Volker Strenger

Diagnostic and prognostic impact of urinary catecholamines in neuroblastoma patients

Urinary catecholamine metabolites are well‐known to be elevated in patients with neuroblastoma. Some investigators have described different patterns in favorable and unfavorable cases. However, extended studies have not been published.

Weaver syndrome and EZH2 mutations: Clarifying the clinical phenotype

Weaver syndrome, first described in 1974, is characterized by tall stature, a typical facial appearance, and variable intellectual disability. In 2011, mutations in the histone methyltransferase, EZH2, were shown to cause Weaver syndrome. To date, we have identified 48 individuals with EZH2 mutations. The mutations were primarily missense mutations occurring throughout the gene, with some clustering in the SET domain (12/48). Truncating mutations were uncommon (4/48) and only identified in the final exon, after the SET domain. Through analyses of clinical data and facial photographs of EZH2 mutation‐positive individuals, we have shown that the facial features can be subtle and the clinical diagnosis of Weaver syndrome is thus challenging, especially in older individuals. However, tall stature is very common, reported in >90% of affected individuals. Intellectual disability is also common, present in ∼80%, but is highly variable and frequently mild. Additional clinical features which may help in stratifying individuals to EZH2 mutation testing include camptodactyly, soft, doughy skin, umbilical hernia, and a low, hoarse cry. Considerable phenotypic overlap between Sotos and Weaver syndromes is also evident. The identification of an EZH2 mutation can therefore provide an objective means of confirming a subtle presentation of Weaver syndrome and/or distinguishing Weaver and Sotos syndromes. As mutation testing becomes increasingly accessible and larger numbers of EZH2 mutation‐positive individuals are identified, knowledge of the clinical spectrum and prognostic implications of EZH2 mutations should improve.

Intracerebral Cavernous Hemangioma after Cranial Irradiation in Childhood

Background and Purpose:Radiotherapy is an integral part of various therapeutic regimens in pediatric and adult oncology. Endocrine dysfunction, neurologic and psychiatric deficits, secondary malignancies and radiation-induced necrosis are well-known possible late effects of cranial irradiation. However, only sporadic cases of radiation-induced cavernous hemangiomas (RICH) have been reported so far.Patients and Methods:Pediatric patients who underwent cranial radiation therapy for malignant diseases between January 1980 and December 2003 were retrospectively analyzed. After the end of therapy they entered a detailed follow-up program.Results:Of 171 patients, eight (three patients with medulloblastoma, three patients with acute lymphoblastic leukemia, and one patient each with ependymoma and craniopharyngioma) developed intracerebral cavernoma 2.9–18.4 years after irradiation representing a cumulative incidence (according to the Kaplan-Meier method) of 2.24%, 3.86%, 4.95%, and 6.74% within 5, 10, 15, and 20 years following radiation therapy, respectively. In patients treated in the first 10 years of life, RICH occurred with shorter latency and significantly more often (p = 0.044) resulting in an even higher cumulative incidence.Conclusion:These findings and previously published cases show that cavernous hemangiomas may occur after irradiation of the brain several years after the end of therapy irrespective of the radiation dose and type of malignancy. Particularly children < 10 years of age at the time of irradiation are at higher risk. Since patients with RICH frequently do not show symptoms but hemorrhage is a possible severe complication, imaging of the central nervous system should be performed routinely for longer follow- ups, particularly in patients who were treated as young children.Hintergrund und Ziel:Strahlentherapie ist ein wichtiger Bestandteil bei der onkologischen Behandlung pädiatrischer sowie erwachsener Patienten. Endokrine Dysfunktion, neurologische und psychiatrische Defizite, Sekundärmalignome und strahleninduzierte Nekrosen sind bekannte Spätfolgen nach kranieller Bestrahlung. Das Auftreten strahleninduzierter kavernöser Hämangiome (Kavernome) ist bisher nur vereinzelt beschrieben worden.Patienten und Methodik:Es wurden alle pädiatrischen Patienten, die an der eigenen Abteilung zwischen Januar 1980 und Dezember 2003 aufgrund unterschiedlicher maligner Erkrankungen einer Schädelbestrahlung unterzogen und danach in ein umfassendes Nachsorgeprogramm eingeschleust wurden, retrospektiv analysiert.Ergebnisse:Von 171 Patienten entwickelten acht (drei Patienten mit Medulloblastom, drei Patienten mit akuter lymphatischer Leukämie und je ein Patient mit Ependymom und Kraniopharyngeom) 2,9–18,4 Jahre nach der Strahlentherapie intrazerebrale Kavernome (s. Tabelle 1). Nach der Kaplan-Meier-Methode entspricht dies einer kumulativen Inzidenz von 2,24%, 3,86%, 4,95% bzw. 6,74% innerhalb von 5, 10, 15 bzw. 20 Jahren nach Strahlentherapie (s. Abbildung 1). Bei Patienten, welche in den ersten 10 Lebensjahren behandelt wurden, traten Kavernome mit kürzerer Latenzzeit und häufiger (p = 0,044) auf (s. Abbildung 2).Schlussfolgerung:Diese Ergebnisse und die bisher veröffentlichten Daten zeigen, dass Kavernome – unabhängig von der Art der Grunderkrankung und der Strahlendosis – auch viele Jahre nach kranieller Bestrahlung auftreten können. Kinder < 10 Jahre haben ein höheres Risiko, eine solche Gefäßmalformation zu entwickeln. Da Patienten mit Kavernomen häufig keine Symptome zeigen diagund Blutungen mögliche schwere Komplikationen darstellen, sollte eine regelmäßige Bildgebung des Neurokraniums im Rahmen der Nachsorge auch noch viele Jahre nach Therapieende durchgeführt werden.

European Organization for the Research and Treatment of Cancer/Mycoses Study Group (EORTC/MSG) host factors and invasive fungal infections in patients with haematological malignancies

OBJECTIVES Fulfilment of host factors defined by the revised European Organization for the Research and Treatment of Cancer/Mycoses Study Group (EORTC/MSG) criteria is required for establishing the diagnosis of possible or probable invasive fungal infection (IFI). This case-control study evaluates EORTC/MSG host factors among patients with haematological malignancies. METHODS Fifty-eight patients with haematological malignancies who developed probable (n = 38) or proven (n = 20) IFI over a 5 year period were retrospectively evaluated regarding EORTC/MSG host factors. Results were compared with those obtained from patients with haematological malignancies who did not develop IFI (116 patients who received systemic antifungal prophylaxis or empirical therapy and 116 patients who did not; all data collected in 2010). RESULTS Fourteen patients had invasive yeast infection and 44 patients had invasive mould infection (IMI). Prolonged neutropenia (35/58, 60% versus 29/116, 25%), prolonged systemic corticosteroid (cut-off 21 days: 13/58, 22% versus 6/116, 5%; cut-off 14 days: 18/58, 31% versus 9/116, 8%) and T cell suppressive therapy (35/44, 80% versus 69/116, 59%) were significantly associated with development of IFI/IMI in our cohort. Previous allogeneic stem cell transplantation (SCT; >6 months prior to episode) was not significantly associated with development of IMI (8/44, 18% versus 22/116, 19%), while recent SCT (<6 months prior to episode) was (11/44, 25% versus 12/116, 10%). CONCLUSIONS We conclude that host factors according to revised EORTC/MSG criteria were significantly associated with the development of IFI/IMI in our patients. Previous allogeneic SCT was not a predisposing host factor for the development of IMI. Concerning prolonged corticosteroid treatment, a cut-off of 14 days seems preferable to the proposed cut-off.

Orally administered colistin leads to colistin-resistant intestinal flora and fails to prevent faecal colonisation with extended-spectrum β-lactamase-producing enterobacteria in hospitalised newborns.

Colonisation and infection with extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-E) is an emerging problem. The aim of this study was to investigate whether colistin, which is reported to be effective against multiresistant enterobacteria, prevents ESBL-E colonisation in neonates. For prophylaxis of necrotising enterocolitis, oral gentamicin (15 mg/kg/day) is routinely used in all neonates hospitalised at the Neonatal Intensive Care Unit of University Hospital Graz (Austria). During the study period from May 2005 to September 2007, three ESBL-E outbreaks (total duration 18 months) occurred. During these outbreaks, gentamicin was immediately replaced by oral colistin (8 mg/kg/day) in all hospitalised neonates. All neonates colonised with ESBL-E during the study period were retrospectively analysed with regard to the influence of colistin on ESBL-E colonisation. Genetic relatedness of isolates was assessed by repetitive sequence-based polymerase chain reaction (rep-PCR). During the study period, 30 (4.5%) of 667 neonates were colonised with ESBL-E. Twelve of twenty-one patients colonised with Klebsiella pneumoniae (ESBL-Kp) and one of nine patients colonised with Klebsiella oxytoca (ESBL-Ko) had received oral colistin at time of colonisation with ESBL-E. Amongst ESBL-Kp, the rate of colistin resistance was significantly higher in the colistin group (P=0.0075). Four different clones of ESBL-Kp and three different clones of ESBL-Ko were isolated, indicating the occurrence of patient-to-patient transmission. Colistin-resistant as well as colistin-susceptible isolates were detected within the same clones, indicating induction of resistance. At the dosage used, oral colistin did not prevent colonisation with ESBL-E and appeared to select colistin-resistant strains or to induce colistin resistance.

Procalcitonin—a marker of invasive fungal infection?

Procalcitonin (PCT) has been described as a marker of bacterial sepsis. However, little is known of its diagnostic value in fungal infections. We calculated the sensitivity of PCT for detection of invasive fungal infections (IFI) by analyzing 55 episodes of proven or probable IFI (three in our series, 52 reported in the recent literature). In the early phase of IFI, PCT was elevated in fewer than half of invasive candidiasis episodes and in only one patient (5.3%) with invasive aspergillosis. Due to low sensitivity and specificity, PCT adds little to the diagnosis of IFI.

Sensitivity of galactomannan enzyme immunoassay for diagnosing breakthrough invasive aspergillosis under antifungal prophylaxis and empirical therapy

Data on diagnostic performance of Galactomannan (GM) testing in patients under mould‐active regimens are limited. Whether sensitivity of GM testing for diagnosing breakthrough invasive aspergillosis (IA) is decreased under antifungal prophylaxis/therapy remains therefore a point of discussion. We retrospectively analysed GM test results in patients who were admitted with underlying haematological malignancies to two Divisions of the Medical University Hospital of Graz, Austria, between 2009 and 2012. Only cases of probable and proven IA that were diagnosed by other methods than GM testing were included (time of diagnosis = day 0). We compared GM results of patients with/without therapy/prophylaxis for the period of 2 weeks prior (week −2) until 3 weeks postdiagnosis. A total of 76 GM test results in nine patients were identified. Six patients had received antifungal therapy/prophylaxis from week −2, whereas three patients were treated with therapy from the time of diagnosis at week 0. GM testing was positive in 45/76 (59%) of samples. Sensitivity of GM testing for detection of proven or probable IA at week −1 and 0 was 77% and 79% in patients with mould‐active regimens. We conclude that GM testing might be a useful diagnostic method for breakthrough IA in patients receiving mould‐active prophylaxis/therapy.

Procalcitonin and C-reactive protein do not discriminate between febrile reaction to anti-T-lymphocyte antibodies and Gram-negative sepsis

Summary:Treatment with antibodies against T-lymphocytes usually triggers a febrile response potentially mimicking or masking infection. Procalcitonin (PCT) is considered a sensitive and specific marker of systemic bacterial and fungal infection. It was the aim of this study to investigate the characteristics of PCT and C-reactive protein (CRP) during treatment with polyclonal or monoclonal anti-T-cell antibodies, in order to examine the ability of these parameters to distinguish between systemic bacterial infection and reaction to antibody treatment. Thus, 15 consecutive febrile episodes after T-cell antibody infusion without clinical signs of infection were compared with nine episodes of Gram-negative sepsis. After T-cell antibody infusion PCT and CRP serum levels increased to a similar extent as in Gram-negative sepsis. Therefore, during T-cell antibody treatment neither PCT nor CRP are adequate for differentiating between fever due to infection or to unspecific cytokine release.

Fecal carriage and intrafamilial spread of extended-spectrum β-lactamase-producing enterobacteriaceae following colonization at the neonatal ICU.

Objective: Fecal carriage of extended-spectrum &bgr;-lactamase-producing enterobacteriaceae may contribute to the spread of extended-spectrum &bgr;-lactamase-producing enterobacteriaceae into the community. The objective of this study was to assess the duration of fecal carriage after discharge and the occurrence of intrafamilial transmission. Design: Case series. Setting: Quaternary care children’s hospital. Patients: Patients colonized with extended-spectrum &bgr;-lactamase-producing enterobacteriaceae at the neonatal ICU and the respective household members. Interventions: Screening for intestinal extended-spectrum &bgr;-lactamase-producing enterobacteriaceae colonization was done at 1, 2, 4, 6, 9, and 12 months after discharge. Genetic relatedness of isolated extended-spectrum &bgr;-lactamase-producing enterobacteriaceae strains was determined using automated rep-PCR. Results: Twenty-five neonates (case-patients) colonized with extended-spectrum &bgr;-lactamase-producing enterobacteriaceae (one extended-spectrum &bgr;-lactamase-Escherichia coli; six extended-spectrum &bgr;-lactamase-Klebsiella pneumoniae; 11 extended-spectrum &bgr;-lactamase-Klebsiella oxytoca; and seven extended-spectrum &bgr;-lactamase-Serratia marcescens) were included. Duration of fecal carriage was longer (up to 1 yr) in case-patients colonized with Klebsiella species than in case-patients colonized with Serratia marcescens (<4 months). During follow-up, strains and species of extended-spectrum &bgr;-lactamase-producing enterobacteriaceae different from the primary strain were found in four and three case-patients, respectively. In nine of 49 (18.4%) included household members, extended-spectrum &bgr;-lactamase-producing enterobacteriaceae were found during the follow-up period. In two of nine colonized household members, the isolated extended-spectrum &bgr;-lactamase-producing enterobacteriaceae was identical to the primary strains of the respective case-patients. Conclusions: After intestinal colonization with extended-spectrum &bgr;-lactamase-producing enterobacteriaceae at the neonatal ICU, infants potentially remain carriers during the first year after discharge. Intrafamilial spread has been proven.

Detection of HHV-6-specific mRNA and antigens in PBMCs of individuals with chromosomally integrated HHV-6 (ciHHV-6).

After inheritance of chromosomally integrated HHV-6 (ciHHV-6), viral DNA is found in every nucleated cell. The prevalence of ciHHV-6 is estimated to be 0.2-5% of humans. There are conflicting data on the potential for replication, possibly leading to clinical implications. We analysed peripheral blood mononuclear cells (PBMCs) from individuals with ciHHV-6 proven by fluorescence in situ hybridization (FISH) for HHV-6-specific mRNA (U94, U42, U22) and antigens by means of reverse transcription PCR and an indirect immunoperoxidase staining. U94 transcripts indicative of latent infection were detected in six (54.5%) out of 11 individuals at least once. Transcripts indicative of lytic infection (i.e. U42 and U22) were detected in four (36.4%) out of 11 individuals at least once. HHV-6 antigen was detected in seven (70%) out of 10 individuals at least once. The presence of viral mRNA and proteins supports virus gene expression from ciHHV-6, which may lead to virus replication. Considering the properties of active HHV-6 infection together with obvious replicative activity in individuals with ciHHV-6, pathophysiological effects leading to clinical consequences of chromosomally integrated viral DNA might be considered.