Pulmonary Actinomycosis and Mucormycosis Coinfection in a Patient With Philadelphia Chromosome-positive Acute Lymphoblastic Leukemia Undergoing Chemotherapy.

Mucormycosis is an opportunistic and progressive infection, while actinomycosis usually grows gradually and rarely develops in immunocompromised patients. Here we report a patient with Philadelphia chromosome-positive acute lymphoblastic leukemia who developed a pulmonary actinomycosis and mucormycosis coinfection. Once the diagnosis of actinomycosis was confirmed by bronchoscopy, lobectomy performed before stem cell transplantation revealed mucormycosis. The patient successfully underwent transplantation using a therapeutic antifungal agent for mucormycosis. When an immunocompromised patient develops an infection of unknown etiology, physicians should consider these pathogens as the possible cause. In addition, surgical intervention should be considered as an important treatment option.

Fatal graft-versus-host disease after living-donor liver transplantation from an HLA-DR-mismatched donor.

Acute GVHD is a rare complication after liver transplantation that has a high mortality rate. We experienced an infant case complicated with acute GVHD. An 8-month-old infant with biliary atresia underwent LDLT with a graft obtained from his mother. Their HLAs showed a donor-dominant one-way match, not at HLA-DR but at HLA-A, HLA-B, and HLA-C (recipient; A 31/33, B 51/54, C 1/14, DR 9/11, donor; A 31/-, B 51/-, C 14/-, DR 8/11). The patient exhibited a high fever, skin rash, and diarrhea, and was diagnosed with acute GVHD based on the blood chimerism test. Despite immunosuppression treatment with prednisolone and tacrolimus, plasma exchange, blood transfusion including cord blood transplantation, and antibiotics, the child died on postoperative day 126. Donor-dominant one-way matching at HLA class 1 can be a high-risk factor for acute GVHD despite HLA class 2 mismatching.

Carbamazepine-imatinib interaction in a child with chronic myeloid leukemia.

Imatinib mesylate, a selective tyrosine kinase inhibitor, is the frontline therapeutic agent used for the treatment of chronic myeloid leukemia (CML), and its therapeutic efficacy is associated with trough concentrations. Therefore, monitoring imatinib trough concentrations is strongly recommended for successful treatment of CML patients. It has been recently shown that some drugs altered imatinib plasma levels in adult patients. However, drug interactions with imatinib in children are still unknown. Here, we report a case of a 12-year-old child with epilepsy who was also diagnosed with CML and given imatinib in addition to an enzyme-inducing antiepileptic drug, carbamazepine. Compared to population kinetics data, the data obtained for the patient showed a significant decrease of imatinib plasma concentrations. Our findings suggest that monitoring imatinib plasma concentrations in children receiving enzyme-inducing antiepileptic drugs is needed to optimize the therapeutic efficacy of imatinib.

Heterochronous bilateral adrenal neuroblastoma: stage 4S in early infancy following resection of stage I lesion in the neonatal period.

A girl presented with a right adrenal mass, and multiple hepatic lesions and subcutaneous nodules 3 months after complete resection of left adrenal neuroblastoma in the neonatal period. She was treated with six cycles of chemotherapy and is well after 13 months' follow-up. This is the first case report of heterochronous bilateral adrenal stage 4S NB.

[Comparison of micafungin and fosfluconazole as prophylaxis for invasive fungal infection during neutropenia in children undergoing chemotherapy and hematopoietic stem cell transplantation].

Invasive fungal infection (IFI) is a serious complication of chemotherapy for hematological malignancies and autologous/allogeneic hematopoietic stem cell transplantation in children and shows a high mortality rate. We performed a randomized trial comparing micafungin (MCFG), a new anti-fungal agent, with fosfluconazole, a prodrug of fluconazole (FF) conventionally used as a prophylactic agent, for prophylaxis against IFI. Cefpirome was administered as prophylaxis against bacterial infection, and meropenem+minocycline as an empiric window therapy for febrile neutropenia. MCFG 2 mg/kg/day (max 100 mg/day) and FF 10 mg/kg/day (max 400 mg/day) were both safe and effective (event free ratio of IFI, MCFG 94.4% vs FF 94.3%) without significant difference. Thus, MCFG is safe and can be used for prophylaxis against IFI in children.

[Encouraging results of stem cell transplantation following a melphalan-preceding intensified preparative regimen for refractory acute leukemia in children].

The results of allogeneic stem cell transplantation for patients with chemotherapy-resistant non-remission acute leukemia have been very poor. We have used a melphalan-preceding intensified preparative regimen in which a six-day interval is set between melphalan 70 mg/m2 and the main part of the preparative regimen to avoid toxicity in 15 consecutive pediatric patients with refractory acute leukemia. Only one patient died of transplant-related toxicity within 100 days of transplant. One patient had refractory anemia originating from donor cells at three months after transplant. Eight patients relapsed at a median of six months after transplant; therefore, five of 15 patients have been in complete remission (CR) for a median of 61 months. Four of six patients who did not have blasts in their peripheral blood before melphalan are in CR This method seems to be safe and effective for refractory acute leukemia.

[The role of cord blood stem cell transplantation in children; a retrospective analysis of 39 cases in a single institute].

We report the results of 39 children who underwent cord blood stem cell transplantation (CBSCT) at our institute during the period from February 1996 to July 2005. The patients consisted of 9 with non-malignant disease, 26 with malignant disease and 4 with Epstein-Barr virus (EBV) associated disease. The median age of the patients was 4 years and 8 months (range, 6 months to 16 years 2 months). The median infused cell dose was 4.9 (range, 1.7-11.4) x 10(7)/kg. Thirty-four transplants were from HLA-mismatched donors, and 33 patients underwent a tacrolimus-containing regimen for GVHD prophylaxis. As for CBSCT as the first transplant, 3 out of 4 children with non-malignant disease achieved engraftment after CBSCT with the use of a reduced-intensity conditioning regimen. For acute leukemia, 3 patients out of 5 in their first remission and 2 out of 9 in advanced stage at CBSCT continue in remission at the time of writing. Fourteen patients received CBSCT as a second or a third transplant. None of 4 patients who underwent CBSCT as rescue therapy after rejection/graft failure achieved engraftment. It should be emphasized that EBV-associated disease seems to be a suitable disease for CBSCT, because all of the 4 patients who underwent CBSCT are still in CR.