Cardiac complications and immunophenotypic profile of infectious mononucleosis syndrome in children.

OBJECTIVE: To investigate cardiac complications in infectious mononucleosis patients and to associate them with biochemical and immunological parameters, as well as with spleen ultrasound findings. DESIGN: Cross-sectional study with follow-up. SETTING: Tertiary care pediatric unit, in the city of Thessaloniki, Greece. PARTICIPANTS AND INTERVENTIONS: Twenty-five children (15 boys, aged 1-11.6 years) suffering from infectious mononucleosis were studied during the acute phase and after 3-6 months. Cardiac evaluation comprised of electrocardiogram, echocardiogram, and measurement of creatine phosphokinase, creatine phosphokinase cardiac isoenzyme, and troponin levels. Biochemical and immunological tests included serum transaminases, serum amylase, CD3+/CD8+ T-lymphocytes subpopulation and CD4+/CD8+ T-lymphocytes ratio. RESULTS: During acute phase, all children had splenomegaly and normal serum amylase values. 17 patients had elevated serum transaminases. Percentages of CD3+/CD8+ T-lymphocytes subpopulation were elevated and CD4+/CD8+ ratio was decreased in all patients. Echocardiography revealed mild pericardial effusion in 13 patients (10/21 with Epstein-Barr infection, 3/4 with cytomegalovirus infection), but none presented with myocarditis. Four out of these 13 patients also had markedly elevated liver enzymes, 10/13 had significant splenomegaly and 12/13 presented very low CD4+/CD8+ T-lymphocytes ratio. Pericardial effusion demonstrated a statistically significant association solely with very low CD4+/CD8+ T-lymphocytes ratio (<0.5). Repetition of laboratory tests 3-6 months post-discharge detected persistent mild pericardial effusion in five patients, along with decreased CD4+/CD8+ ratio in 1/5. CONCLUSIONS: In infectious mononucleosis syndrome, asymptomatic pericardial effusion could be associated with very low CD4+/CD8+ ratio (<0.5). Further studies would extend and confirm such an association.

Plasma citrulline levels in paediatric patients with celiac disease and the effect of a gluten-free diet.

OBJECTIVE: Citrulline is a nonprotein amino acid synthesized in the small intestine. The aim of this study is to explore plasma citrulline levels in children with celiac disease (CD) and monitor the time-related changes of these levels after initiation of a gluten-free diet (GFD). METHODS: Fasting-plasma citrulline levels were determined by high-performance liquid chromatography in (i) 23 patients with CD before the institution of GFD, (ii) 20 patients with CD under treatment for more than 2 years responsive to a GFD, (iii) 10 children with gastrointestinal symptoms and normal small bowel biopsy, and (iv) 20 healthy controls. In group A, citrulline levels were also measured after 1, 3, 6, and 12 months on a GFD. RESULTS: Mean plasma citrulline levels were lower in untreated patients with CD (24.5±4.9) than in patients on a GFD (31.2±6.7 µmol/l, P<0.001), patients with gastrointestinal symptoms and normal intestinal mucosa (30.3±4.7 µmol/l, P<0.01), and healthy controls (32.4±7.5 µmol/l, P<0.001). In untreated patients with CD,an inverse correlation was observed between citrulline concentrations and the severity of villous atrophy (r=-0.67, P<0.01). After 1 month on a GFD, patients had significantly higher levels than before diet (P<0.05) and after 3 months on diet, levels were similar to those observed in the healthy controls. CONCLUSIONS: Plasma citrulline levels are lower in celiacs reflecting small bowel involvement in this disease. After a short period on GFD, citrulline levels increased rapidly, indicating that citrulline is a sensitive marker of the positive effect of GFD on intestinal repair.

Regulatory Τ-cell differentiation between maternal and cord blood samples in pregnancies with spontaneous vaginal delivery and with elective cesarian section.

PROBLEM: The immunological mechanisms preventing fetal antigenic rejection during normal pregnancy and the extent to which the type of delivery influences lymphocyte reactions are elusive. METHOD OF STUDY: Maternal peripheral blood and neonatal umbilical cord blood (CB) was collected upon labor after vaginal delivery or cesarian section. Leukocytes were analyzed with flow cytometry, focusing on regulatory and γ/δ T-cells. RESULTS: In CB from neonates delivered by vaginal delivery, natural killer cells were increased. On the other hand, in maternal blood, γ/δ T-cells were increased, and activated T-cells (cluster of differentiation [CD]4+/25(dim) /122+ cells) were decreased. Moreover, maternal blood presented increased levels of T regulatory cell subsets like CD4+/25(high) /45RO+, CD4+/25(high) /DR+, CD4+/25(high) /CD38+ and CD4+/25(high) /71+. In CB, CD19+, CD4+/25(high) /45RA+ and CD4+/25(high) /122+ cells were increased. CONCLUSION: The effect of delivery type on lymphocyte immunophenotype was minimal. Mothers' and neonates' lymphocyte subsets differed significantly. Mothers' phenotype comprised significantly of lymphocytes involved in tolerance (memory and activated regulatory T-cells, γ/δ T-cells).

Biocompatibility study based on differential sequestration kinetics of CD14+CD16+ blood monocyte subsets with different dialyzers.

The immune defect in hemodialysis (HD) patients is associated with a monocyte dysfunction, including an increase in the production of proinflammatory cytokines. Blood membrane contact leads to an increase in cellular activation and sequestration into the capillary bed of the lung. The influence of the sequestration on the number of mature monocytes was studied by analyzing the fate of monocytes, particularly, the CD14+CD16+ subpopulation, during HD treatment. In thirty stable HD patients, the distinct cell populations were determined by differential blood counts and flow cytometry. Patients with diabetes or systemic vasculitis, those showing evidence of infectious complications or malignancy, or those taking immunosuppressive medications were excluded from the study. Cells from this study population were analyzed before the start, 30 min thereafter, and at the end of HD treatment, each time using a different dialyzer: hemophan, methylmethacrylate (PMMA), triacetate membrane, cuprophane/vitamin E, acrylonitrile, and sodium methallylsulfonate polymer (AN69). The CD14+CD16+ subset decreased at 30 min and remained suppressed for the course of dialysis. To examine whether currently used biocompatible membranes differ in their effect on the sequestration of monocyte subpopulations, temporal monocytic changes were comparatively analyzed during HD with a different dialyzer. The drop in the first 30 min until the end of HD treatment was significant (p<0.05), very uniform, and sharp in all patients, and was independent upon membrane type. The CD14+CD16+ monocyte subpopulation showed increased and longer margination from the blood circulation during HD. Given the fact that CD14+CD16+ monocytes represent a sensitive marker for inflammation or cellular activation, the depletion of these cells may offer an easily accessible parameter that is more sensitive than complement activation for biocompatibility studies on forthcoming, improved dialyzer membranes.

Comparison of blood and peritoneal lymphocytes from continuous ambulatory peritoneal dialysis patients, asymptomatic and with peritonitis.

OBJECTIVE: The purpose of this study was to compare the characteristics of the blood immunophenotype of CAPD patients with and without peritonitis and to compare the phenotypes of peripheral blood lymphocytes (PBL) and peritoneal lymphocytes (PL) in CAPD patients with peritonitis. METHODS: Fifty-seven CAPD patients (20 with peritonitis and 37 without peritonitis) were recruited in the study (mean age 66,88 +/- 13,48, male/ female 16/21). Lymphocyte subsets (CD2+, CD3+, CD3+/4+, CD3+/8+, CD3-/16 + 56+, CD4/CD8 ratio) were quantitated by using monoclonal antibodies and dual-color flow cytometric analysis. With the above method we measured PBL in patients with and without peritonitis. In patients with peritonitis we also measured PL. RESULTS: CD2 were slightly decreased in patients with peritonitis. Those patients also had more intense CD3 + / CD4+ lymphopenia (p < 0.05) and larger expansion of NK cells (p < 0.05). Patients with peritonitis appeared to have a lower ratio of CD4/CD8 (p < 0.05). All the above results are shown to Table 2. Following the onset of peritonitis, a consistent finding in all patients was a significant increase in CD2 population of PL compared with PBL (85.71 +/- 9.20 versus 82.60 +/- 7.34, p < 0.05) as well as in CD3 population (77.01 +/- 13.09 versus 68.74 +/- 13.43, p < 0.05). An increased number of CD3/8 in PL compared with PBL (33.70 +/- 9.34 versus 27.98 +/- 10.77, p < 0.05) was also noted. CONCLUSIONS: In the present study, we found important immune activation in asymptomatic CAPD patients. The activation increases during peritonitis. The causes and the clinical consequences of chronic activation remain unknown.

Do serum and red blood cell folate levels indicate iron response in hemodialysis patients?

The relationship among iron status, ferritin, and folate levels, and the possible contribution of folate measurement in the prediction of iron response in hemodialysis patients, have not been assessed. In addition to serum ferritin and transferrin saturation (TSAT), serum and red blood cell (RBC) folate levels were evaluated as indices for intravenous iron therapy responsiveness in 60 hemodialysis patients. Patients were classified as iron responders or nonresponders depending on whether they exhibited a rise in hemoglobin above 1 g/dl after administration of 1 g of iron sucrose. An inverse relation between serum ferritin concentration and RBC folate levels was found in iron responders (n=26, r=-0.62, p<0.001) but not in nonresponders (n=34, r=0.07, p=nonsignificant). Only serum and RBC folate levels could predict iron response in patients with ferritin levels above 150 microg/l (n=25), with a sensitivity of 83.3% and a specificity of 94.7%. Our findings suggest that RBC folate concentration is inversely related with ferritin levels in iron-responsive but not in non-responsive hemodialysis patients. Serum and RBC folate concentration seems to predict response to iron administration better than serum ferritin or TSAT in patients with ferritin levels above 150 microg/l; therefore, in these patients, it might be used to guide iron management.

Evaluation of hypochromic erythrocytes in combination with sTfR-F index for predicting response to r-HuEPO in anemic patients with multiple myeloma.

The purpose of this study was to evaluate the sTfR-F index and hypochromic erythrocytes (HYPO%) as potential predictors of response to recombinant human erythropoietin (r-HuEPO) of anemic patients with multiple myeloma (MM) before treatment, as well as early in the course of treatment. Twenty-six newly diagnosed anemic MM patients received r-HuEPO 30,000 IU/wk sc, for six weeks. The sTfR-F index and HYPO% were determined at baseline and at weeks 2 and 6. Patients were classified in 1 of 4 categories of a diagnostic plot, according to erythropoietic state (ES I-IV), defined by the combination of sTfR-F index and HYPO%. Sixteen of 20 patients in ES I and II before treatment responded to r-HuEPO, whereas none of the 6 patients in ES III and IV responded (P < .001). At week 2, 44% of patients who responded and 60% of the nonresponders were in functional iron deficiency (FID) and the proportion increased to 69% and 80%, respectively, by week 6. Seven of the patients who did not respond received in addition 200 mg iron sucrose IV weekly, for the next 4 weeks, and 6 of them responded. These results suggest that combination of sTfR-F index and HYPO% in a diagnostic plot can be used as a predictive model to recognize patients who will benefit from r-HuEPO and identify FID requiring iron supplementation, before treatment and early in the course of treatment, contributing thus to optimization of r-HuEPO therapy.

Increase in serum magnesium level in haemodialysis patients receiving sevelamer hydrochloride.

BACKGROUND: Clinical studies have shown that sevelamer hydrochloride improves lipid profiles and attenuates the progression of the cardiovascular calcifications in haemodialysis patients. It is known that both of these properties are associated with increased magnesium levels. The effect of sevelamer on serum magnesium level is not well documented. The aim of this study was to determine the effects of sevelamer treatment on serum magnesium in haemodialysis patients and to assess the association of magnesium levels with lipid profiles and intact parathyroid hormone (iPTH). METHODS: Phosphate binders were discontinued during a two week washout period. Forty-seven patients, whose serum phosphate was greater than 6.0 mg/dl at the end of washout, received sevelamer hydrochloride for eight weeks. The patients were then washed off sevelamer for another two weeks. RESULTS: Mean serum phosphorus concentration declined from 7.5 +/- 1.3 to 6.4 +/- 1.2 mg/dl (P < 0.001), mean serum magnesium levels increased from 2.75 +/- 0.35 to 2.90 +/- 0.41 mg/dl (P < 0.001) and median serum iPTH levels decreased from 297 to 213 pg/ml (P=0.001) during the eight weeks of sevelamer treatment. After the two week post-treatment washout phosphorus levels increased to 7.3 +/- 1.3 mg/dl (P < 0.001), magnesium levels were reduced to 2.77 +/- 0.39 mg/dl (P < 0.001) and iPTH levels increased to 240 pg/ml (P=0.012). No change was observed in serum calcium levels during the sevelamer treatment period and the subsequent washout period. The mean decline in total and low density lipoprotein (LDL) cholesterol during sevelamer treatment was 16.3 and 28.3 (P < 0.001), respectively. The mean increase in high density lipoprotein (HDL) cholesterol and in apolipoprotein A1 was 2.9 +/- 5.8 mg/dl (P=0.004) and 6.8 +/- 11.1 mg/dl (P=0.001), respectively. Multivariate analysis showed that the rise in serum magnesium concentration significantly correlated with reductions in iPTH levels (r=-0.40, P=0.016), but did not have any significant correlation with the changes in lipid profiles. CONCLUSIONS: Our findings indicate that patients on haemodialysis receiving sevelamer have a significant increase in serum magnesium concentrations. This increase in serum magnesium is associated with reduction in iPTH levels. The changes in lipid profiles of these patients however are not related to changes in serum magnesium levels.

Molecular epidemiology of adenovirus strains isolated from patients with ocular disease in the area of Thessaloniki, Greece (1998-2002).

Thirty strains of adenovirus (Ads) associated with ocular disease have been isolated over a period of 4 years in Thessaloniki, Northern Greece. Eleven strains were isolated from sporadic patients with conjunctivitis or keratoconjunctivitis in Thessaloniki city between 1998 and 2000. Nineteen strains were isolated from patients with keratoconjunctivitis during an outbreak of Ads in the area of Thessaloniki (Thessaloniki and Serres cities) in 2002. PCR-sequence method using primers targeted against the hypervariable regions (HVRs) of hexon gene, as well as the neutralization test were used for typing the Ad isolates and assessing a possible relation among these strains, and their genetic variability. Ad4 with very close homology to variant Z-G 95-873 was the most frequent genotype causing sporadic conjunctivitis over a period of 4 years. Two other strains, one Ad2, and one Ad3 were similar to the prototype ones, and a third one shows close homology to the variant of prototype Ad15, the Morrison strain. The genome typing of twenty two Ad8 isolates showed very close homology in their amino acid and nucleotide sequences to the variant of Ad8, strain 1127 (accession no. X74663). Four were isolated from patients with keratoconjunctivitis in 1998, 1999, 2000 and 18 during the outbreak in 2002. As far as strain 1127 is concerned, all the Ad8 isolates showed the same changes in the HVR 1 and HVR 2 except one isolate in 1998, which showed some changes outside the HVRs. During the outbreak of Ad8 keratoconjunctivitis, it was not possible to identify the exact source of infection (nosocomial or/and outpatients). Finally, Ad4 variant Z-G 95-873 and Ad8 which is closely related to the strain 1127, were found to be the predominant adenoviruses circulating in Northern Greece during 1998-2002.