A six-year-old boy with homozygous beta-thalassemia in the favorable class 1 risk group received a bone marrow transplant, from his histocompatible sister. He developed grade IV skin and eye graft-versus-host disease (GVHD) following varicella zoster reactivation. Despite the appropriate prophylactic use of cyclosporin A (CsA), methotrexate (MTX), and prompt treatment with high-dose steroids, GVHD progressed resulting in total body epidermal necrolysis. Anti-IL-2 receptor monoclonal antibodies (anti-IL-2R moAb) in combination with steroids were administered to selectively block the activated T cells. After 27 days of daily administration, followed by 17 doses of alternate-day therapy with anti-IL-2R moAb, the severe skin and eye GVHD resolved. The patient, at two years posttransplant, has full engraftment and immune reconstitution without chronic GVHD (cGVHD). In conclusion, we suggest that in the HLA-genoidentical bone marrow transplantation setting, very severe and steroid-resistant GVHD can be controlled through the use of anti-IL-2 receptor antibodies which specifically block the activated IL-2 receptor expressing T cells.

X-linked chronic granulomatous disease (X-CGD) is a primary immunodeficiency with complete absence or malfunction of the nicotinamide adenine dinucleotide phosphate (NADPH) oxidase in the phagocytic cells. Life-threatening infections especially with aspergillus are common despite optimal antimicrobial therapy. Bone marrow transplantation (BMT) is contraindicated during invasive aspergillosis in any disease setting. We report an 8-year-old patient with CGD who underwent HLA-genoidentical BMT during invasive multifocal aspergillus nidulans infection, nonresponsive to treatment with amphotericin-B and gamma-interferon. During the first 10 days post-BMT, the patient received granulocyte colony-stimulating factor (G-CSF)-mobilized, 25 Gy irradiated granulocytes from healthy volunteers plus G-CSF beginning on day 3 to prolong the viability of the transfused granulocytes. This was confirmed in vitro by apoptosis assays and in vivo by finding nitroblue tetrazolium (NBT)-positive granulocytes in peripheral blood 12 and 36 hours after the transfusions. Clinical and biological signs of infection began to disappear on day 7 post-BMT. Positron emission tomography with F18-fluorodeoxyglucose (FDG-PET) and computed tomography (CT) scans at 3 months post-BMT showed complete disappearance of infectious foci. At 2 years post-BMT, the patient is well with full immune reconstitution and no sign of aspergillus infection. Our results show that HLA-identical BMT may be successful during invasive, noncontrollable aspergillus infection, provided that supportive therapy is optimal.

Vitamin K deficiency bleeding within the first 24 h of life is caused in most cases by maternal drug intake (e.g. coumarins, anticonvulsants, tuberculostatics) during pregnancy. Haemorrhage is often life-threatening and usually not prevented by vitamin K prophylaxis at birth. We report a case of severe intracranial bleeding at birth secondary to phenobarbital-induced vitamin K deficiency and traumatic delivery. Burr hole trepanations of the skull were performed and the subdural haematoma was evacuated. Despite the severe prognosis, the infant showed an unexpected good recovery. At the age of 3 years, neurological examinations were normal as was the EEG at the age of 9 months. CT showed close to normal intracranial structures.Conclusion This case report stresses the importance of antenatal vitamin K prophylaxis and the consideration of a primary Caesarean section in maternal vitamin K deficiency states and demonstrates the successful management of massive subdural haemorrhage by a limited surgical approach.

We investigated whether neuron-specific enolase (NSE) in serum or cerebrospinal fluid (CSF) reflects subtle or manifest brain injury in children undergoing cardiac surgery using cardiopulmonary bypass (CPB). NSE was measured in serum (s-NSE) before, and up to, 102 h after surgery in 27 children undergoing cardiac surgery with CPB. In 11 children, CSF-NSE was also measured 48 or 66 h post-surgery. As erythrocytes contain NSE, hemoglobin concentration in the samples was determined spectrophotometrically at 550 nm (cut-off limit: absorbance 0.4 = 560 mg/l) in 14 children and in a further 13 children by spectroscopic multicomponent analysis (cut-off limit 5 micromol/l = 80 mg/l). One hundred and one of 214 post-operative serum samples (47%) had to be discarded because of hemolysis (18% spectrophotometrically at 550 nm and 88% with spectroscopic multicomponent analysis). On the first and second post-operative day, the median s-NSE values were significantly higher when compared with samples taken after 54 h or longer (P = 0.008 and P = 0.002). All CSF-NSE levels were within the normal range and below the s-NSE measured in the same patient. Although in our study elevated s-NSE seems to indicate brain injury in CPB-surgery, the low concentration of NSE in the post-operative CSF of 11 children puts the neuronal origin of s-NSE in question. NSE from other non-neuronal tissues probably contributes to the elevated s-NSE. Additionally, normal post-operative CSF-NSE values in two children with post-operative neurological sequelae might question the predictive value of CSF-NSE with regard to brain injury.

Adenosine deaminase (ADA) deficiency typically causes severe combined immunodeficiency (SCID) in infants. We report metabolic, immunologic, and genetic findings in two ADA-deficient adults with distinct phenotypes. Patient no. 1 (39 years of age) had combined immunodeficiency. She had frequent infections, lymphopenia, and recurrent hepatitis as a child but did relatively well in her second and third decades. Then she developed chronic sinopulmonary infections, including tuberculosis, and hepatobiliary disease; she died of viral leukoencephalopathy at 40 years of age. Patient no. 2, a healthy 28-year-old man with normal immune function, was identified after his niece died of SCID. Both patients lacked erythrocyte ADA activity but had only modestly elevated deoxyadenosine nucleotides. Both were heteroallelic for missense mutations: patient no. 1, G216R and P126Q (novel); patient no. 2, R101Q and A215T. Three of these mutations eliminated ADA activity, but A215T reduced activity by only 85%. Owing to a single nucleotide change in the middle of exon 7, A215T also appeared to induce exon 7 skipping. ADA deficiency is treatable and should be considered in older patients with unexplained lymphopenia and immune deficiency, who may also manifest autoimmunity or unexplained hepatobiliary disease. Metabolic status and genotype may help in assessing prognosis of more mildly affected patients.

We diagnosed cartilagehair hypoplasia (CHH) in a female child with prenatal-onset short stature, metaphyseal chondrodysplasia, and severe combined immunodeficiency leading to recurrent, severe respiratory tract infections. The patient required several hospital admissions during her 1st year of life and failed to thrive in spite of antimicrobial therapy and hypercaloric nutrition. Bone marrow transplantation (BMT) from an HLA-identical sister was performed at age 16 months after conditioning with busulphan and cyclophosphamide, using 9×108 nucleated bone marrow cells/kg body weight. Graft-versus-host disase prophylaxis consisted of cyclosporine and methotrexate. The post-transplantation period was uneventful. She developed full and sustained chimerism as demonstrated by DNA analysis of granulocytes and mononucleated cells on days 44, 69 and 455 post BMT. Cellular immunity was completely reconstituted at 4 months, humoral immunity at 15 months post BMT. The patient is alive and well 24 months post BMT without medication, but the radiological osseous changes persist, and longitudinal growth remains markedly below the 10th percentile for CHH standards; her height at age 3 years 4 months is 66 cm.

Four percent of human severe combined immunodeficiency cases are caused by a deficiency of the enzyme purine nucleoside phosphorylase (PNP). In this study we investigated the molecular basis for this rare autosomal recessive disease. Sequence analyses led to the identification of two new mutations in the PNP gene: an A to G transition in exon 5, which leads to the substitution of tyrosine 192 by a cysteine residue, and a 1-bp deletion in exon 6, which causes premature translation termination of the PNP protein. Both PNP mutations affect predicted major structural motifs of the protein and result in posttranslational instability of the enzyme.

There is increasing evidence that haemopoietic growth factors are effective in reversal of neutropenia associated with large granular lymphocytes (LGLs) proliferation. A 19-year-old woman with CD3(+)/TCR gamma delta(+), CD4(-), CD8(-) LGL proliferation and severe neutropenia repeatedly developed blood eosinophilia, fever and dyspnoea after administration of GM-CSF. Acute eosinophilic pneumonia with a lobar lung infiltrate pleural effusion, and marked bronchoalveolar lavage fluid eosinophilia was diagnosed. Treatment with corticosteroids and discontinuation of GM-CSF lead to rapid improvement. In addition, haematological analysis revealed that H*1 Technicon, a widely-used automated cell counter, may misinterpret eosinophils erroneously as neutrophils, therefore examination of blood smears to prevent eosinophil-mediated toxicity during GMCSF treatment is recommended.

A male infant with primary combined immunodeficiency, microcephaly with marked cerebellar hypoplasia, and growth failure of prenatal onset is presented. He developed progressive pancytopenia in the 3rd year of life and died at 42 months from disseminated aspergillosis. Laboratory studies and post mortem examination failed to reveal any known aetiology for his disorder. Hreidarsson et al. [3] previously described a syndrome of progressive pancytopenia with microcephaly, cerebellar hypoplasia and growth failure in three boys, with similar clinical and laboratory findings. Although extensive immunological investigations were not performed in those previous patients, recurrent infections in two of them are suggestive of immunodeficiency. In the light of the immunological findings in our patient, we propose that the condition of the four patients belongs to the same syndrome, which has to be considered as a primary combined immunodeficiency syndrome. This syndrome can be distinguished from the other known immunodeficiency syndromes by its associated characteristic features, namely microcephaly with cerebellar hypoplasia, growth failure of prenatal onset and progressive pancytopenia.

We report a patient with a clinical picture consisting of small birth weight, connatal hypoplastic anaemia, vacuolised bone marrow precursors, failure to thrive, and, subsequently, by insulin-dependent diabetes, renal Fanconi syndrome, lactic acidosis, complex organic aciduria, and elevation of haemoglobin F and of adenosine deaminase activity. The clinical course was progressive and death occurred at age 19 months. A high proportion of mitochondrial (mt) DNA molecules with a deletion of nucleotides 9238 to 15575 were identified in several tissues; about half of the shortened mtDNA molecules were concatenated to form circular dimers. The clinical and laboratory findings support recent conclusions that Pearson syndrome is not confined to bone marrow and pancreas, as originally described, but is a multi-organ disorder associated with deletions in part of the mtDNA molecules. The tissue distribution and the relative proportions of the abnormal mtDNA molecules apparently determine the phenotype and clinical course.

Severe thrombopenia of the newborn involves appreciable morbidity and mortality. Effective treatment exists for all forms of neonatal thrombopenia. Swiftest possible correction of thrombopenia must be the prime aim of all measures. Delaying of effective treatment due to workup must be avoided. If there is suspicion of nAIT, effective results have been achieved with transfusion of irradiated and washed maternal thrombocytes, and with immunoglobulin therapy in the case of suspected thrombopenia due to maternal autoantibodies (ITP or SLE). Transfusion of unselected thrombocytes is the therapy of choice in non-immune thrombopenia, and in immune thrombopenias it serves as an emergency measure if there is a high bleeding risk.

Alloimmune thrombocytopenia (AIT) in fetuses and newborn, a disease resembling Rh incompatibility, is caused by transplacental transfer of an IgG-class antibody against fetal platelets. In humans five different platelet antigen systems are so far known which lead to AIT. The disease occurs in 1:2000-1:5000 deliveries. In contrast to Rh disease, immunization occurs in the first pregnancy in the majoritiy of cases. The main significance of AIT lies in the occurrence of fetal (-10%) and neonatal (20%) intracranial hemorrhage. Newborns are treated with compatible platelets, if necessary in combination with immunoglobulins. The high rate of fetal intracranial hemorrhage justifies therapy during pregnancy as well. Antenatal measures include treatment of the mother with high-dose immunoglobulin, treatment of the fetus with immunoglobulin by cordocentesis, and fetal platelet transfusions. However, all therapeutic measures involving the fetus remain in the experimental stage at present. International cooperative studies are necessary to evaluate cost-benefit of intervention during pregnancy.

Severe thrombopenia of the newborn involves appreciable morbidity and mortality. Effective treatment exists for all forms of neonatal thrombopenia. Swiftest possible correction of thrombopenia must be the prime aim of all measures. Delaying of effective treatment due to workup must be avoided. If there is suspicion of nAIT, effective results have been achieved with transfusion of irradiated and washed maternal thrombocytes, and with immunoglobulin therapy in the case of suspected thrombopenia due to maternal autoantibodies (ITP or SLE). Transfusion of unselected thrombocytes is the therapy of choice in non-immune thrombopenia, and in immune thrombopenias it serves as an emergency measure if there is a high bleeding risk.

Alloimmune thrombocytopenia (AIT) in fetuses and newborn, a disease resembling Rh incompatibility, is caused by transplacental transfer of an IgG-class antibody against fetal platelets. In humans five different platelet antigen systems are so far known which lead to AIT. The disease occurs in 1:2000-1:5000 deliveries. In contrast to Rh disease, immunization occurs in the first pregnancy in the majority of cases. The main significance of AIT lies in the occurrence of fetal (-10%) and neonatal (-20%) intracranial hemorrhage. Newborns are treated with compatible platelets, if necessary in combination with immunoglobulins. The high rate of fetal intracranial hemorrhage justifies therapy during pregnancy as well. Antenatal measures include treatment of the mother with high-dose immunoglobulin, treatment of the fetus with immunoglobulin by cordocentesis, and fetal platelet transfusions. However, all therapeutic measures involving the fetus remain in the experimental stage at present. International cooperative studies are necessary to evaluate cost-benefit of intervention during pregnancy.

Synthesis of human haemoglobin is directed by α-, β-, δ-, Glyγ- and Alaγ-genes. The switch from fetal to adult erythropoiesis includes a genetically controlled suppression of the γ- and activation of the β- and δ-chain synthesis. The two γ-genes are not equally inactivated. In animals external influences on the switch could be demonstrated, but no influence of extrauterine (EU) life on the switch in human newborns could be clearly demonstrated. The long half life of red cells hampers the detection of subtle influences on the switch by comparing the concentrations of HbA, HbF and HbA2. We studied therefor the de-novo synthesis of α-, β-, Alaγ- and Glyγ chains by measuring the incorporation of 3H-Leuctne into reticulocytes and subsequent separation of the globin chains by HPLC. 228 single measurements were obtained from 88 newborns (gestational age 26.3 to 42.1 weeks) at the age of 0 to 116 days; 16 babies were studied longitudinally. The results show that the switch γ→β is governed by the biological age (BA = intrauterine + EU age). A significant acceleration of the switch by EU life could be demonstrated: 1. The BA when 16 babies reached 50% (33%) of the full switch was not constant but correlated with GA: p<0.01 (p<0.05). 2. When 31 babies were studied at a BA of 40 to 43 weeks, a significant (p<0.02) acceleration of the switch was found in those with an EU age of 6 to 7 weeks (47%±21%, n=14) when compared to babies of 1 week ,or less of EU age (37%±25%, n=14). No comparable changes of the Alaγ/Glyγ-pattern was observed during the observation time of 26 to 43 weeks. Conclusion: γ→β-switch is accelerated by factors of EU life.Inactivation pattern of Alaγ/Glyγ is not concerted with the γ→β-switch.

Vitamin E deficiency [VED] in exocrine pancreatic insufficiency [EPI] and cholestatic liver disease [CLD] is well documented. In the clinical management of CF patients, high dose oral dl-α-T acetate supplements [α-TS] are routinely used. Yet, no data have been available concerning the need and effectiveness of these supplements. In 52 CF patients (0.8-27.6 yrs), we investigated the significance of oral α-TS and the contribution of EPI (72 hr fecal fat, coefficient of fat absorption, absorbed fat [AF]), associated CLD (sonography, yGT, AP, serum bile acids) and nutritional status (weight, upper arm circumference [UAC], skinfolds) on α-T status. Fat malabsorption [FMA] was found in 48, CLD in 10, poor fat intake in 28, and malnutrition [UAC] in 9 patients. VED defined by plasma-α-T (1), RBC-α-T (2), and plasma-α-T/cholesterol (3) below the cutoff was found in 45% (1), 17% (2), 42% (3) of group A (50-600 mg/d α-TS, n=36) and 87%, 50%, 71% of group B (no α-TS, n=16), resp. 19%. 83%, 58% of group A had normal α-T, as did 13%, 50%, 29% of group B. There was no correlation between α-T and the total daily dose. α-T of 9 matched pairs (daily α-TS, degree of FMA) with and without CLD, revealed no significant difference. En patients with CLD, a multiplicative relationship (y=axb) between plasma-α-T/cholesterol and γGT was found (slope sign, at p=0.004). No regression model could be fitted for α-T depending on AF. In 2 out of 4 patients with corrected FMA, α-T deficiency was still present. In CF patients, high dose oral α-TS do not protect against α-T deficiency and do not correlate with α-T status. The prevalence of α-T deficiency varies markedly depending on the parameters used to evaluate α-T status. Indication and effectiveness of α-TS in CF patients should be documented. Special attention has to be paid to concomitant factors such as uncorrected FMA and CLD.