Cerebral toxoplasmosis in an adolescent post allogeneic hematopoietic stem cell transplantation: successful outcome by antiprotozoal chemotherapy and CD4+ T-lymphocyte recovery.

Toxoplasmosis is a rare opportunistic infection in pediatric allogeneic hematopoietic stem cell transplant (allo-HSCT) recipients and associated with severe T-cell deficiency. Here, we report the successful management of cerebral toxoplasmosis in a 15-year-old adolescent 4 months post allo-HSCT for non-Hodgkin lymphoma through rapid invasive diagnostics, long-term antiprotozoal chemotherapy, and an hematopoietic stem cell boost for persistently poor graft function. While supportive care and antiprotozoal chemotherapy achieved stabilization, definite improvement only occurred following recovery of CD4(+) T lymphocytes to >100 cells/µL. At 5 years after the diagnosis of toxoplasmosis, the patient is in continuing remission with normalized clinical and imaging findings.

Sonographic examination of the apophysis of the iliac crest for forensic age estimation in living persons.

The present study examines the applicability of ultrasound diagnostics in assessing the ossification processes of the apophysis of the Crista iliaca of the pelvis for the purposes of forensic age diagnostics in living persons. To this end, the apophyseal ossification stages were determined in 307 female and 309 male study participants aged between 10 and 25 years. In females, ossification stage I was identifiable at an age of 10.1 years at the earliest (x¯=11.8), ossification stage II at 11.2 years at the earliest (x¯=14.6), ossification stage III at 14.7 years at the earliest (x¯ =18.6), and ossification stage IV at 17.9 years at the earliest (x¯=22.7). In males, ossification stage I was observable from an age of 10.0 years (x¯=11.8), ossification stage II from 10.5 years (x¯=14.9), ossification stage III from 15.6 years (x¯=18.9), and ossification stage IV from 17.4 years (x¯=22.6). In forensic age estimation procedures in living persons, sonographic examination of the iliac crest apophysis makes it possible to minimise exposure of the individual to radiation in accordance with the existing legal basis for the use of X-rays on humans. In application areas with no legal basis to justify X-ray examinations, the accuracy of an age diagnosis can be improved by integrating skeletal maturity as a criterion.

Age dependence of epiphyseal ossification of the distal radius in ultrasound diagnostics.

By determining the ossification stage of the distal radial epiphysis, it is possible to gain important information to help clarify the question of whether various legally relevant age limits have been exceeded. Any examination of the hand by means of projection radiography such as that used in conventional skeletal age diagnostics is strictly regulated for reasons of radiation hygiene. In many areas of the law, there are no basic legal provisions authorising the performance of X-ray examinations. The present study examines the applicability of ultrasound diagnostics in assessing ossification processes in the distal radius. To this end, the ossification stages of the distal radial epiphysis were determined in 306 female and 309 male study participants aged between 10 and 25 years. In the female gender, ossification stage III was determined at an age of 13.4 years at the earliest, and ossification stage IV at 15.0 years at the earliest. In the male gender, ossification stage III was not observed until 14.3 years, and ossification stage IV not until 15.2 years. In the practice of forensic age estimation in living persons, sonographic examination of the distal radius in areas of application with no legal basis for authorising X-ray examinations makes it possible to improve the accuracy of age diagnosis by including criteria of skeletal maturation. In view of the existing legislative basis for the use of X-rays on human subjects, the exposure of individuals to radiation can be minimised.

Fatal human metapneumovirus infection following allogeneic hematopoietic stem cell transplantation.

Respiratory viruses are an important yet underestimated cause of infectious morbidity and mortality in immunocompromised children and adolescents. Here, we report the occurrence of fatal lower respiratory tract disease associated with human metapneumovirus (HMPV) infection in a 10-year-old girl with chronic graft-versus-host disease following allogeneic hematopoietic stem cell transplantation (HSCT) for secondary chronic myeloid leukemia. Symptoms occurred 8 months after HSCT while on immunosuppression with 0.2 mg/kg/day of prednisone, and presented as dry cough, bilateral pneumonitis, and progressive respiratory distress. Non-invasive and invasive microbiological investigations revealed HMPV type B as the sole pathogen. Histopathological findings showed interstitial and intra-alveolar pneumonitis with profound alveolar cell damage. The patient was treated with intravenous and oral ribavirin and polyvalent immunoglobulins, but ultimately died from respiratory failure. The case reflects the potentially fatal impact of infections by respiratory viruses in immunocompromised patients and the need for effective approaches to their prevention and treatment.

[Obstructive uropathy in childhood]. / Obstruktive Uropathien im Kindesalter.

"Obstructive uropathy" is a generic term which combines different diseases in infants and childhood. Both the upper and lower urinary tract may be affected. Diseases of the urinary tract can cause an intrinsic obstruction. Sometimes tumours may cause a compression and as secondary effect an obstruction (extrinsic). Ultrasound is the key diagnostic tool and shows dilatation of the obstructed urinary tract. But for the functional exploration of babies and toddlers, renal scanning and X-ray examinations are necessary. These examinations lead to an exposure to radiation which necessitates careful indication. Some of the congenital diseases (for example ureteropelvic junction obstruction, megaureter) show a maturation without any intervention. So one has to decide whether to wait and see or to operate. A percutaneous nephrostomy or a DJ-catheter is not often used in the treatment of obstruction in general. These forms of drainage are more often used in the treatment of stones or of extrinsic obstruction. A pyelocutaneostomy or ureterocutaneostomy is a special surgical procedure in pediatric urology for transient drainage of the upper urinary tract (megaureter). The operation of a seriously ill new-born should be done in a centre for pediatric urology and pediatric nephrology. When the upper urinary tract is dilated, patients may need an antibiotic prophylaxis, because the dilatation of the upper urinary tract increases the risk of urinary tract infections (UTI). The indication for antibiotic prophylaxis should by guided by the criteria of the APN-Consensus Paper. Long-term follow-up is necessary and should comprise ultrasound, physical examination, controlling the blood pressure, urine analysis and blood tests. The aims of diagnostics, treatment and long-term follow-up are the preservation of renal function and to protect the children from UTI. This goal must be reached under conditions that are appropriate for children and their parents.

Central nervous system involvement in hemolytic uremic syndrome (HUS)--a retrospective analysis of cerebral CT and MRI studies.

PURPOSE: To evaluate the morphological changes of cerebral involvement in children with HUS utilizing CT and MRI. METHOD AND PATIENTS: We retrospectively analyzed 13 cranial CTs (CCT) and 3 cranial MRI studies of 5 out of 93 patients with clinically proven HUS and severe CNS involvement (seizures and coma and dysregulation of breathing) referred to the department of pediatric nephrology (aged 1.5-15 years, median 2 years, 2 girls, 3 boys) between 1987-2000. RESULTS: Three of 5 patients had CT and MRI studies, 2 patients had CT scans only. One of 2 patients with isolated basal ganglia ischemia and normal first CCT developed a secondary hemorrhagic infarction. Another patient with an initially normal MRI developed an infarction of the right cerebral arteries with mass effects. One of 2 patients with basal ganglia involvement showed additional infarction of thalami and external and internal capsules whereas the other had only minimal involvement of adjacent white matter, but consecutive hemorrhagic infarction. Four of 5 children died (3 of them with varying extents of basal ganglia and adjacent white matter involvement, 1 with right cerebral artery infarction). Basal ganglia involvement was found in the majority of cases as well as in all lethal cases. The surviving patient with isolated basal ganglia involvement now suffers from tetraspastic disorder and convulsions. CONCLUSION: Cerebral involvement is one of the major complications of HUS. According to the literature, basal ganglia involvement in HUS is common and quite often associated with other cerebral pathologies. First imaging findings may not show pathologies. Contradictory to previous reports, even children with isolated basal ganglia pathology and/or less involvement of white matter and coma may either die from the underlying disease or their clinical outcome may be poor.