Cellular defenses against Toxoplasma gondii in newborns.

Mononuclear phagocytes, particularly macrophages (M phi) that have been activated by lymphokines, are the principal defense against intracellular pathogens such as Toxoplasma gondii. To determine reasons for the newborns' susceptibility to Toxoplasma infection, we compared: the interaction of Toxoplasma with newborns' mononuclear phagocytes (blood monocytes and two types of newborn M phi, those derived from blood monocytes or from placental tissue) with adults' blood monocytes and monocyte-derived M phi and the production of M phi-activating lymphokines (MAF) by Concanavalin A (ConA)-stimulated newborn and adult blood mononuclear cells (MC). Newborn and adult monocytes killed Toxoplasma with equal efficiency. Similarly, survival and replication of Toxoplasma were comparable in control newborn and adult M phi. Exposure to adult ConA supernatants significantly decreased the survival and replication of Toxoplasma both in adult and newborn M phi. In contrast, exposure to cord blood ConA supernatants failed to affect the survival or the replication of Toxoplasma in newborn M phi and decreased the replication but not the survival of Toxoplasma in adult M phi. Exposure to ConA supernatants of peripheral blood MC from 2-5-d old newborns failed to affect survival or replication of Toxoplasma in newborn or adult M phi. Thus, both generation of MAF by newborn blood MC and response to newborn MAF by newborn M phi were impaired. Generation of MAF by adult blood mononuclear cells was not inhibited by cord blood MC nor was generation of MAF by cord blood MC increased by depletion of OKT8 antibody-binding cells, by depletion of adherent cells with or without addition of adult adherent cells, or by addition of indomethacin. Depletion of OKT4 antibody-binding cells abrogated the generation of MAF both by adult and cord blood MC. The activity of adult ConA supernatants was abrogated by dialysis at pH 2 or by addition of anti-gamma-interferon but not anti-alpha-interferon antibody. However, the correlation between antiviral interferon activity and anti-Toxoplasma activity was weak (r = 0.40). Enhanced M phi anti-Toxoplasma activity was not associated with detectably enhanced superoxide anion generation, nitroblue tetrazolium reduction, or phagolysosome fusion, and was not inhibited by catalase, superoxide dismutase, or mannitol. These results indicate that generation of and response to MAF is decreased in cells from human newborns and that gamma-interferon may be the major MAF under these conditions.

Interaction of primate alveolar macrophages and Legionella pneumophila.

We studied the interaction between Legionella pneumophila, which is principally a pulmonary pathogen, with primate alveolar macrophages (AM), which are the primary pulmonary cellular defense mechanism. For these studies we used L. pneumophila, type I, which were grown in albumin-yeast extract broth, were greater than 80% viable, and were comparable in virulence for guinea pigs to organisms from guinea pig spleen homogenates. For comparison, avirulent agar-passed L. pneumophila, type I, and a strain of Escherichia coli were also used. In the absence of detectable antibody, AM phagocytosed similar numbers of virulent and avirulent Legionella and killed the majority of ingested Legionella in 15-30 min, as determined by two different assays. The virulent and avirulent Legionella appeared to be equally susceptible to the cidal systems of the AM and both were killed more readily than were E. coli under both assay conditions. Phagocytosis of Legionella by AM was associated with a localized respiratory burst, as indicated by nitroblue tetrazolium reduction around ingested organisms. Killing of AM-associated Legionella was inhibited by the hydroxyl radical (OH.) scavenger mannitol (but not by an equiosmolar concentration of sodium sulfate), and by a combination of superoxide dismutase and catalase (but not by either enzyme alone). These findings suggest a contribution by OH., one generated by the metal-catalyzed interaction of superoxide and hydrogen peroxide (Haber-Weiss reaction) in the anti-Legionella activity of AM. The virulent Legionella that survived intracellularly increased in number from 4 X 10(4) at 1 h to 6 X 10(6) at 96 h after infection. In contrast, avirulent Legionella replicated more slowly, increasing in number from 4 X 10(4) to 1 X 10(5) over the same period. Replication of virulent Legionella destroyed the AM monolayers by 120 h, whereas monolayers containing avirulent organisms remained intact. Thus, virulence of Legionella appears not to correlate with its ability to survive early killing by AM, but rather with the ability of the small fraction of surviving organisms to replicate within these cells.

Effective treatment of unresectable or metastatic hepatoblastoma with cisplatin and continuous infusion doxorubicin chemotherapy: a report from the Childrens Cancer Study Group.

The Childrens Cancer Study Group (CCSG) undertook a study (CCG-823F) to test the feasibility of administering continuous infusion doxorubicin (CI DOX) and cisplatin (CDDP) in patients with unresectable or incompletely resected hepatoblastoma (HB) or hepatocellular carcinoma (HCC). Chemotherapy consisted of CI DOX 20 mg/m2/d for days 1 to 4 and CDDP 100 mg/m2 on day 1 followed by a 21-day rest period. Second-look surgery was performed after the administration of four chemotherapy courses. Forty-seven (47) assessable patients were entered on study, 33 with HB and 14 with HCC; of these, 34 (26 HB and eight HCC) completed the initial four courses of chemotherapy. Of the 26 HB patients, 25 were evaluated as responding to chemotherapy before the scheduled second-look procedure and were considered surgically resectable at that time. Surgery was performed on 22 patients; three patients refused the second-look surgery. Nine patients had no evidence of residual malignant disease, seven underwent surgical resection of remaining tumor, four were left with microscopic residual disease, one had a partial resection with gross tumor left behind, and one remained unresectable. Nine HCC patients completed four chemotherapy courses. Eight patients achieved a partial remission and second-look surgery was attempted on seven. Only two had all malignant disease removed at the second procedure. Data from 225 courses of chemotherapy were evaluated for toxicity. Neutropenia (absolute granulocyte count less than 500/mL) was observed in 68 courses, and five of these episodes were associated with sepsis. Severe mucositis was documented in 21 courses, and hypomagnesemia (magnesium less than 1.2 mg) was noted in 30 patients. Two patients developed decreased left ventricular shortening fraction, which resolved when chemotherapy was discontinued. In summary, CI DOX plus CDDP is a well-tolerated and effective regimen in inducing surgical resectability in HB patients who are unresectable at diagnosis and significantly improves survival for this group of patients to 66.6%.

Randomized comparison of cisplatin/vincristine/fluorouracil and cisplatin/continuous infusion doxorubicin for treatment of pediatric hepatoblastoma: A report from the Children's Cancer Group and the Pediatric Oncology Group.

PURPOSE: Previous studies demonstrated that chemotherapy with either cisplatin, vincristine, and fluorouracil (regimen A) or cisplatin and continuous infusion doxorubicin (regimen B) improved survival in children with hepatoblastoma. The current trial is a randomized comparison of these two regimens. PATIENTS AND METHODS: Patients (N = 182) were enrolled onto study between August 1989 and December 1992. After initial surgery, patients with stage I-unfavorable histology (UH; n = 43), stage II (n = 7), stage III (n = 83), and stage IV (n = 40) hepatoblastoma were randomized to receive regimen A (n = 92) or regimen B (n = 81). Patients with stage I-favorable histology (FH; n = 9) were treated with four cycles of doxorubicin alone. RESULTS: There were no events among patients with stage I-FH disease. Five-year event-free survival (EFS) estimates were 57% (SD = 5%) and 69% (SD = 5%) for patients on regimens A and B, respectively (P =.09) with a relative risk of 1.54 (95% confidence interval, 0.93 to 2.5) for regimen A versus B. Toxicities were more frequent on regimen B. Patients with stage I-UH, stage II, stage III, or stage IV disease had 5-year EFS estimates of 91% (SD = 4%), 100%, 64% (SD = 5%), and 25% (SD = 7%), respectively. Outcome was similar for either regimen within disease stages. At postinduction surgery I, patients with stage III or IV disease who were found to be tumor-free had no events; those who had complete resections achieved a 5-year EFS of 83% (SD = 6%); other patients with stage III or IV disease had worse outcome. CONCLUSION: Treatment outcome was not significantly different between regimen A and regimen B. Excellent outcome was achieved for patients with stage I-UH and stage II hepatoblastoma and for subsets of patients with stage III disease. New treatment strategies are needed for the majority of patients with advanced-stage hepatoblastoma.

Isolation, purification and characteristics of mononuclear phagocytes from human placentas.

Methods for the isolation of mononuclear phagocytes from human placentas by digestion with collagenase or with trypsin are described. Mononuclear phagocytes were approximately 35% of the cells obtained. Preparations were enriched for mononuclear phagocytes by sequential density gradient centrifugation over Ficoll-Hypaque and Percoll, adherence to plastic and removal of contaminating trophoblastic cells with brief trypsin exposure. Monolayers obtained by these methods were greater than 85% mononuclear phagocytes. These cells were predominantly of fetal origin; most were mature macrophages but up to 20% appeared to be recently derived from blood monocytes as determined by ultrastructural peroxidase cytochemistry.

Symptomatic splenic hemartoma: a report of two cases and review of the literature.

Two cases of large, multiple splenic hamartomas in children with pancytopenia, bone marrow hyperplasia, lymphadenopathy, hepatosplenomegaly, frequent infections, growth retardation, and fever are reported. These symptoms were relieved by splenectomy, and have not recurred during follow-up periods of one year and nine years. The sharply circumscribed lesions comprised large portions of the resected spleens and were composed of dilated vascular channels filled with mononuclear cells and iummunoblasts. The lesions lacked splenic cords or trabeculae, lymphoid follicles, Reed-Sternberg cells, and granulomas or other evidence of infection. Splenic hamartomas are usually single small lesions found incidentally at necropsy or laparotomy. Splenic hamartomas associated with symptoms and hypersplenism are large, and often confluent multiple tumors. Recognition of their benign nature is important in light of the current practice of laparotomy for staging and diagnosis of malignant conditions.

Biliary atresia, cytomegalovirus, and age at referral.

OBJECTIVE: To determine the frequency with which patients with extrahepatic biliary atresia (EHBA) are infected with cytomegalovirus (CMV) and to ascertain the age at referral to a specialty center for surgical correction of EHBA. METHODS: The charts of all patients discharged from the Children's Hospital and Medical Center between July 1, 1989 and December 31, 1993 with a new diagnosis of EHBA were reviewed to determine the frequency with which EHBA was accompanied by CMV infection. Data analyzed included age at referral and sex of patients, histopathologic evidence of CMV infection and size of bile ducts in the resected liver, and serologic (IgM) or culture diagnosis of CMV infection. RESULTS: Twenty-three patients with EHBA were evaluated at Children's Hospital and Medical Center in the study period. Twenty-one of the patients with EHBA were appropriately evaluated for infection with CMV and infection was documented in 5 (24%) patients. The median age of referral for all patients was 61 days (range 10 to 124 days). Infected patients were referred later (82.4 +/- 28.7 days) than noninfected patients (48.8 +/- 21.8 days) (P = .01) and were more likely to be girls, bu the medians of the diameters of the bile ducts in the resected porta hepatis were similar. Viral inclusions were not identified in any of the liver specimens. CONCLUSIONS: CMV infection is present in an unexpectedly large proportion of patients with EHBA at the time of referral. The establishment of CMV infection in infants with cholestasis should not deter the search for EHBA. Physicians should strive to reduce the age of referral of patients with EHBA to pediatric surgical centers by evaluating infants who remained jaundiced at 4 weeks of age.

Hepatic injury in a child caused by trimethoprim-sulfamethoxazole.

Trimethoprim-sulfamethoxazole was given to a 16-year-old boy as prophylaxis for a urinary tract infection. He developed severe cholestatic hepatitis 41 days after administration of the drug. A liver biopsy specimen showed a mixed inflammatory infiltrate in the portal triads and prominent bile stasis. The clinical course in this patient supports the concept of an indirect hypersensitivity reaction to sulfamethoxazole.

Relationship between epidemiologic risk factors and clinicopathologic findings in the sudden infant death syndrome.

The risk of sudden infant death syndrome (SIDS) is said to be enhanced by factors such as prematurity, low birth weight, and perinatal distress. The significance of risk factors for SIDS research was questioned because the majority of SIDS victims seem to lack them. Therefore, postmortem records of 1144 infants who died suddenly and unexpectedly in King County, Washington, over a 25-year period were studied. Deaths were classified as "explained" if a cause was apparent, "classic" SIDS if the history and autopsy were unrevealing or, where the diagnosis of SIDS was doubtful, as "probable" or "possible" SIDS. The infants' birth certificates were compared with those of 3647 infants born during a similar period. Seventy-nine deaths (7%) were explained. The 1065 previously certified as SIDS were reclassified classic SIDS (82%), probable SIDS (13%), and possible SIDS (5%). Low birth weight, small size for gestational age, prematurity, and low 5-minute Apgar scores each form a "continuum"; the possible-SIDS group had the highest proportion of such infants, followed by the probable- and classic-SIDS groups, which exhibit extensive overlap with the control population. A 5-minute Apgar score of less than 7 and delayed postnatal growth rate are not risk factors for classic SIDS. Risk factors are more prevalent in SIDS infants where the diagnosis may be doubtful. The great majority of SIDS victims possess fewer risk factors. To avoid the bias of confounding variables, SIDS research should focus on as "pure" a SIDS population as is possible.

Extending the Pallister-Hall syndrome to include other central nervous system malformations.

Hall-Pallister syndrome is defined by specific facial anomalies, post axial polydactyly, imperforate anus, and brain anomalies including a rare diencephalic mass, hypothalamic hamartoblastoma. In this article, two patients are described with the usual features of Hall-Pallister syndrome, including diencephalic anomalies, but without hamartoblastomas. These patients may suggest an appropriate extension of the definition of the Hall-Pallister syndrome.

Ultrastructure of malignant rhabdoid tumor of the kidney. A distinctive renal tumor of children.

An unusual and highly malignant childhood renal tumor has been noted among the specimens of the National Wilms' Tumor Study. Prominent nucleoli, PAS positive cytoplasmic inclusions, and light microscopic features suggestive of rhabdomyoblastic differentiation are hallmarks of this tumor. Ultrastructural examination of 11 specimens revealed the filamentous.

Constitutional balanced translocations in alveolar rhabdomyosarcoma.

Chromosomal analysis of tumor tissue from two children with alveolar rhabdomyosarcoma revealed t(1;5)(q32;q31) and t(1;22)(q21;q11.2) in all metaphases examined, respectively. Peripheral blood lymphocytes carried the same cytogenetic abnormality as that of the tumor cells in both patients. Parental lymphocytes were karyotypically normal in the patient with t(1;22), indicating a de novo constitutional translocation, but t(1;5) was paternally inherited in the other patient. The presence of constitutional translocations in these two children might have contributed to the development of alveolar rhabdomyosarcoma.

Fatal infantile muscle phosphorylase deficiency.

A premature female infant born of a consanguineous union exhibited joint contractures and signs and symptoms of perinatal asphyxia. A muscle biopsy examined by light microscopic, histochemical, and electron microscopic techniques exhibited changes of muscle phosphorylase deficiency and glycogenosis, identical to those of McArdle's disease. Postmortem ultrastructural examination of liver and heart did not reveal lysosomal storage. This case and one previously reported example of fatal infantile phosphorylase deficiency suggest that the clinical spectrum of McArdle's disease may be broader than previously recognized.

Megalencephaly in sudden infant death syndrome.

The fresh brain weights of 79 infants with sudden infant death syndrome (SIDS) were tabulated and compared with expected "normal" brain weights. The series included 47 males and 32 females. Their ages ranged from 8 days to 16 months with a median of 2.5 months. The weights of all these brains were above the 50th percentile for age, and 64 of 79 brains (81%) were above the 95th percentile, including 15 (19%) at or above the 99.9th percentile. The ratio of the brain stem plus cerebellum weight to the whole brain weight of 93 formalin-fixed brains from victims of SIDS showed that the cerebrum was disproportionately heavier in most cases. No gross or microscopic evidence of cerebral edema was noted to account for the heavier weight. The significance of these findings is debatable. The increase in brain weight was less obvious in infants younger than 1 month of age but accelerated after that age. The brain weights of infants with SIDS may represent the really "normal" weights, since these patients were not known to be ill prior to death. If the brain weights of SIDS infants are really heavier than "normal," the possibility must be considered that disproportionately rapid growth of the brain during early infancy may be detrimental to the neural control of the cardiorespiratory system.

Childhood polymyositis as a paraneoplastic phenomenon.

Childhood polymyositis and dermatomyositis are rare conditions that are not generally associated with malignancy even though an association between adult-onset and malignancy has been reported. A child is presented with typical polymyositis in whom an immunoblastic sarcoma subsequently became manifest; the literature also is reviewed concerning the association between malignancy and these childhood conditions.

Arteritis and fatal subarachnoid hemorrhage complicating occult Candida meningitis: unusual presentation in pediatric acquired immunodeficiency syndrome.

We report the case of an 11-month-old child with acquired immunodeficiency syndrome, who despite treatment for systemic candidiasis developed undetected Candida meningitis. This uncommon manifestation of candidiasis was accompanied by basilar granulomatous inflammation and fibrosis of meninges with arteritis, vascular invasion by fungi, and terminal subarachold hemorrhage. To our knowledge, this constellation of findings has not been reported previously in pediatric acquired immunodeficiency syndrome.

Improved three-year disease-free survival in osteogenic sarcoma.

Of 41 consecutive patients with newly diagnosed osteogenic sarcoma admitted to the Children's Orthopedic Hospital and Medical Center in Seattle, Washington, between 1952 and 1977, 19 treated before 1973 did not receive adjunctive chemotherapy (histological group) whereas after 1972 22 have been so treated (chemotherapy group). Chemotherapy consisted primarily of high doses of methotrexate and adriamycin for 16 months after surgical treatment. Patients in the historical group have been observed for a minimum of nine years (six patients) or until death (13 patients). The 13 surviving patients in the chemotherapy group have been followed for a minimum of three years (median five years) and all 12 disease-free patients have been off therapy for between one and a half and five and a half years (median three years). Overall, the chemotherapy group has had a significant increase in both survival (p = 0.03) and disease-free survival (P = 0.02) compared to the historical group. In 35 patients with localised disease at diagnosis, the three-year disease-free survival and the three-year survival rates were 18 per cent and 41 per cent respectively in the historical group, and 67 per cent and 78 per cent (life table estimates) respectively in the chemotherapy group. With adjunctive chemotherapy only one of the seven patients developing pulmonary metastases did so later than nine months after diagnosis. The superior results in the chemotherapy group could not be accounted for by differences in age, sex, presence of metastases at diagnosis, histopathology, location of primary tumour, type of initial or subsequent surgical treatment, or the use of standard or computerised lung tomography. Although the use of historical controls in this study does not exclude other changes as contributing to the observed improvement in outcome, our data support the contention that adjunctive chemotherapy improves both the disease-free survival and the overall survival of patients with osteosarcoma and rarely delays the onset of recurrent or metastatic disease.

Left ventricular hypoplasia in congenital diaphragmatic hernia.

Quantitative anatomic study of the hearts of eight infants with left-sided congenital diaphragmatic hernia (CDH) has revealed significantly decreased cardiac mass, due to hypoplasia of the left atrium and ventricle and interventricular septum. These morphologic deficiencies may be a result of compression of mediastinal structures by herniated abdominal viscera during prenatal life. Left ventricular hypoplasia is likely to be an important factor in the pathogenesis of cardiac insufficiency in patients with left CDH.

Biliary Atresia: histopathologic observations and reflections upon its natural history.

Operative liver biopsies and specimens of the extrahepatic ducts and porta hepatis have been studied in 12 cases of biliary atresia. In all cases, the liver showed giant cell transformation and inflammation with mononuclear cells and neutrophils. Most had other features of neonatal hepatitis, including necrosis of hepatocytes. In the intrahepatic bile ducts of all cases but one, the hepatic ducts and glands at the porta hepatis, and in the extrahepatic ducts where epithelium remained, there was degeneration of the epithelium and intramural inflammation. In the ducts at the porta hepatis and in 6 of 8 extrahepatic ducts where epithelium remained, there was extensive mural fibrosis compromising the diameter of the duct lumens. Three cases showed the inflammatory changes distal to sites of closure of the extrahepatic ducts. These findings demonstrate that in biliary atresia, hepatitis, intrahepatic cholangitis, and sclerosing cholangitis of the extrahepatic ducts all interact to produce acquired obstruction to bile flow.