%), and decreased numbers of myeloid cells (CD13 4.7%; CD14 1.9%; CD33 3.3%) and haematopoietic stem cells (CD34 1.5%), compared with investigations performed at the age of 30 months. Severe anaemia and thrombocytopenia necessitated transfusions of erythrocytes and platelets every week. However, treatment with granulocyte colonystimulating factor did not increase the granulocyte count. Pyrexia and bilateral parotid gland enlargement (Fig. 2A) had been noted twice, at the age of 33 and 36 months. Immunological examination showed high serum levels of IgG (2,042 mg/dl) and IgE (1,899 mg/dl) and low CH50 activity (6.2 U/ml). In addition, M. Akiyama (&) Æ T. Yanagisawa Æ Y. Yuza Æ K. Yokoi K. Fujisawa Æ S. Kobayashi Æ Y. Eto Department of Paediatrics, Jikei University School of Medicine, 3-25-8 Nishi-shinbashi, Minato-ku, 105-8461 Tokyo, Japan E-mail: makiyama@jikei.ac.jp Tel.: +81-3-34331111 Fax: +81-3-34358665

Hemoglobin Hammersmith [β 42(CD1) Phe → Ser] causing severe hemolytic anemia in a Japanese girl

Hemoglobin Hammersmith, a rare, unstable hemoglobin variant, was diagnosed in a 9‐year‐old Japanese girl. She presented with the typical manifestations of this disorder, including neonatal hyperbilirubinemia, followed by progressive hepatosplenomegaly, jaundice, and bilirubinuria. Because of severe hemolytic anemia, she received transfusions of red blood cells every 3 to 4 weeks. However, she underwent splenectomy at the age of 4 years and has continued to be in partial remission without requiring further transfusions. DNA sequence analysis of the polymerase chain reaction‐amplified β‐globin gene revealed a point mutation (T → C) in the second nucleotide of the 42nd codon of the β‐globin chain (β 42(CD1) Phe → Ser). Pediatric Blood Cancer 2006;47:839–841.

Early onset of cecal perforation in neonatal, recto‐sigmoid type Hirschsprung's disease

Hirschsprungs disease has been considered to cause intestinal perforation in rare cases. Even if a perforation occurs, the majority of cases are associated with the long‐segment or total colonic type. Our case developed the perforation in the neonatal period in spite of being of the recto‐sigmoidal type, and it affected the cecum. We do not have a good explanation for this condition. However, the pathological examination of the specimens of the perforated cecum revealed some necrosis (ulceration, subcutaneous hemorrhage, congestion and severe edema) which was considered to be caused by ischemia, secondary to a localized vascular accident in the wall of the distended intestine.

Autoantibodies and CD5+ B cells in childhood onset immune thrombocytopenic purpura

We evaluated platelet associated immunoglobulin (PaIg) G, PaIgM, platelet associated autoantibodies to platelet glycoprotein IIb/IIIa (Pa‐GPIIb/IIIa), the percentage of CD5+ B cells and the amount of platelet‐bound anti‐GPIIb/IIIa monoclonal antibody (mAb) in the peripheral blood of 29 patients with childhood onset chronic immune thrombocytopenic purpura (c‐ITP). The percentage of CD5+ B cells ranged from 2 to 8% (4.7 ± 2.0) in control patients and 1 to 18% (6.2 ± 4.2) in the ITP patients. There was no overall significant difference between the two groups, but the percentage of CD5+ B cells in six of the ITP patients was higher than the mean + 2 s.d. of the controls. There was a significant correlation between the percentage of CD5+ B cells and PaIgM (y = 1.73x + 13.4, r = 0.40, P < 0.05). This finding is the basis for the speculation that CD5+ B cells may play an important role in the production of PaIgM in vivo. There was no correlation between the amounts of PaIgG and Pa‐GPIIb/IIIa. This suggests that the amount of PaIgG does not accurately reflect of the amount of Pa‐GPIIb/IIIa. Furthermore, we have demonstrated that autoantibodies to GPIIb/IIIa are directed to more than one epitope.