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Serum levels of interferon (IFN)-gamma, cytotoxic factor (CF) and soluble interleukin-2 receptor (sIL2R) were assayed in relation to hyperferritinemia in eleven cases of malignant histiocytosis (MH), seven of virus-associated hemophagocytic syndrome (VAHS) and one of familial erythrophagocytic lymphohistiocytosis (FEL). IFN-gamma was markedly elevated (>10,000 U/ml) in 5 MH cases and only in one case of VAHS. CF was significantly elevated (> 150 U/ml) in 5 MH and 4 VAHS/FEL patients. sIL2R were remarkably elevated (> 10,000 U/ml) in 5 MH and 4 VAHS patients. In individual cases, the patterns of these parameters were quite different, suggesting the existence of a variable pathophysiology in cases with hemophagocytic syndromes. In terms of the patients' outcome, high IFN-gamma or sIL2R levels were associated with a poor prognosis while high CF appeared to be associated with a better prognosis.

Background and Objectives Epstein-Barr virus (EBV) is etiologically associated with various hematologic disorders, including primary acute infectious mononucleosis (IM), hemophagocytic lymphohistiocytosis (EBV-HLH), chronic active EBV infection (CAEBV) and malignant lymphomas. Although cytokines play a central role in EBV-related immune responses, the exact mechanisms causing different clinical responses remain unclear. In this study, the pattern of cytokine gene polymorphisms was comparatively analyzed in EBV-related diseases. Design and Methods Eighty-nine patients with EBV-related disease were analyzed; 30 with IM, 28 with EBV-HLH and 31 with CAEBV. Eighty-one EBV-seropositive healthy adults were also used as controls. Associations with polymorphisms of various cytokines, including interleukin (IL)-1α and IL-1β were evaluated. The gene polymorphisms were typed by polymerase chain reaction with sequence-specific primers. Results A significant difference of polymorphisms was found for transforming growth factor (TGF)-β1; the frequency of TGF-β1 codon 10 C allele was significantly higher in patients with EBV-related diseases than in controls ( p

To determine useful prognostic factors in treating childhood acute lymphoblastic leukemia (ALL), we correlated conventional risk factors and bone marrow response 14 days after induction chemotherapy. Our study included 116 precursor B-cell (n = 104) and T-cell (n = 12) ALL patients treated with our protocol between 1988 and 1999. The patients were classified into 3 initial risk groups on the basis of conventional risk factors (56 in the low-risk, 33 in the high-risk, and 27 in the very high-risk groups). All patients received similar systemic chemotherapy regimens before the evaluation of their bone marrow on day 14. We evaluated the marrow of 69 patients as M1 (less than 5% blasts), 25 as M2 (5%-25% blasts), and 22 as M3 (more than 25% blasts). Although all patients attained an initial complete remission (CR), relapse was noted in 33 of the 116 patients, and 15 patients died. All of the M1 marrow patients, irrespective of the initial risk group, showed the best event-free survival rate (85.1% +/- 3 4.4%), the lowest relapse rate (14.5%), and the highest attainment of a second CR (100%); they were defined as the new R1 prognostic group. The low-risk patients with M2 or M3 marrow (R2 group) had a relatively high relapse rate, but all of these relapsed patients were treated successfully with subsequent therapy. High- or very high-risk patients with M2 or M3 marrow (R3 group) had the worst prognosis. Our new prognostic definition (R1, R2, R3) incorporating day 14 marrow findings is useful to tailor early-phase treatments for better therapeutic results in childhood ALL.

Hemoglobin (Hb) Bristol-Alesha is caused by a GTG --ATG mutation at codon 67 in the Hb beta chain, resulting in abnormal beta globin chains with mutated molecules from normal beta67 valine (Val) to beta67 methionine (Met) or beta67 aspartate (Asp). We describe a Japanese child with this rare hemoglobinopathy and a very unstable Hb molecule phenotype. The diagnosis of hemolytic anemia was made when the patient was 6 months of age. Development of marked splenomegaly necessitated red blood cell transfusions twice a month. After splenectomy when the patient was 4 years of age, laboratory findings of hemolytic anemia became more prominent. Specific abnormal Hb molecules initially were not detected, and the alpha/beta globin synthesis ratio was abnormal at 2.22. After splenectomy, we identified the presence of abnormal beta-globin chains with a beta67Val:beta67Met:beta67Asp molecule ratio of 74:11:15. We speculate that the high fraction of the beta67Met molecule in this patient, compared with that in previously reported cases, caused extreme Hb instability, which resulted in thalassemic hyperunstable hemoglobinopathy and very severe clinical findings.

Of the several kinds of therapy-related leukemia, therapy-related acute promyelocytic leukemia (t-APL) is most closely associated with topoisomerase II inhibitor administration for treatment of malignancies in adults. Although rare in children, the majority of therapy-related malignancies have been etoposide-related APL associated with Langerhans cell histiocytosis. The authors describe the development of t-APL after chemotherapy administered for non-Hodgkin's lymphoma (NHL) in an 8-year-old girl. One month after cessation of the 3-year chemotherapy regimen of doxorubicin and other agents but not etoposide or radiotherapy, the patient was diagnosed with t-APL with positive PML-RARA molecular abnormality. The patient attained a complete remission following treatment with all-trans retinoic acid-containing chemotherapy. Thereafter, she successfully received hematopoietic stem cell transplantation from an HLA-matched sibling donor. Development of t-APL associated with NHL in children appears to be rare.

We report the case of a 3-year-old Japanese boy with phosphoglycerate kinase 1 (PGK1) deficiency (Online Mendelian Inheritance in Man entry 311800). The patient had anaemia and jaundice at birth, necessitating exchange transfusions for 2 d. After one red blood cell transfusion at age 2 months, his Hb level was 8-9 g/dl, his reticulocyte counts were 300-500 x 109/l, and his total bilirubin level was 25.65-42.75 micro mol/l. The patient suffered two episodes of respiratory infection-associated haemolytic crisis and rhabdomyolysis during early infancy. At age 3.0 years, his developmental milestones (developmental quotients measured using the Tsumori-Inage methods) score was 49% (normal 74-131%), and his height was below average by -2.0 standard deviations. The diagnosis of PGK1 deficiency was made based on his remarkably low ( C) PGK1 gene mutation. This mutation results in the Ala-353Pro amino acid substitution, which has been designated PGK Kyoto. The patient developed the full clinical symptoms of PGK1 deficiency including haemolytic anaemia, myopathy, central nervous system disorder and growth retardation, which is unusual.

A rare association of Epstein-Barr virus-associated T- and B-lymphoproliferative disease (EBV(+) T- and EBV(+) B-LPD) in a patient with WHIM (warts, hypogammaglobulinemia, infections, and myelokathexis) syndrome is reported. A 26-year-old Japanese female, who had been treated for WHIM syndrome since early childhood, developed hemophagocytic syndrome associated with EBV(+) T-LPD at the lymph nodes and spleen. The disease rapidly resolved in response to prednisolone therapy. However, 6 weeks later, fatal EBV(+) B lymphoma unresponsive to chemotherapy occurred in the intestine and other organs. Caution must be exercised that the patient with WHIM syndrome may be at risk for EBV-LPD.

While studying Ikaros proteins in childhood acute myeloid leukemia (AML), Ikaros isoform 6 (Ik6) expression was detected in 7 of 10 cases of M4 and M5 leukemia, but in none of the remaining French-American-British subtypes (M2, 8 cases; M7, 6 cases). The spliced Ikaros isoforms 4 to 8 (Ik4-8) suppress the function of full-length Ik1 or Ik2 in a dominant-negative manner, owing to their reduced numbers of DNA binding sites. Thus, dominant-negative Ikaros isoforms may inhibit the normal transcriptional regulation of hematopoietic cell development. To clarify the function of Ik6 in developing blood cells, this isoform was transiently transfected into an Ik2+, interleukin-3 (IL-3)–dependent 32D murine myeloid precursor cell line and studied the expression of Bcl-2 family proteins in relation to in vitro cell growth, using a tetracycline-inducible TREx system. The possibility of aberrant cell regulation due to Ikaros functional changes was examined by cotransfecting both Ik2 and Ik6 into Ikaros/Aiolos/Helios triple-negative Cos-7 cells. The results demonstrated IL-3–independent growth by Ik6-transfected 32D clones coincident with up-regulation of the antiapoptotic protein Bcl-XL. Up-regulation of Bcl-XL, but not of other Bcl-2 family proteins, was associated with the suppression of functional Ik2 by Ik6 in a dominant-negative fashion. Thus, the pathogenesis of myelomonocytic/monocytic AML may involve aberrant regulation of apoptosis due to unscheduled expression of the Ik6 isoform.

Two cases of cytomegalovirus (CMV) retinitis following bone marrow transplantation (BMT) from unrelated donors are reported. 1 patient had been treated for severe aplastic anemia (SAA) and the other for hypoplastic myelodysplastic syndrome (MDS). Because first line therapy with antithymocyte globulin (ATG) and cyclosporin A (CsA) had failed, BMT was performed following a conditioning regimen of ATG, cyclophosphamide, and total lymphoid irradiation. Treatment for CMV retinitis was successfully carried out with gancyclovir (systemic and intraocular injection), foscarnet, and photocoagulation (Case 1) and gancyclovir and foscarnet (Case 2). Both patients also developed Epstein-Barr virus-associated lymphoproliferative disease (EBV-LPD). We compared these 2 cases with 14 SAA patients who did not develop CMV retinitis after BMT using marrow from either HLA-identical siblings (n = 9) or from unrelated donors (n = 5). Unlike the retinitis patients, the latter 5 patients received ATG only once. The retinitis patients had significantly lower CD4+ T-cell levels in their peripheral blood than the 14 patients who did not develop CMV retinitis. We believe that repeated treatment with ATG and transplantation from unrelated donors may lead to immune dysfunction that could increase the likelihood of CMV retinitis, as well as LPD. For such BMT patients, regular ophthalmic examinations and careful testing for CMV antigenemia are recommended.

The pathogenesis of haemophagocytic lymphohistiocytosis (HLH) in children without a known familial pattern of inheritance is often difficult to establish. Splenic enlargement, one of the main clinical findings in this disorder, has led to the use of splenectomy for uncontrollable coagulopathy, persistent cytopenia or both. This procedure is also thought to be a useful tool in making a differential diagnosis in cases of the immunochemotherapy-resistant HLH. We report here five cases of splenectomized childhood HLH, in which subsets of mononuclear spleen cells were analysed either by flow cytometry or immunohistochemistry, and the results were compared with those from cases of hereditary spherocytosis (controls). There was a statistically significant depletion of CD19+ B cells in the HLH cases (3.8 ± 3.2% vs. 52.6 ± 4.5%, P

FK506-related leukoencephalopathy has been reported to be reversible and readily treated by discontinuation or reduction of FK506. We describe two pediatric cases of FK506-related leukoencephalopathy following allogeneic bone marrow transplantation, which could not be readily controlled. These cases show that FK506-related leukoencephalopathy is not always reversible, and patients may develop epilepsy. Bone Marrow Transplantation (2000) 25, 331-334.

Latent membrane protein 1 (LMP1) of Epstein-Barr virus (EBV) is considered to be an oncoprotein because it is crucial for B-lymphocyte transformation. Since a 30 base pair (bp) deletion in the carboxy-terminal portion of the LMP1 gene was found in a CAO cell line derived from nasopharyngeal carcinoma containing EBV, an association between EB viral genetic alteration and tumorigenicity has been postulated. In this study we have analyzed LMP1 DNA isolated from 10 Japanese patients with EBV-associated hemophagocytic lymphohistiocytosis (EBV-HLH). In all HLH patients, we found the 30 bp deletion and 4-8-tandem repeats of the sequence DNGPQDPDNTD in the LMP1 gene. Furthermore, detailed amino acid (aa) sequence analysis revealed that 7 aa substitutions identical to those found in CAO-LMP1 but not in B95.8 cell line-LMP1 were found in all the HLH cases. NF-kappaB assay revealed that HLH-LMP1 activated NF-kappaB significantly more than that of B95.8-LMP1 (p=0.032). We conclude that EBV from all of our HLH cases shared common genetic characteristics with EBV obtained from the CAO cell line, which is distinct from the wild-type EBV isolated from the B95.8 cell line. These data suggest that the mutational changes of the LMP1 gene may play an important role in the pathogenesis of these fatal EBV-related disorders.

The current status of hemophagocytic lymphohistiocytosis (HLH) in infants and children has been studied.Eighty-two cases of pediatric HLH, for which there was no confirmed familial inheritance, were comparatively studied between 36 patients less than 2 years of age and 46 patients more than 2 years of age.In all cases, persistent fever, cytopenia, liver dysfunction, and hepatosplenomegaly were the most frequently noted symptoms. Hyperferritinemia (1000 micrograms/L) and elevated blood levels of lactate dehydrogenase (1000 IU/L) were observed in 90% and 89.7%, respectively. These figures were considerably higher than for either hypertriglyceridemia (2 mmol/L) (50%) or hypofibrinogenemia (1.5 gm/L) (57.4%), indicating that increased serum ferritin and lactate dehydrogenase concentrations might be good diagnostic parameters for HLH. These parameters are nonspecific but are of follow-up and prognostic value in these HLH cases. No differences were found in clinical signs and symptoms or other laboratory findings for the two age groups. Immunochemotherapy was administered in the similar regimens to patients in both groups. Of the 82 patients, 13 (15.9%) succumbed to a fatal course within 2 months after diagnosis, and Kaplan-Meir analysis for all cases predicted the overall disease-free patient survival at 4 years from the onset of disease to be 57.2% (95% confidence interval (CI), 45.1% to 69.3%). There was a slightly, but not statistically significant, poorer prognosis for the younger patients: 44.2% (95% CI, 26.0% to 62.4%) survival for the infant group versus 67.2% (95% CI, 51.8% to 82.6%) survival for the older group (p = 0.0569).Refinement of the treatment is mandatory to improve the outcome of HLH in both infants and older pediatric patients.

Clinical features in patients with haemophagocytic lymphohistiocytosis (HLH) have been demonstrated to be characterized by hypercytokinaemia. Previously, we reported the impact of high serum levels of interferon (IFN)-gamma and soluble IL-2 receptor (sIL-2R) on patient outcome; however, it was not known if serum levels of interleukin (IL)-6 also could be a prognostic factor. In a study during the active phase of disease in 25 cases of HLH in children and young adults (median age 3 years, range 0.1-23 years), we noted 12 cases which showed serum IL-6100 (normal4.0) pg/ml. Five of these cases showed hyper-IL-6-naemia alone without hyper-IFN-gamma-naemia (group A) whereas seven cases showed both hyper-IL-6- and IFN-gamma-naemia (group B). Patient outcome did not differ between the patients with IL-6100 pg/ml and those with IL-6100 pg/ml, suggesting that high serum concentrations of IL-6 alone do not necessarily indicate poor prognosis in patients with HLH. Among the cases with hyper-IL-6-naemia (100 pg/ml), underlying disorders causing haemophagocytosis were found to be different between groups A and B.

BACKGROUND Previous reports suggesting a correlation between lymphoproliferative disease and serum levels of beta-2-microglobulin (beta-2M) and in vitro data indicating a role of cytokines in the production of beta-2M prompted a study of serum and urine beta-2M concentration in patients with hemophagocytic syndrome (HPS), because no data were previously available for HPS, a pathologic state associated with excessive cytokines secreted from activated reactive/malignant lymphocytes and histiocytes. METHODS Serum and urine beta-2M levels were measured in six children with HPS during active and convalescent phase and in other diseases. RESULTS Serum and urine beta-2M levels during active phase HPS were significantly high not only in serum (median, 7.5 mg/l; range, 2.3-16.0 mg/l; P 31,650 micrograms/gram Creatinine (gCr); range, 8179-236,333 micrograms/gCr; P < 0.01), compared with levels during convalescent phase HPS (median, 2.0 mg/l; range, 0.9-2.5 mg/l in serum and median, 338 micrograms/gCr; range, 223-585 micrograms/gCr in urine) and in control subjects with diseases such as acute lymphocytic leukemia (median, 2.3 mg/l; range, 1.0-2.8 mg/l in serum and median, 327 micrograms/gCr; range, 48-2684 micrograms/gCr in urine), infectious mononucleosis (median, 2.9 mg/l; range, 2.5-5.5 mg/l in serum and median, 348 micrograms/gCr; range, 80-1325 micrograms/gCr in urine), and Kawasaki disease (median, 2.8 mg/l; range, 1.5-3.3 mg/l in serum and median, 1016 micrograms/gCr; range, 214-4500 micrograms/gCr in urine). Noteworthy was the observation that urine beta-2M levels correlated closely with HPS disease activity. CONCLUSIONS Urine beta-2M appears to be a useful marker for assessing disease activity in patients with HPS.

An 11-year-old girl presented with fever and a large cervical lymphadenopathy. Indicators of inflammation were remarkable: she had extremely high levels of serum interleukin-6 (IL-6) (398 pg/ml) in addition to hypergammaglobulinemia and hypoalbuminemia. Computed tomography (CT) revealed swollen systemic lymph nodes. Two weeks after the onset of symptoms she developed polyarthralgia. Biopsy of the cervical lymph node revealed massive infiltration of plasma cells without hyaline vascular changes. She was diagnosed with systemic juvenile idiopathic arthritis (JIA). The patient's symptoms and hypercytokinemia disappeared soon after corticosteroid treatment was started. This case demonstrates that overproduction of IL-6 is common to systemic JIA and multicentric Castleman's disease.

A 6-month-old boy with familial erythrophagocytic lymphohistiocytosis (FEL) received allogeneic bone marrow transplantation (BMT) from an HLA-identical brother, after first achieving remission with Etoposide (VP16) and prednisone. The conditioning regimen for BMT consisted of high dose busulfan (16 mg/kg), cyclophosphamide (120 mg/kg), high dose VP16 (60 mg/kg) and intrathecal methotrexate and was well tolerated. Engraftment was achieved, and grade II GVHD was controlled with prednisone. Impaired NK activity present on admission gradually improved after BMT. The patient continues to be in complete remission more than 10 months after BMT.

A 28-month-old girl with acute lymphoblastic leukemia (ALL) showing a t(4;11)(q21;q23) karyotype successfully underwent allogeneic bone marrow transplantation (BMT) at relapse. The chimeric MLL-AF4 message on her bone marrow (BM) specimens, examined by reverse transcriptase-polymerase chain reaction, was detectable at diagnosis, relapse, and just before BMT but became undetectable following BMT. She has since maintained complete remission. This observation suggests that detection of the chimeric message in BM may be useful to predict clinical outcome in patients with t(4;11) ALL.

Fourteen patients with stage III–IV neuroblastoma were treated with alternating combination chemotherapy consisting of (a) VP16/cisplatin and (b) doxorubicin/vincristine/cyclophosphamide. The initial response to induction chemotherapy, especially to VP16/cisplatin was evaluated by determining t 1/2 for urinary vanillylmandelic acid (VMA), homovanillic acid and serum neuron specific enolase (NSE). The period prior to normalization of these parameters was also determined. The patients could be classified as 7 rapid responders, with less than 3 weeks oft 1/2 VMA, or t 1/2 NSE, and 7 slow responders longer than 4 weeks of t 1/2 VMA. An analysis of the data indicates that an initial rapid response correlated with subsequent high complete response rate, but did not necessarily predict better prognosis in these patients.

A 10-month-old male infant underwent splenectomy because of life-threatening hypersplenism due to malignant histiocytosis. The spleen tissue positive for herpes simplex virus (HSV)-DNA, histologically and immunologically revealed a marked B cell depletion replaced by proliferation of activated cytotoxic T cells. S100-positive histiomonocytoid cells and lysozyme-positive hemophagocytes were also significantly increased. No metaphases were obtained by cytogenetic studies and Southern blot analysis of spleen cell DNA demonstrated only germ bands of immunoglobulin and both T gamma and beta genes, providing no evidence of monoclonality in this case of so-called malignant histiocytosis.

The prognosis of patients with acute lymphoblastic leukemia (ALL) and central nervous system (CNS) relapse has historically been very poor. Although chemo-radiotherapy has improved outcomes, some patients still have a poor prognosis after CNS relapse. Therefore, allogeneic hematopoietic stem cell transplantation (allo-SCT) has recently become an option for treatment of CNS leukemia; however, information, particularly on the long-term outcome of transplant recipients, is limited. We performed allo-SCT in eight pediatric patients with ALL (n=7) or T-cell type non-Hodgkin's lymphoma (n=1), who had isolated CNS relapse. All patients survived for a median of 70.5 (range, 13-153) months after SCT. Sequelae developed late in some patients: mental retardation (IQ=47) in one patient, severe alopecia in two patients, limited chronic graft-versus-host-disease in three patients, and amenorrhea and/or hypothyroidism in three patients. Except for a pre-school child with post transplant CNS relapse, six out of seven patients show normal school/social performance. Our results clearly indicate a high cure rate of isolated CNS relapse by allo-SCT in pediatric lymphoid malignancies; however, there needs to be further studies to determine which are the appropriate candidates for transplantation and what is the best transplant regimen to achieve high cure rate and maintain good quality of life.

We report here the first case with Diamond-Blackfan anemia (DBA) who responded to rituximab. The patient is an 8-yr-old Japanese girl with refractory DBA accompanied by complex congenital heart disease. She received two doses of rituximab, 375 mg/m(2)/wk. She became transfusion independent 6 months after the treatment without any serious side effect. However, after 8 months of transfusion-free period, her condition returned to the pretreatment level with recovery of peripheral B cells. Rituximab may be a successful therapy for refractory DBA where B cells play a crucial role in the pathogenesis of the severe anemia.

Secondary lymphoid malignancy, particularly acute lymphoblastic leukemia (ALL), is rare. We report one case of ALL and another case of mediastinal lymphoblastic lymphoma developed after treatment for neuroblastoma. The secondary ALL characterized by short latency period and an 11q23 translocation apparently was induced by etoposide treatment. The pathogenesis of the secondary lymphoma is less certain and may be related to previous treatment with cyclophosphamide and radiotherapy, host susceptibility, or chance occurrence. One child died of progressive lymphoma and the other remains in remission 1 year following allogeneic bone marrow transplantation. Additional studies are needed to determine the risk, pathogenesis, and optimal treatment for secondary lymphoid malignancy.

Based on recent fetomaternal microchimerism/tolerance theory, two children with acute lymphoblastic leukemia underwent non-T-cell-depleted hematopoietic stem cell transplants (SCT) from haploidentical HLA 2 loci-mismatched family donors (one from a sibling, one from the mother). Engraftment was achieved in two patients. In two recipients, acute graft-versus-host disease was limited to grade II or less, and no chronic graft-versus-host disease developed. Both of these patients have maintained complete remission for more than 8 months post-SCT. Non-T-cell-depleted SCT from haploidentical HLA 2 loci-mismatched family donors seems feasible if microchimerism is detectable.

The glutathione-S-transferase (GST) polymorphism may affect the outcome of treatment of leukemia because GSTs play an important role in detoxifying the chemotherapeutic agents used to kill leukemia cells. However, results of previous reports have been controversial. This study was undertaken to clarify the influence of GST polymorphism on the outcome of childhood B-precursor acute lymphoblastic leukemia (ALL).Eighty-two patients with childhood B-precursor ALL treated during 1988-1999 with our ALL protocol (median follow-up time 89.5 months, range 31 -169 months) were examined for GST gene patterns. The effect of GSTM1 and GSTT1 deletion genotypes on the clinical features and therapeutic results was analyzed.All patients attained complete remission but 12 had an early relapse (within 30 months of the initiation of treatment). In univariate analysis, early relapse of ALL was correlated significantly with the presence of the t(9;22)(q34;q11) cytogenetic abnormality (p=0.0003), high white blood cell counts (p=0.015) and double null genotype (p=0.027). Multivariate analysis revealed that the GST double null genotype was the only significant independent predictor of early relapse (p=0.018).The simultaneous deletion of both the GSTM1 and GSTT1 genes is more predictive than any other parameter of early relapse of childhood B-precursor ALL.

We report the case of a 3-year-old Japanese boy with phosphoglycerate kinase 1 (PGK1) deficiency (Online Mendelian Inheritance in Man entry 311800). The patient had anaemia and jaundice at birth, necessitating exchange transfusions for 2 d. After one red blood cell transfusion at age 2 months, his Hb level was 8-9 g/dl, his reticulocyte counts were 300-500 x 109/l, and his total bilirubin level was 25.65-42.75 micro mol/l. The patient suffered two episodes of respiratory infection-associated haemolytic crisis and rhabdomyolysis during early infancy. At age 3.0 years, his developmental milestones (developmental quotients measured using the Tsumori-Inage methods) score was 49% (normal 74-131%), and his height was below average by -2.0 standard deviations. The diagnosis of PGK1 deficiency was made based on his remarkably low (10% of normal) erythrocyte PGK enzyme activity level and the identification of a novel missense (1060G--C) PGK1 gene mutation. This mutation results in the Ala-353Pro amino acid substitution, which has been designated PGK Kyoto. The patient developed the full clinical symptoms of PGK1 deficiency including haemolytic anaemia, myopathy, central nervous system disorder and growth retardation, which is unusual.

The therapeutic results of allogeneic bone marrow transplantation (BMT), following a conditioning regimen of total body irradiation and busulphan and melphalan administration, were evaluated in 20 pediatric patients with high-risk leukemia or lymphoma. Twelve patients received BMT from HLA-matched related (MR) donors while eight received transplants from mismatched related or unrelated (MisR/UR) donors. The post-BMT five-year survival rates were much better for patients in the MR donor group (p = 0.0008). The outcomes of patients in the MisR/UR donor group were significantly worse. This was not due to disease recurrence, but to a high incidence of fatal post-transplant infections (p = 0.004). Nine out of twelve patients who received transplants from MR donors have remained in complete remission for a median of 57 (range 27-78) months. These results suggest that this conditioning regimen has a significant anti-neoplastic benefit useful for the preparation of pediatric patients receiving transplants from MR donors; however, refinement is essential before it can be used in patients receiving transplants from MisR/UR donors.

An attractive hypothesis is that in utero exposure of hematopoietic cells to oncogenic agents can induce molecular changes leading to overt acute lymphoblastic leukemia (ALL) in infants and perhaps older children as well. Although supported by studies of identical infant twins with concordant leukemia, and of nontwined patients withMLL gene rearrangements, this concept has not been extended to the larger population of B-lineage ALL patients who lack unique nonconstitutive mutations or abnormally rearranged genes. We therefore sought to demonstrate a prenatal origin for 7 cases of B-cell precursor ALL (either CD10+ or CD10−) that had been diagnosed in infants and children 14 days to 9 years of age. Using a polymerase chain reaction–based assay, we identified the same clonotypic immunoglobulin heavy-chain complementarity determining region or T-cell receptor VD2-DD3 sequences in the neonatal blood spots (Guthrie card) and leukemic cell DNAs of 2 infants with CD10− ALL and 2 of the 5 older patients with CD10+ ALL. Nucleotide sequencing showed a paucity of N or P regions and shortened D germ line and conserved J sequences, indicative of cells arising from fetal hematopoiesis. Our findings strongly suggest a prenatal origin for some cases of B-cell precursor ALL lacking specific clonotypic abnormalities.

Seventeen cases (age at onset, 1 month to 18 years; M/F, 9/8) of hemophagocytic syndrome which received allogeneic hematopoietic stem cell transplantation (SCT) in Japan during the period 1988-1998 are reported. The patients consisted of six familial inheritance-proven erythrophagocytic lymphohistiocytosis (FEL), five familial inheritance-unknown and infective agents-unknown HLH (of which two were highly likely to have been FEL with characteristic CNS signs), and six aggressive Epstein-Barr virus (EBV)-related HLH (of which two were natural killer cell-type large granular leukemia/lymphoma-associated hemophagocytic syndrome, EBV-NK-LGLL-HPS). All cases were treated intensively with immuno-chemotherapy, or with chemotherapy before SCT. As sources of SCT, 12 cases received bone marrow cells (sibling six, father one, URD five), two cord blood, two purified CD34-positive cells, and one PBSC. SCTs were successful in all 17 cases, apart from one receiving CD34-positive SCT. Following SCT, four patients relapsed and five died with a median follow-up of 23 months. Among the relapsed cases, the two EBV-NK-LGLL-HPS previously published as successfully transplanted were included. Among the fatal cases, three patients died from relapsed active disease and the remaining two from fatal post-SCT EBV-positive T cell lymphoma and extensive chronic GVHD, respectively. As of the end of September 1998, 10 patients are alive without disease for 3.5 months to 147 months, while two post-SCT patients are still having therapy for residual/recurrent disease. The Kaplan-Meier analysis showed a 2-year event-free survival after SCT as 54.0+/-13.0%.

Summary: We report a 14-year-old boy who had successfully received allogeneic BMT for chronic granulomatous disease and 3 years later was treated with donor lymphocyte infusion (DLI, 3.3 〈 10 8 cells/kg) at unstable mixed chimerism in association with reduced neutrophil function. Following DLI, the patient developed transient acute hepatic GVHD, which was confirmed by liver biopsy and was manageable with cyclosporin A and prednisolone. The patient eventually attained complete chimerism with improved neutrophil function. At the time of writing (2.5 years from the DLI), the patient is doing well, free from infectious episodes and chronic GVHD. Our experience suggests that DLI could be a safe and effective strategy for dissolution of unstable mixed chimerism in BMT recipients for inherited disorders.

A 2-year-old girl with acute lymphoblastic leukemia (ALL) showing a t(4;11)(q21;q23) karyotype underwent allogeneic bone marrow transplantation (BMT) with the conditioning regimen of L-PAM (70 mg/m2/d for 3 days), busulfan (140 mg/m2/d for 2 days), and total body irradiation (12 Gy). On day 57, the patient developed pneumatosis cystoides intestinalis (PCI) when she received cyclosporin A and corticosteroids for graft-versus-host disease (GVHD). Because of the presence of massive abdominal free air and the suspicion of peritonitis, she underwent surgical intervention, which, however, revealed neither intestinal perforation nor peritoneal infection. She recovered from PCI in 10 days with nasogastric suction, fasting, and systemic broad-spectrum antibiotics. PCI with massive abdominal free air after BMT should be manageable by conservative therapy alone.

To evaluate the chimeric status of mononuclear cells in the CSF after allogeneic BMT, cells were analyzed by FISH using satellite DNA probes for human X and Y chromosomes. CSF cells were obtained from five pediatric ALL patients who received BMT from sex-mismatched donors. All patients received TBI-containing conditioning regimens. We found that CSF cells showed complete donor type in 19-97 days after BMT, when complete donor type hematopoiesis was observed. The rapid entry of the donor leukocytes into the brain may exert beneficial effects to eradicate the residual CNS leukemic cells and prevent a CNS relapse in ALL patients after BMT.

A patient with AML (FAB M4Eo) developed EBV-LPD 1.5 months after allogeneic BMT from his one locus-mismatched mother, the diagnosis being confirmed on day +82. Attempts to eradicate the monoclonally proliferating LPD using chemotherapy (VP16/dexamethasone) followed by two doses of EBV-specific CTL and one dose of unstimulated donor leukocytes were not successful. We assume delay of infusions (day +100, +107) and insufficient CTL cell doses (total 9.2 x 10(6)) may have been responsible for the poor outcome in this case.

Summary. Myelodysplasia and acute myeloid leukaemia (MDS/AML) developed in three cases of severe aplastic anaemia (SAA) and one case of congenital neutropenia (CN, Kostmann's disease) who received recombinant human granulocyte colony-stimulating factor (G-CSF) are reported. In these four MDS/AML cases, age at diagnosis of SAA/CN was 0–13 years, the cumulative dose of G-CSF was 98 μg/kg to 10 mg/kg over 1–57 months, and the interval from initiation of G-CSF to MDS/AML was 25, 23, 31 and 57 months, respectively. These results suggest a link between SAA/CN and MDS/AML in relation to G-CSF administration; however, large studies are necessary to determine if such a risk is significant in patients with SAA/CN who are treated with G-CSF.

To clarify the correlation between Epstein-Barr virus (EBV) involvement and hypercytokinaemia in haemophagocytic lymphohistiocytosis (HLH), we analysed serum interferon-gamma levels and EBV-DNA in biological specimens obtained from 25 HLH cases (23 children and two adults). We found that HLH patients showed a wide range of serum IFN-gamma levels from 0.2 to 1300 U/ml, with a median 126 U/ml for EBV-DNA-positive (n = 9) and 4.5 U/ml for EBV-DNA-negative (n = 16) groups. The latter group could be classified further into a group with hyper-IFN-gamma-naemia (> 4.5 U/ml) (n = 8) and a group without hyper-IFN-gamma-naemia (n = 8). The survival of the hyper-IFN-gamma-naemic cases was significantly poorer than non-hyper-IFN-gamma-naemic cases. We conclude that EBV is probably involved in one third of the HLH cases, all of whom show hyper-IFN-gamma-naemia, and in the half of the HLH cases with hyper-IFN-gamma-naemia who have a rapidly fatal outcome.

An adenocarcinoma was found in a choledochal cyst in a 12-year-old girl. This is the youngest patient so far reported with an adenocarcinoma in a choledochal cyst. The cyst consisted of dilatations of the intrahepatic bile ducts and the extrahepatic bile duct. Most of the cyst wall was resected. However, resection of the distal part of the cyst wall in the infrapancreatic region was impossible because of invasion of the portal vein and the inferior vena cava. This patient is now being treated with chemotherapy. We believe that early diagnosis is mandatory, and that total excision of a choledochal cyst is advisably to prevent the development of carcinoma.

A 1-month-old boy with familial erythrophagocytic lymphohistiocytosis (FEL) had a barely detectable natural killer (NK) activity of 0% to 7% (median, 0.5%) with an effector/target ratio of 20:1. The number of Leu7+ and Leu11+ cells was within normal range. In terms of interleukin-2 (IL-2) receptor antigens, IL-2R/p55 (Tac) was marginally expressed whereas IL-2R/p75 related antigen recognized by YTA-1 monoclonal antibody (MAb),i.e., YTA-1 antigen, was moderately expressed on the patient's mononuclear cells. Since the NK activity was restored in vitro by IL-2 stimulation, insufficient in vivo IL-2 production or altered cooperation of IL-2R/p75 and IL-2R/p55 (Tac) in the IL-2 mediated immune response was suspected to be present. The induction of IL-2R/p55 (Tac) in vitro was found to be imparied after stimulation with IL-2, or YTA-1MAb. When the patient attained remission the IL-2R/p55 (Tac) induction had normalized, but low NK activity persisted. The results indicate that the IL-2/IL-2R system may play an important role in the etiology and pathogenesis of FEL.

Bone marrow transplatation for Epstein-Barr virus-related clonal T cell proliferation associated with hemophagocytosis

Although hypercalcemia is a well-recognized complication in malignant disorders, neither the incidence and prognostic significance of hypercalcemia, nor the role of parathormone related peptide (PTHrP) in pediatric acute lymphoblastic leukemia (ALL) have been clarified. Of 83 newly diagnosed pediatric ALL patients with early pre-B cell phenotype treated at our hospital during the last 8 years, four patients were diagnosed as having hypercalcemia (> 14 mg/dl). In these 4 hypercalcemic ALL patients at onset, serum calcium levels ranged from 14.6 to 20.8 mg/dl (normal 7.4-9.0 mg/dl), and serum PTHrP levels were markedly elevated to 112-240 pmol/l (normal range: 17.6-61.2 pmol/l). Unlike patients with ordinary ALL in childhood, gastrointestinal symptoms (nausea, vomiting, abdominal pain) and skeletal symptoms (bone pain, gait disturbance) were the chief complaints. Because of these characteristic symptoms, bone marrow aspiration was carried out in two patients in an attempt to diagnose ALL before leukemic cells appeared in peripheral blood. Serum calcium levels were promptly normalized by induction chemotherapy. The four patients have been in complete remission from 35+ to 125+ months. Based on these results, the incidence of hypercalcemia in pediatric ALL patients with early pre-B cell phenotype at our institute is calculated to be about 4.8%. Gastrointestinal and skeletal problems are the characteristic initial symptoms, and hypercalcemia does not seem to be significant in the prognosis of these patients.