Purpura fulminans (PF) is a severe disorder of acute onset with high morbidity and mortality. In children, this rapidly progressive illness is usually associated with severe bacterial or viral infections. However, some other conditions may participate in the development of PF. Our objective was to investigate the underlying and associated disorders and the outcomes of the disease in 16 children, 7 males and 9 females ranging in age from 3.5 months to 12 years (median age, 2 years). Thirteen of the 16 children (81%) were 4 years of age or younger. The remaining 3 patients were 9, 10, and 12 years of age. Among these 13 infants and small children, 7 (43%) had infection, 2 infants had congenital cardiac disorders necessitating minor or major surgical intervention, and 1 infant and 3 children had different miscellaneous disorders. The factor V G1691A mutation was present in six of the 13 small children (46%). None of the 3 older children carried the mutation. Six (37.5%) of the 16 patients had protein C deficiencies, and 9 (56%) had protein S deficiencies. These deficiencies, except one for protein S, were acquired. Ten patients except two who were diagnosed at this center were treated with fresh frozen plasma. They were also given heparin. Nine (69%) of the 13 children 4 years of age or younger and one of the older children (33%) required amputation. Five of the six patients (83%) who had factor V G1691A mutation, and who also exhibited severe infection, required amputation. This study suggests that an age of 4 years or less is a risk factor for the development of PF during severe infections, especially in the presence of factor V G1691A mutation and congenital heart disease, necessitating major or minor surgical interventions. This study also shows that the amputation rate in 10 patients, after excluding the patients who had been referred to our center after development of sequelae, was 60%. The survival rate among these 10 patients may indicate that, with the treatment protocol, PF need not be regarded as a lethal disease any more. It is also suggested that effective immunization programs and better health care have probably resulted in some changes in the etiological profile of PF.

Factor V (FV) G1691A mutation, in a heterozygous state, is one of the most common inherited risk factors for development of thrombosis. However, the clinical manifestations of homozygosity for the FV G1691A mutation in children is largely unknown because of the limited number of studies reported. The purpose of this study was to evaluate the clinical manifestations and laboratory findings of children with thrombosis who were homozygous for this mutation. Ten patients (four male/six female; mean age, 4.5 years; age range, 1-13 years) who were found to be homozygous for the FV G1691A mutation among 360 consecutive children with thrombosis (2.8%) were the subjects of this study. Six of the 10 patients had venous thrombosis, two had purpura fulminans, one had diffuse skin ecchymosis and one had arterial thrombosis. No history of thrombosis was present in their family members. Seven of the 10 children were under the age of 5 years. One or more additional risk factors (infection, protein S and protein C deficiencies, elevated factor VIII, etc.) were also present in nine of these patients. None of these patients had prothrombin G20210A mutation but one patient had risk-associated plasminogen activator inhibitor-1 gene 4G/4G genotype. These findings suggest that, in the presence of other underlying risk factors, homozygosity for FV G1691A mutation may lead to development of thrombosis at a very young age.

A boy presented at age 4 years with severe congenital hemolytic anemia characterized by highly elevated reticulocyte count (30-50%) and prominent basophilic stippling. Hb had been 4 g/dL at age 7 months. The patient was on a monthly transfusion regimen up to the age of 7 years, when he underwent splenectomy. After removal of the spleen, his Hb stabilized at 11 g/dL. No abnormal pattern was detected in hemoglobin electrophoresis at pH 9 and 6. In-vitro globin synthesis revealed the presence of an abnormal beta-chain in front of the gamma-chain. The beta(A)/beta(X) ratio was 0.77 at 30 min and 0.74 at 2 hr of incubation. Molecular analysis revealed that the patient had GCC-->GAC alteration at codon 27 (beta27(B9)Ala-->Asp) causing the abnormal hemoglobin Volga. The beta-cDNA derived from the beta-Hb Volga allele could be differentiated from HbA beta-cDNA on silver-stained gel. No imbalance in the mRNA of beta(A)/beta(Hb Volga) ratio was observed.

We report two novel mutations in factor XIIIA (FXIIIA) gene that caused congenital factor XIII deficiency in two unrelated patients. The first alteration, a missense mutation Leu235Arg in exon 6 of FXIIIA gene, is located in the putative calcium-binding part of the core domain of the enzyme. Replacement of non-polar hydrophobic leucine residue with positively charged arginine residue is likely to effect protein folding thus destabilizing the molecule. The second mutation is a 3-bp deletion in exon 14 of FXIIIA gene. This deletion is located in beta barrel 2 domain of the protein and results in translation of an aberrant FXIIIA molecule that lacks lysine residue either at positions 677 or 678. As this inframe deletion is located in a direct repetetive sequence of AAGAAG, that codes for two lysine residues, the exact location of deletion could not be detected.

Pyrimidine 5' nucleotidase-I (P5N-I) deficiency is a rare autosomal recessive disorder associated with hemolytic anemia, marked basophilic stippling, and accumulation of high concentrations of pyrimidine nucleotides within the erythrocyte. Recently, the structure and location of the P5N-I gene have been published. This paper presents the results of a study characterizing the molecular pathologies of P5N-I deficiency in a total of 6 Turkish patients from 4 unrelated families of consanguineous marriages. Mutation analysis in the P5N-I gene led to the identification of 3 novel mutations in these patients. In 4 patients from 2 families, a homozygous insertion of double G at position 743 was detected in exon 9 (743-744insGG), leading to premature termination of translation 23 bp downstream. In one family, a homozygous T to G transition at position 543 (543T>G) in exon 8 resulted in the replacement of tyrosine (Tyr) with a stop codon (Tyr181Stop). In another family, a homozygous insertion of a single A in exon 7 (384-385insA) created a stop signal at the codon nearby. In all families, the parents were heterozygous for the relevant mutations. None of these changes was detected in 200 chromosomes from a healthy Turkish population. These mutations were not correlated with any particular phenotype.

Dear Sir, The presence of 4G allele at the promoter region of PAI-I gene is associated with thrombotic disorders [1Eriksson P. Kallin B. Van't Hooft F.M. Bavenholm P. Hamsten A. Allele-specific increase in basal transcription of the plasminogen-activator inhibitor 1 gene is associated with myocardial infarction.Proc Natl Acad Sci USA. 1995; 92: 1851-5Crossref PubMed Scopus (740) Google Scholar, 2Balta G. Altay C. Gurgey A. PAI-1 gene 4G/5G genotype: a risk for thrombosis in vessels of internal organs.Am J Hematol. 2002; 71: 89-93Crossref PubMed Scopus (0) Google Scholar]. Hence, there is a reason to believe that population studies on PAI-1 genotype may provide clues about the susceptibility of a given population to development of thrombotic disorders. Although this polymorphism was extensively studied in many countries worldwide, there is no information regarding the allele frequencies in Turkic countries in Asia. This study presents data on the prevalence of PAI-1 gene 4G/5G genotype in two Turkic populations: Azerbaijan bordering the Caspian Sea and Kyrgyzstan in central Asia. A total of 198 unrelated apparently healthy subjects from Azerbaijan and Kyrgyzstan were the subjects of this study. Out of 60 subjects studied from Azerbaijan population, 12 (20%) had 4G/4G, 31 (51.6%) had 4G/5G and 17 (28.3%) had 5G/5G genotypes. The allele frequency for 4G was 0.46. Among 138 unrelated healthy subjects from Kyrgyzstan population, 41 (29.9%) had 4G/4G, 73 (52.9%) had 4G/5G and 24 (17.4%) had 5G/5G genotypes. The allele frequency for 4G was 0.56 (Table 1). The genotype frequencies for both populations were in Hardy–Weinberg equilibrium (P < 0.05). Genotype frequencies from different regions of the world were also given for comparison and review of prevalences worldwide (Table 1).Table 1Genotype frequencies of PAI-I gene 4G/5G polymorphism in Azerbaijan, Kyrgyzstan and in some countries worldwideCountryTotal subjects4G/4G (%)4G/5G (%)5G/5G (%)Total chromosomeAllele 4G (%)Frequency 5G (%)Azerbaijan*Present study. Due to limitations in the number, a complete list of references could not be provided, but will be available upon request.6012 (20)31 (52)17 (28)12055 (46)65 (54)Kyrgyzstan*Present study. Due to limitations in the number, a complete list of references could not be provided, but will be available upon request.13841 (30)73 (53)24 (17)276155 (56)121 (44)Finland (male)6512 (19)36 (55)17 (26)13060 (46)70 (54)Sweden (male) [1Eriksson P. Kallin B. Van't Hooft F.M. Bavenholm P. Hamsten A. Allele-specific increase in basal transcription of the plasminogen-activator inhibitor 1 gene is associated with myocardial infarction.Proc Natl Acad Sci USA. 1995; 92: 1851-5Crossref PubMed Scopus (740) Google Scholar]10026 (26)54 (54)20 (20)200106 (53)94 (47)UK9926 (26)43 (43)30 (30)19895 (48)103 (52)Holland13135 (27)69 (53)27 (21)262139 (53)123 (47)France (south) [3Canavy I. Henry M. Morange P.E. Tiret L. Poirier O. Ebagosti A. Bory M. Juhan-Vague I. Genetic polymorphisms and coronary artery disease in the south of France.Thromb Haemost. 2000; 83: 212-6Crossref PubMed Scopus (94) Google Scholar]24464 (26)121 (50)59 (24)488249 (51)239 (49)Germany [4Nowak-Gottl U. Strater R. Kosch A. Von Eckardstein A. Schobess R. Luigs P. Nabel P. Vielhaber H. Kurnik K. Junker R. The plasminogen activator inhibitor (PAI)-1 promoter 4G/4G genotype is not associated with ischemic stroke in a population of German children.Eur J Hematol. 2001; 66: 57-62Crossref PubMed Scopus (0) Google Scholar]951275 (29)473 (50)203 (21)19021023 (54)879 (46)Austria11548 (42)48 (42)19 (16)230144 (63)86 (37)Slovenia14538 (26)76 (52)31 (21)290151 (52)139 (48)Spain9319 (20)39 (42)35 (38)18677 (41)109 (59)Italy [5Ardissino D. Mannucci P.M. Merlini P.A. Duca F. Fetiveau R. Tagliabue L. Tubaro M. Galvani M. Ottani F. Ferrario M. Corral J. Margaglione M. Prothrombic genetic risk factors in young survivors of myocardial infarction.Blood. 1999; 94: 46-51Crossref PubMed Google Scholar]20066 (33)102 (51)32 (16)400166 (42)234 (59)Turkey [2Balta G. Altay C. Gurgey A. PAI-1 gene 4G/5G genotype: a risk for thrombosis in vessels of internal organs.Am J Hematol. 2002; 71: 89-93Crossref PubMed Scopus (0) Google Scholar]28173 (26)112 (40)96 (34)562258 (46)304 (54)China10337 (36)48 (47)18 (18)206122 (59)84 (41)Korea13954 (39)60 (43)25 (18)278167 (60)111 (40)Japan (male)10439 (38)52 (50)13 (13)208130 (63)78 (38)New Zealand [6Rossaak J.I. Van Rij A.M. Jones G.T. Harris E.L. Association of the 4G/5G polymorphism in the promoter region of plasminogen activator inhibitor-1 with abdominal aortic aneurysms.J Vasc Surg. 2000; 31: 1026-32Abstract Full Text Full Text PDF PubMed Google Scholar]16357 (35)84 (51)21 (13)326199 (61)127 (39)USA White [7Gluek C.J. Fontaine R.N. Gruppo R. Stroop D. Sieve-Smith L. Tracy T. Wang P. The plasminogen activator inhibitor-1 gene, hypofibrinolysis and osteonecrosis.Clin Orthop. 1999; 366: 133-46Crossref Scopus (108) Google Scholar]23447 (20)103 (44)84 (36)468197 (42)271 (58) African [8Hooper W.C. Lally C. Austin H. Renshaw M. Dilley A. The role of the t-PA I/D and PAI-1 4G/5G polymorphisms in African-American adults with a diagnosis of myocardial infarction or venous thromboembolism.Thromb Res. 2000; 99: 223-30Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar]18537093 (25)277 (75)* Present study. Due to limitations in the number, a complete list of references could not be provided, but will be available upon request. Open table in a new tab Table 1 shows that the 4G allele is present with a relatively high frequency in almost all regions in the world. It is slightly more common in Far East Asia (60–63%) than in Europe (41–54%) except Austria (63%). The reported allele frequency of 4G is lowest in African-Americans (25%) and is close to Europe in the Caucasian population in the USA (42%). Despite its Asian location, the 4G allele frequency for Azerbaijan (46%) is closer to Europe than it is to Far East Asia. The allele frequency of 4G in Kyrgyzstan (56%), on the other hand, is between Europe and Far East Asia. We are grateful to D. K. Kudayarov, R. Rustamov and J. Togrul for providing the blood samples from the healthy Kyrgyzstan and Azerbaijan populations.

The role of methylenetetrahydrofolate reductase (MTHFR C677T), glutathione S‐transferases (GSTM1 and GSTT1 null, GSTP1 Ile105Val), and cytochromes p450 (CYP1A1*2A) genotypes in the etiology of childhood leukemia was simultaneously investigated. 144 Turkish children with acute lymphoblastic leukemia (ALL) and 33 with acute nonlymphoblastic leukemia (ANLL) were studied and compared with 185 healthy pediatric controls. The frequency of MTHFR genotype was insignificantly higher in ALL (7.7%) and ANLL (6.3%) than in controls (4.4%). Equal distribution of the GSTM1 null genotype was detected between ALL patients and controls (55%), while its incidence was slightly higher in ANLL patients (61.3%). Although GSTT1 null genotype was insignificantly lower in ALL patients (20.9%) than controls (22.7%), it was significantly underrepresented in ANLL patients (6.5%) (P = 0.05, OR 0.24, 95% CI 0.05–1.03). The homozygous frequency of GSTP1 genotype did not differ significantly between groups of ALL (3.7%), ANLL patients (9.1%) and controls (4.9%). Homozygous CYP1A1*2A genotype was underrepresented in ALL patients (1%) as compared to control (4.8%) but the differences did not reach to statistical significance (OR 0.21; 95% CI 0.03–1.72). Homozygosity for this genotype was not detected in ANLL patients. No particular association was noted between different combinations of combined genotypes and risk of development of childhood ALL and ANLL. These results suggested that there are no significant associations between the studied genotypes and the risk of developing either form of acute leukemia except GSTT1 null and homozygosity for CYP1A1 genotypes that may play protective roles in the development of ANLL in Turkish children. Am. J. Hematol. 73:154–160, 2003. © 2003 Wiley‐Liss, Inc.

Purpose: To investigate the frequency of high erythrocyte count (red blood cell count greater than or equal to5.0 x 10(6)/muL) in infants and young children with iron deficiency anemia and to document the differences in hematologic parameters at diagnosis and during iron therapy in IDA patients with and without a high erythrocyte count.Patients and Methods: A total of 140 infants and young children aged 6 to 48 months with nutritional IDA without a history of any bleeding disorder were the subjects of this study. The patients were divided into three groups according to the severity of anemia. Group A1 children had Hb values 8.0 g/dL or less (severe anemia): group A2, 8.1 to 10.0 g/dL (moderate anemia) and group A3, 10.1-11.0 g/dL (mild anemia). All children received oral iron (3-5 mg/kg per day) for 12 weeks. Complete blood counts were done weekly during treatment.Results: A total of 36 of the 140 patients (26%) had a high erythrocyte count. Of the 140 patients, 37 were in group A1, 80 in A2, and 23 in A3. The frequency of high erythrocyte count was 11%, 23%, and 61% in groups A1, A2, and A3, respectively. The patients with a high erythrocyte count had significantly higher Hb and Her but significantly lower mean corpuscular volume and mean corpuscular hemoglobin (MCH) values than those with a low erythrocyte count (n = 104). A continuous elevation in the erythrocyte count has been observed in patients with a high red cell count, as in those with a low red cell count. after the institution of iron therapy.Conclusions: A high erythrocyte count is a common feature of iron deficiency anemia in infants and young children, with an increasing frequency front severe to moderate to mild anemia. High erythrocyte count cannot be regarded as a reliable preliminary parameter in differentiating iron deficiency from thalassemias in infants and children aged up to 48 months.

Although the common 4G/5G polymorphism in the promoter of the PAI-1 gene was suggested to be a risk factor for some of the thrombotic disorders, its significance in the development of thrombosis is still controversial. This study presents the data on a total of 357 patients with different types of thrombosis and 281 unrelated healthy controls. It was found that the 4G/4G genotype is associated with a higher risk of thrombosis (OR, 1.7; 95% CI, 1.1-2.5). Patients were divided into five distinct groups according to the site of thrombosis. Both 4G/4G and 4G/5G genotypes were associated with a higher risk of thrombosis development in a group of 69 patients with internal organ thrombosis (OR, 6.35; 95% CI, 2.5-16.1 and OR, 4.85; 95% CI, 2.0-12.1, respectively). Interestingly, this association was even stronger in a subgroup of 33 patients with portal vein thrombosis (PVT) and 4G/4G and 4G/5G genotypes conferred more than 10- and 6-fold increases in the risk of developing PVT (95% CI: 2.3-47.1 and 1.4-28.8), respectively. No statistically significant association was found between 4G/4G genotype and the groups of deep vein thrombosis (126 patients), cerebral thrombosis (80 patients), retinal thrombosis (72 patients), and purpura fulminans (16 patients). Factor V Leiden or prothrombin G20210A mutations did not emerge as additional risk factors for thrombosis in any of the groups studied. To conclude, this study suggests that there may be an association between 4G/4G and 4G/5G genotypes and the thrombosis in vessels of internal organs especially in the portal veins.

Molecular analysis of factor XIII A gene on three unrelated Turkish families identified two novel and one known mutations. One novel mutation is a substitution of cytidine by guanine at codon 541 in exon 12, beta barrel 1 domain of the coagulation factor XIII A subunit gene resulting in the conversion of asparagine to lysine. The mutation alters the restriction site of the enzyme MboII. The second novel mutation, a 4 bp (-CAAA) deletion located in a direct repetitive sequence (CAAACAAA) between codons 466-469, results in premature termination of translation at codon 474. The third mutation is a previously reported single nucleotide (cytidine) insertion at codon 400 in exon 9 of the factor XIII gene.

The case of an 8-year-old male child with severe kernicterus sequelae is presented in this paper. The child's hemoglobin value varied between 6.0 and 10.8 g/dL and his reticulocyte count ranged between 3.4 and 46.0% during the steady-state condition and hyperhemolytic crisis, respectively. A chronic hemolytic typeof red cell G6PD deficiency was diagnosed. DNA studies indicate that the mutation was G6PD Guadalajara 1159 C M T (387 Arg M Cys) that is situated at the NADP binding site. Additionally, extra nucleotides of (TA) in the A(TA) n TAA motif of the promoter region of the uridine diphosphate-glucuronosyltransferase gene (UGT-1) were found to be homozygous in the patient. The coexistence of Gilbert syndrome with a chronic type of G6PD deficiency was suggested as a cause of neonatal hyperbilirubinemia leading to kernicterus.

Red cell distribution width (RDW) was studied in adults carrying delta-beta thalassemia traits (deltabeta-TT) who were 20-40 years of age (n = 29), beta thalassemia traits (beta-TT) with an age range of 18-60 years (n = 49), iron deficiency anemia (IDA) in individuals aged 1-18 years (n = 27), and in controls with an age range of 20-40 years (n = 20). Although red blood cell count, MCV, and MCH values showed no statistically significant differences between deltabeta-TT and beta-TT, the mean RDW value was significantly higher in deltabeta-TT (20.14 +/- 1.21) compared to beta-TT (14.88 +/- 1.77) (P < 0.001). No difference was observed between the means of RDW in deltabeta-TT and IDA (18.00 +/- 1.94) (P > 0.05). A significant rise in RDW in IDA 5-7 days after initiation of iron therapy (P = 0.00) which was continued to rise up to the 4(th) week of therapy was suggested as an important tool in differentiation of IDA from deltabeta-TT. These observations could be kept in mind in the differential diagnosis of deltabeta-TT from beta-TT and IDA by determining the red blood cell count, red cell indices, and RDW only.

Recently, measurement of serum alpha-fetoprotein (sAFP) was introduced as a preliminary test for diagnosis of Fanconi's anemia (FA). In the present study, sAFP levels were measured in order to determine its sensitivity and specificity in 33 Turkish FA patients (17 males and 16 females) with a mean age of 11.6 +/- 7.7 (1.0-28.0) (median 10.0). Complementation groups were available in 12 patients. Nineteen age-matched healthy children, 17 patients with bone marrow failure syndromes, 37 FA heterozygotes, and 37 children with acute leukemia served as negative control groups. The sAFP was measured by particle immunoassay. The level of sAFP was found to be higher than the cut-off value, 8 IU/mL in 46% and was within normal limits in 54% of the FA patients. The AFP values were within normal limits in all of the subjects belonging to the control groups. This method provided 46% sensitivity and 100% specificity in the diagnosis of FA. The sAFP values were high in 4 of 17 (24%) FA patients who did not receive any androgen therapy, while the sAFP level was high in 7 of 9 (78%) patients who received such a therapy. The statistical analysis of incidence of a high sAFP level between these two groups indicated a significant difference (P = 0.014), suggesting that androgen therapy might be a contributing factor for elevation of sAFP. The comparison of several clinical and laboratory parameters between FA patients with high and normal levels of AFP revealed no statistically significant differences. The level of sAFP was elevated in only 5 of the 11 patients with complementation group A; in addition, variable levels of sAFP were noted among the affected members in 4 families, indicating that complementation groups, type of mutation, or familial factors were not responsible for elevation of sAFP.

A 30-year-old female who is homozygous for a Hb E-like abnormal hemoglobin and her immediate relatives were studied. Clinical examination of the proband revealed no abnormality. Routine hematological analysis showed that her hemoglobin level was 12 g/dL, MCV 82 fL, MCH 28 pg, RDW 15%. DNA sequence analysis indicated the presence of a G-->A substitution at codon 22 corresponding to an abnormal hemoglobin, namely Hb E-Saskatoon [beta22(B4)Glu-->Lys (GAA-->AAA)]. Absence of any abnormalities in clinical and routine hematological investigations of the homozygous patient indicated that the phenotypical expression of the Hb E-Saskatoon is very mild. Using a reverse transcription-polymerase chain reaction technique, the alpha/beta and betaX/betaA-mRNA (X = Hb E-Saskatoon) ratios were determined. Normal alpha/beta and betaX/betaA-mRNA ratios were found in the homozygous patient and in all heterozygotes, indicating that the respective mutation did not alter the stability of the mRNA. FokI restriction enzyme analysis of the polymerase chain reaction products obtained from the genomic DNA and/or beta-globin mRNA made it possible for rapid diagnosis of Hb E-Saskatoon, and for its differentiation from Hb E [beta26(B8)Glu-->Lys (GAG-->AAG)]. Analysis of the restriction fragment length polymorphism (RFLP) in the beta-globin gene complex of the index patient and of another unrelated family with a compound heterozygosity for Hb E-Saskatoon and beta-thalassemia revealed that the Hb E-Saskatoon mutation shared a common allele.