The burden of pneumococcal meningitis in Austrian children between 2001 and 2008.

UNLABELLED: The present study was conducted to evaluate the burden of pneumococcal meningitis in Austrian children between 2001 and 2008. Clinical outcome was retrospectively analyzed both on discharge and on follow-up investigations. This study was based on a prospective multicentre surveillance study on hospitalized invasive pneumococcal infections in Austrian children with a total annual "study population" of about 399,000 children aged below 5 years per year. Between 2001 and 2008, 74 cases of pneumococcal meningitis were identified in children aged below 5 years. The mean annual incidence rate for pneumococcal meningitis was 2.3 per 100,000 children in this age group. In 57/74 children (mean age on admission 14.5 ± 13.3 months), outcome data on hospital discharge were available: 5 deaths (8.8%), 20 children (35.1%) with sequelae and 32 children (56.1%) without sequelae were observed. Sequelae on discharge included motor impairment in 8 children (14.0%), hearing impairment in 9 children (15.8%) and/or other complications in 14 children (24.6%). In 7/8 children with motor deficits, matching cerebral lesions were identified by neuroimaging: cerebral infarction in five children, cerebral vasculitis and cerebral abscess in one child each. In 40/57 children, long-term outcome (18.9 ± 20.2 months after discharge) could be assessed: 1 child (2.5%) died 9 months after hospital discharge, 11 children (27.5%) had one or two long-term sequelae and 28 children (70.0%) had no sequelae. Long-term sequelae included motor impairment in three children (7.5%), hearing impairment in nine children (22.5%) and other deficits in two children (5.0%). CONCLUSION: Our study confirms that pneumococcal meningitis causes high mortality and severe long-term sequelae. On long-term follow-up, we observed improvements of motor impairment, but not of hearing impairment.

The Austrian version of the Childhood Health Assessment Questionnaire (CHAQ) and the Child Health Questionnaire (CHQ).

We report herein the results of the cross-cultural adaptation and validation into the Austrian language of the parentís version of two health related quality of life instruments. The Childhood Health Assessment Questionnaire (CHAQ) is a disease specific health instrument that measures functional ability in daily living activities in children with juvenile idiopathic arthritis (JIA). The Child Health Questionnaire (CHQ) is a generic health instrument designed to capture the physical and psychosocial well-being of children independently from the underlying disease. The Austrian CHAQ CHQ were adapted from the German version of the CHAQ-CHQ, and revalidated in this study. A total of 134 subjects were enrolled: 74 patients with JIA (9.5% systemic onset, 42% polyarticular onset, 9.5% extended oligoarticular subtype, and 39% persistent oligoarticular subtype) and 60 healthy children. The CHAQ clinically discriminated between healthy subjects and JIA patients, with the systemic, polyarticular and extended oligoarticular subtypes having a higher degree of disability, pain, and a lower overall well-being when compared to their healthy peers. Also the CHQ clinically discriminated between healthy subjects and JIA patients, with the systemic onset, polyarticular onset and extended oligoarticular subtypes having a lower physical and psychosocial well-being when compared to their healthy peers. In conclusion the Austrian version of the CHAQ-CHQ is a reliable, and valid tool for the functional, physical and psychosocial assessment of children with JIA.

Serum cytokines in juvenile rheumatoid arthritis. Correlation with conventional inflammation parameters and clinical subtypes.

OBJECTIVE: To examine the usefulness of determining extended serum cytokine profiles in patients with juvenile rheumatoid arthritis (JRA), for the purpose of improving differential diagnosis and monitoring disease activity. METHODS: In a 2-year prospective study, serum levels of interleukin-1 beta (IL-1 beta), soluble IL-2 receptor (sIL-2R), IL-6, IL-8, tumor necrosis factor alpha (TNF alpha), and the p55 soluble TNF receptor (sTNFR) were repeatedly determined by enzyme-linked immunosorbent assay in 40 patients with JRA, 13 patients with postinfectious arthropathies, and 30 healthy controls. The data were compared with conventional parameters of inflammation, such as C-reactive protein (CRP), iron and hemoglobin levels, erythrocyte sedimentation rate (ESR), white blood cell (WBC) counts, and platelet counts. WBC subsets were analyzed by flow cytofluorometry. RESULTS: At the first visit and at the peak of inflammatory activity according to CRP levels and/or ESR, serum levels of sIL-2R, IL-6, and sTNFR in JRA patients correlated significantly with conventional inflammation indicators, whereas IL-1 beta, IL-8, and TNF alpha did not. No changes in leukocyte subset distribution were noted. Among the different clinical subtypes of JRA, sIL-2R, IL-6, and sTNFR values at the time of the initial visit showed a pattern similar to CRP, whereby patients with systemic disease exhibited by far the highest values. TNF alpha and IL-1 beta were variably elevated in certain JRA subtypes. Patients with postinfectious arthropathies showed elevated levels of CRP, sIL-2R, TNF alpha, and sTNFR, which did not differ significantly from levels in the various JRA subtypes with the exception of systemic disease. Detailed analysis of types I and II pauciarticular JRA revealed that levels of CRP, IL-1 beta, and TNF alpha were elevated in patients with type I disease. While these parameters were invariably normal in patients with type II disease, sTNFR and sIL-2R were still found to be significantly elevated. Followup studies suggested that persistently high sTNFR values are a better indicator of JRA activity than are measurements of other cytokines or CRP. CONCLUSION: JRA is associated with significant and consistent changes in serum levels of inflammatory cytokines and soluble receptors. For the clinical monitoring of JRA, determination of levels of sTNFR, and to some extent sIL-2R, may be particularly useful, since these determinations yield information about subtype and/or activity of disease that is not available from conventional parameters of inflammation.

156Pro-->Gln substitution in the light chain of cytochrome b558 of the human NADPH oxidase (p22-phox) leads to defective translocation of the cytosolic proteins p47-phox and p67-phox.

Src homology 3 (SH3) domains have been suggested to play an important role in the assembly of the superoxide-forming nicotinamide adenine dinucleotide phosphate (NADPH) oxidase upon activation of phagocytes, which involves the association of membrane-bound and cytosolic components. We studied the translocation of the cytosolic proteins to the plasma membrane in neutrophils of a patient with a point mutation in the gene encoding the light chain of cytochrome b558. This mutation leads to a substitution at residue 156 of a proline into a glutamine in a putative SH3 binding domain of p22-phox (Dinauer, M., E. A. Pierce, R. W. Erickson, T. Muhlebach, H. Messner, R. A. Seger, S. H. Orkin, and J. T. Curnutte. 1991. Proc. Natl. Acad. Sci. 88:11231). In PMA-stimulated neutrophils and in a cell-free translocation assay with neutrophil membranes and cytosol, association of the cytosolic proteins p47-phox and p67-phox with the membrane fraction of the patient's neutrophils was virtually absent. In contrast, when solubilized membranes of the patient's neutrophils were activated with phospholipids in the absence of cytosol (Koshkin, V., and E. Pick. 1993. FEBS [Fed. Eur. Biochem. Soc.] Lett. 327:57), the rate of NADPH-dependent oxygen uptake was observed at a rate similar to that of control membranes. We suggest that the binding of an SH3 domain of p47-phox to p22-phox, and thus activation of the oxidase, does not occur in the neutrophils of this patient, although under artificial conditions, electron flow from NADPH to oxygen in cytochrome b558 is possible.

Migratory activity of blood polymorphonuclear leukocytes during juvenile rheumatoid arthritis, demonstrated with a new whole-blood membrane filter assay.

Polymorphonuclear leukocyte (PMN) migration is measured in whole blood in a migration chamber consisting of a membrane filter (3-microns pores, 140 microns thick) with an integrated chemoattractant depot (FMLP in solid form) attached to a plastic container. Control chambers lack FMLP (blanks). One test unit requires 300 microliters blood. Numbers and distribution of the PMN immigrants into the filters are determined microscopically. Altogether 26 measurements of PMN migration in five juvenile rheumatoid arthritis (JRA) patients with varying disease activity were compared with the reactions of a healthy control group (N = 32). Correlations were calculated with conventional laboratory parameters (WBC, PLT, BSR, CRP, Hgb, serum Fe) and disease activity. In comparison with healthy controls, PMNs of JRA patients generally show a markedly increased penetration depth into the filters irrespective the presence of the chemoattractant or the disease activity. Increased migratory reactions to FMLP in comparison to blanks were found during high disease activity only. The PMN penetration depth correlates positively with the CRP, and reciprocally with the Hgb blood levels. The migration assay combines fast and simple processing with good preservation of the genuine PMN activation state.

[Stress and susceptibility to infection]. / Stress und Infektionsbereitschaft.

The influence of various stressors upon the human immune system, was and presently is the subject of many clinically oriented as well as experimental studies. Even though it is not always clear how relevant the reported observations are in behalf to the beginning, the course and the outcome of infectious, neoplastic and autoimmune diseases, there is hardly any doubt, that stress may influence multiple aspects of the immune answer. The sensitivity of the immune system to stress factors is not merely fortuitous, but is an indirect consequence of the regulatory reciprocal influences between the immune system and the central nervous system. These interconnections seem to represent building blocks of a long-loop regulatory feedback-system, which plays an important role in the coordination of stressors and psychological influences upon the course of infections and inflammatory diseases.

Reduction of the dose to the lens in prophylactic cranial irradiation: a comparison of three different treatment techniques and two different beam qualities.

Three treatment techniques using two beam qualities have been compared on the basis of dose to the lens in prophylactic cranial irradiation. The dose to the lens and the globe was measured with thermoluminescent crystals in an anthropomorphic phantom and calculated by a computer-assisted planning system. A comparison was made of large field and small field techniques using 60Co and 8 MV photons. Modifications to the basic techniques studied included angulation of the gantry, angulation of the couch, and placement of an additional eye block close to the surface. The dose to the lens could be reduced to four percent of the midplane dose by applying the small-field technique combined with the use of 8 MV energy photons, by placing an additional block close to the surface, and by five degree occipitally angling the gantry, as well as rotating the treatment couch to account for the divergence of the beam. The use of 60Co produced an underdosage of the posterior segment of the globe in angled treatment techniques.

Cytofluorimetric analysis of mitogen-activated peripheral blood lymphocytes of non-leukemic lymphoma patients reveals an abnormal disease-related expression pattern of activation antigens.

The purpose of this study was to examine patterns of peripheral T-cell-activation antigen expression after polyclonal in vitro stimulation in early stages of lymphoproliferative diseases. With 18 patients afflicted with recently diagnosed, non-leukemic stages of B and T cell lymphoma cytofluorimetric analysis was performed with peripheral blood lymphocytes (PBL) after 72 h in culture with and without phytohemagglutinin, using antibodies against the differentiation antigens CD3, CD8, CD4, CD16, CD19, CDw14, and the activation antigens interleukin-2 receptor (IL-2R, CD25), HLA-DR (DR), CD56 and transferrin receptor (TR). Compared to healthy controls and patients with other diseases, a very significant reduction of large T cells bearing activation markers was found in all lymphoma cases. Furthermore, a pronounced inhibition in the expression of the activation markers IL-2R and TR, but not of DR, was detected on CD3+ cells in phytohemagglutinin-stimulated PBL of all lymphoma cells independently of DNA synthesis, as measured by [3H]thymidine uptake. Determination of the natural-killer-cell-(NK)-associated antigens CD16 and CD56, available for our studies in a CD16 + CD56 combination kit, revealed, after phytohemagglutinin stimulation, significantly increased expression values in 8 lymphoma patients so far investigated, as compared to 12 healthy controls. Thus, polyclonal activation combined with cytofluorimetric screening of activation antigens seems to give useful information on the functional defect(s) of PBL in an early state of lymphoma, and may therefore be of considerable diagnostic value. The observed pattern of T cell activation antigen expression after phytohemagglutinin stimulation may give further clues to the understanding of immune dysfunction(s) associated with lymphoma.

[Primary and secondary inoperable teratoid hepatoblastoma--multidisciplinary management]. / Primär und sekundär inoperables teratoides Hepatoblastom--multidisziplinäres Management.

Hepatoblastomas are the most frequent malignant liver tumors of childhood. Prognosis mostly depends on their resectability. Unresectable tumors are almost invariably fatal, unless their size can be decreased by chemotherapy and/or irradiation to permit surgical removal. In the present case report we discuss the clinical course of a 15 months old boy, who was admitted with primary inoperable teratoid hepatoblastoma. After alternating intravenous and intraarterial chemotherapy as well as radiation therapy, the tumor could be successfully resected. Specific problems of histological diagnosis and of the therapeutic management are discussed, and an overview of the recent literature in behalf of the histological basis, therapeutic possibilities and prognostic factors of hepatoblastomas is given.

[Molecular genetic detection of polyclonal immune response in autoimmune thyroiditis and inflammatory bowel diseases]. / Molekulargenetischer Nachweis einer polyklonalen Immunantwort bei Autoimmunthyreoiditis und entzündlichen Darmerkrankungen.

Southern blot hybridization techniques were used to analyze the arrangements of the immunoglobulin and the T cell antigen receptor genes in lymphocytes of patients with Graves disease and Hashimoto's thyroiditis as well as in patients with Crohn's disease, chronic ulcerative colitis, and with other gastrointestinal disease. The results indicate that the immune response of autoimmune thyroid disease and inflammatory bowel disease is of polyclonal origin.

Successful treatment of CMV retinitis with ganciclovir after allogeneic marrow transplantation.

Cytomegalovirus (CMV) infection of the retina is a well recognized complication in patients with the acquired immune deficiency syndrome but is rarely seen after bone marrow transplantation (BMT). Among a variety of drugs ganciclovir so far appears to be the most effective therapy for CMV retinitis, but in previous studies relapses occurred in all patients in whom ganciclovir was interrupted. We report the clinical findings in a 22-year-old BMT recipient who developed bilateral exudative CMV retinitis 64 days after BMT despite prophylactic treatment with high-titer CMV-immunoglobulins and transfusions of CMV-negative blood products and donor bone marrow. During a 12 day course of treatment with 7.5 mg/kg/day of ganciclovir the CMV retinitis improved and viruria ceased on day 4 of therapy. In contrast to the previous reports, CMV retinitis in this patient continued to improve even after ganciclovir was stopped and eventually complete healing of all intraretinal lesions as well as total reconstitution of the visual acuity was achieved. He is now free of disease and without relapse of CMV retinitis more than 1 year after transplantation.

[Molecular immunology in pediatrics]. / Molekularimmunologie in der Pädiatrie.

Immunoglobulin and T-cell antigen receptor genes in their germline form are organized as discontinuous DNA elements that are joined by recombinations during lymphocyte development. The analysis of immunoglobulin and T-cell receptor gene structure as well as the analysis of chromosomal translocations has been of great value in defining the lineage of neoplasms, determining the clonality of abnormal lymphocyte proliferations, diagnosis and monitoring of lymphoid malignancies and determining the state of maturation of B- and T-cells. The basic principles of molecular genetics have established some common basis for understanding immune activation and regulation, and thereby have opened new possibilities in studying immunodeficiency and autoimmune diseases. Thus, the application of this molecular genetic approach has great potential for complementing conventional marker analysis, cytogenetics and histopathology in the evaluation of these diseases.

[Malignant bone marrow infiltration in nuclear magnetic resonance tomography]. / Maligne Knochenmarksinfiltrate im NMR-Tomogramm.

Magnetic resonance imaging (MRI) is currently the only non-invasive method detecting changes of bone marrow. While yellow bone marrow produces a high signal intensity, which is similar to subcutaneous fat, any other cellular infiltration of the bone marrow causes a decrease of signal intensity because of replacement of marrow fat cells. In this report we describe two patients, who underwent MRI because of clinical symptoms of coxitis, in order to exclude Perthes disease. Both cases showed decreased signal intensity of the bone marrow particularly of the proximal femura, highly indicative of cellular bone marrow infiltration. Bone marrow aspiration in these patients showed acute lymphocytic leukemia in one case and marrow infiltration by neuroblastoma cells respectively in the other case. Because of its high sensitivity, MRI is also suitable in detecting focal bone marrow disease. For these cases a biopsy of these focal bone marrow lesions can be performed in order to stage the disease properly as in the presence of neuroblastoma or malignant lymphoma presenting with localized disease, however, with focal bone marrow metastases on MRI. In addition MRI can also be used to follow up the disease as well as therapy by showing the regression of these bone marrow lesions.

[Cyclosporin A in severe aplastic anemia in children]. / Cyclosporin A bei schwerer aplastischer Anämie im Kindesalter.

Severe aplastic anemia should be treated with bone marrow transplantation if possible. Various clinical and experimental data support the view that the major pathogenetic defect in SAA is a dysregulated cellular immune response which in turn has a negative effect upon hematopoiesis. Therefore a large percentage of patients react favorably to treatment with immunosuppressive agents as antithymocyte globulin and high-dose methylprednisolone. Data concerning the efficiency of Cyclosporine A treatment are limited until now. We present in this report our own experience with Cyclosporine A treatment in three children with severe aplastic anemia who lack a bone marrow donor. Included is also a review of the present therapeutic possibilities.

Polyclonal nature of the intestinal mucosal lymphocyte populations in inflammatory bowel disease. A molecular genetic evaluation of the immunoglobulin and T-cell antigen receptors.

To define the clonality of the intestinal lymphocytes involved in the immune response of inflammatory bowel disease, we performed a molecular genetic analysis of the arrangement of the immunoglobulin and antigen-specific T-cell receptor genes of isolated lamina propria lymphocytes derived from resected intestinal specimens of 12 patients with Crohn's disease, 5 patients with chronic ulcerative colitis, and 7 patients with other gastrointestinal diseases. The sensitivity of this technique is sufficient to detect a monoclonal population when there is as little as 1% clonal expansion in a mixed cell population. In all these groups of patients, deoxyribonucleic acid from the non-T cells demonstrated only a germ-line gene pattern, and no non-germ-line rearrangements of immunoglobulin genes as assessed by an immunoglobulin-joining heavy-chain gene probe. Deoxyribonucleic acid from the lamina propria T cells showed a rearrangement pattern of the antigen-specific T-cell receptor beta- and gamma-chain genes that is characteristic of polyclonal T cells as assessed by T-constant beta- and T-joining gamma-gene probes. These results indicate that the lamina propria non-T and T-lymphocyte populations in inflammatory bowel disease and controls are polyclonal.

Endocrine function after bone marrow transplantation without the use of preparative total body irradiation.

Ten children who underwent allogeneic (n = 5) or autologous (n = 5) bone marrow transplantation (BMT) for chronic myelogenous leukaemia (n = 2), acute lymphoblastic leukaemia (n = 1), acute myelogenous leukaemia (n = 2), severe aplastic anaemia (n = 2), malignant histiocytosis (n = 1), neuroblastoma (n = 1) and teratoma (n = 1) were assessed for endocrinological function. Transplant preparative regimens consisted of high-dose cyclophosphamide, high-dose cyclophosphamide in combination with high-dose busulphan, high-dose melphalan as well as BACT (BCNU, cytarabine, cyclophosphamide and 6-thioguanine) chemotherapy. None of the patients received total body irradiation (TBI). Median survival following BMT was 37 months (range 7-115). Growth hormone deficiency was present in only one patient; none of the patients had abnormal thyroid or adrenocortical function. This is in contrast to previous reports in which growth hormone deficiency and abnormal thyroid and adrenocortical function occurred in a much higher percentage of patients after BMT conditioned with TBI.

Immunoglobulin and T cell antigen receptor gene arrangements indicate that the immune response in autoimmune thyroid disease is polyclonal.

To further define the degree of heterogeneity of the antibody and cellular immune responses in autoimmune thyroid disease, we used Southern blot hybridization techniques to analyze the arrangements of immunoglobulin and T cell antigen receptor genes in circulating lymphocytes and in those infiltrating the thyroid gland in nine patients with thyrotoxicosis due to Graves' disease and five patients with Hashimoto's thyroiditis. The sensitivity of these techniques was sufficient to detect a monoclonal population when there was as little as 1% clonal involvement in a mixed cell population. In the patients studied, DNA from non-T peripheral blood cells and non-T intrathyroid lymphocytes had only a germline gene pattern and no clonal nongermline rearrangements of immunoglobulin genes, as assessed using an immunoglobulin joining heavy chain (IgJH) gene probe. An analysis of the DNA from peripheral blood T cells or intrathyroidal lymphocytes revealed polyclonal gene rearrangement patterns and no clonal nongermline rearrangements of the T cell antigen receptor-beta and -gamma genes, as assessed using T constant-beta and T joining -gamma gene probes. These results indicate that the lymphocytes in peripheral blood and those infiltrating the thyroid gland in patients with autoimmune thyroid disease are of polyclonal origin.

Development of a human monoclonal antibody from a Graves' disease patient that identifies a novel thyroid membrane antigen.

To investigate the interaction between antibodies and the thyroid gland in Graves' disease, PBL were harvested from seven Graves' disease patients and transformed into lymphoblasts by the addition of EBV in the presence of cyclosporine A. These lymphoblasts were cloned by limiting dilution and then assayed for binding activity to human thyroglobulin, thyroid-stimulating hormone, thyroid microsome, and thyroid as well as guinea pig fat cell membranes. Four patients' cells produced antibody that bound to at least one of the Ag; a single clone from one patient that bound equally well to both thyroid and guinea pig fat cell membranes (but not to other thyroid Ag) was selected for further evaluation. Fusion of these cells with SHM-D33 heteromyeloma cells yielded three cell lines that produced genetically identical mAb. Immunostaining of human thyrocytes with this mAb demonstrated an Ag present on both nuclear and cell membranes. This Ag was identified as an 18,000 m.w. protein band on Western blots of both human thyroid and guinea pig fat cell membranes. The mAb was also able to alter thyrocyte physiology as the short term incubation of this mAb with FRTL-5 cells in vitro inhibited thyroid-stimulating hormone-mediated production of cAMP. Thus, this mAb and the Ag it identifies may be relevant to Graves' disease.

[High-dose busulfan with subsequent bone marrow transplantation in poor-risk forms of leukemia]. / Hochdosiertes Busulfan mit anschliessender Knochenmarkstransplantation bei ungünstigen Leukämieformen.

The toxicity and potential late side effects of total body irradiation, especially in children, have caused the evaluation of alternative myeloablative agents. We report the results obtained in 4 patients with acute myelocytic leukaemia, 2 patients with acute lymphocytic leukaemia and 1 patient with chronic myelocytic leukaemia who received high-dose busulfan followed by bone marrow transplantation (4 times allogeneic, 3 times autologous), according to the protocol published by G. W. Santos. 4 patients have survived 708+, 413+, 313+ and 234+ days, respectively, to date, 3 patients died, two of whom had acute myelocytic leukaemia in relapse and died of cardiac and combined organ failure 9 and 10 days post transplantation, respectively, without evidence of leukaemic cells in the bone marrow. One patient with acute lymphocytic leukaemia (T-All) in second remission died of an extramedullary relapse 485 days after bone marrow transplantation. We report our experience in the use of busulfan before transplantation not only in patients with acute myelocytic leukaemia, but also in patients with acute lymphocytic leukaemia and chronic myelocytic leukaemia and discuss the effectiveness and toxicity of high-dose busulfan as alternative to total body irradiation.

[Use of autologous bone marrow transplantation in pediatric malignant diseases--results and conclusions]. / Die Anwendung der autologen Knochenmarkstransplantation (AKMT) bei pädiatrischen malignen Erkrankungen--Ergebnisse und Schlussfolgerungen.

Ultrahigh-dose myeloablative antineoplastic therapy followed by autologous bone marrow transplantation (ABMT) has become an attractive therapeutic option for patients without HLA compatible bone marrow donors. Autologous bone marrow was harvested in 9 patients. In four cases the bone marrow was also treated ex vivo with a stable derivative of 4-hydroperoxycyclophosphamide, ASTA-Z 7654, to eliminate residual tumour cells. Altogether 5 patients, namely a patient with metastatic neuroblastoma, a patient with malignant histiocytosis, a patient with recurrent sacrococcygeal malignant teratoma and two patients with acute myelogenous leukaemia in first remission are in continuous remission so far from 125 + to 821 + days (median 657 + days). These patients were transplanted at the time of minimal tumour load (first remission) and in good clinical condition 3-7 months after diagnosis, while 3 of the four patients who died were transplanted in first or repeated relapse after one to several years of chemotherapy. It is concluded that the earliest possible recognition of a refractory therapeutic situation is of utmost importance for successful ABMT. Patients with an unfavourably responding neoplasm should, therefore, be already primary candidates for ABMT.