Improved treatment results for childhood acute myeloid leukemia in Taiwan.

To improve treatment results for children with de novo acute myeloid leukemia (AML), we introduced a novel protocol, Taiwan Pediatric Oncology Group-AML-97A, for AML other than acute promyelocytic leukemia (APL), for which modified conventional protocols were used. From January 1, 1997, to December 31, 2002, 141 children younger than 17 years old with de novo AML were enrolled. In total, 117 patients with non-APL AML were treated with induction therapy of idarubicin and cytarabine (Ara-C), postremission therapy with high-dose Ara-C - containing regimens for four monthly courses, and moderate-dose therapy with idarubicin and Ara-C for four monthly courses. The first 19 patients with APL were treated with all-trans retinoic acid, idarubicin and Ara-C, with the remaining five patients receiving all-trans retinoic acid and idarubicin, followed by maintenance therapy for 2 years. Stem cell transplantation was performed in 29 patients in first remission with a similar outcome as chemotherapy alone. The remission rate in the AML-97A study was 90%, the 5-year survival 51 +/- 5.3% (s.e.) and the 5-year event-free survival 50 +/- 4.8%; for APL, these were 100%, 86 +/- 7.0, and 75 +/- 9.8%. For the whole group, the 5-year survival was 57 +/- 4.7% and the 5-year event-free survival 54 +/- 4.4%. The AML-97A regimen was well tolerated.

A novel mutation in neonatal isolated sulphite oxidase deficiency.

Isolated sulphite oxidase deficiency (ISOD) is a very rare hereditary metabolic disorder. Imaging findings of the neonatal form of ISOD, including multicystic leukoencephalopathy with brain atrophy, resemble those of severe ischemic changes of the brain. We report the case of a ten-month-old boy who exhibited neonatal seizures on the 24th day after birth. Excessive quantities of sulphite and S-sulphocysteine in the urine and normal blood uric acid were noted. These findings were consistent with those of ISOD. Point mutations were found in two alleles of the sulphite oxidase (SUOX) gene. One of the mutations was a 1029 C > G mutation, which resulted in an amino acid substitution of tyrosine to a stop code (Y343 X); and the other was a 479 G > A mutation, which resulted in an amino acid substitution of arginine to glutamine (R160 Q). Y343 X is a novel SUOX gene mutation. A review of the literature, including data from this report, showed that 3 of 6 cases had typical imaging findings characterized by initial cerebral edema followed by dramatic multicystic leukoencephalopathy. We emphasize that neonatal ISOD should be included in the differential diagnosis of neonates with unexplained hypoxic-ischemic changes on neuroimaging studies.

Mutation analysis of thyroid peroxidase gene in Chinese patients with total iodide organification defect: identification of five novel mutations.

Total iodide organification defect (TIOD), where the iodide in the thyroid gland cannot be oxidized and/or bound to the protein, is caused by a defect in the thyroid peroxidase (TPO) gene. Single strand conformation polymorphism analysis was used to screen for mutations in the TPO gene from five unrelated TIOD patients in Taiwan, and five novel mutations were detected. Three of these were frameshift mutations: a single T insertion between nucleotide position 2268 and 2269 (c.2268-2269 insT) in exon 13 and two single C deletions at nucleotide positions 843 (c.843 delC) and 2413 (c.2413 delC) in exon 8 and 14 respectively. The other two were single nucleotide substitutions (c.G1477>A and c.G2386>T) located in exons 9 and 13 respectively. While the former would result in amino acid substitution (Gly493Ser) in the highly conserved region of the TPO polypeptide, the latter would result in either amino acid substitution (Asp796Tyr) or alternative splicing. Of those identified TPO mutations, c.2268-2269 insT was most prevalent and was detected as heterozygous in all but one TIOD patients. All five TIOD patients investigated in this study were compound heterozygous. The method presented in this study could be used for carrier assessment and mutation analysis of newly identified TIOD patients.

Growth response and final height in growth hormone-deficient patients treated with biosynthetic growth hormone.

Twenty-three patients with growth hormone deficiency (GHD) followed until their final heights (FH) were reported by retrospective review. Seven patients had spontaneous puberty (group 1) and sixteen required induction of puberty (group 2). Their heights prior to growth hormone (GH) therapy were -3.7 +/- 1.4 and -2.8 +/- 1.4 SDS in men and women respectively. The mean ages at initiation of GH therapy were 17.2 +/- 3.3 in men and 13.0 +/- 1.7 years in women, with a growth velocity < 4 cm/year and a mean bone age (BA) of 12.6 +/- 0.7 years (men) and 9.8 +/- 1.2 years (women). The dose of GH was 0.27-0.83 IU/kg/week, with a total duration of 2.5 +/- 1.0 years. Their consecutive annual mean growth velocities on GH therapy were: 10.6 cm/year, 8.0 cm/year, 6.1 cm/year, 5.1 cm/year and 4.6 cm/year respectively. They reached a mean final height of 167.1 +/- 5.3 cm (-0.4 +/- 1.0 SDS) in men and 157.9 +/- 3.5 cm (-0.1 +/- 0.7 SDS) in women, which is slightly taller than their target height. Demographic factors related to growth response and final heights were analyzed. We conclude that GH therapy is very effective in linear growth promotion. Their final height was correlated with initial height SDS, target height SDS, predicted adult height SDS according to the bone age at the start of GH therapy and height SDS at the onset of puberty.

Precocious puberty associated with growth hormone deficiency in a patient with craniopharyngioma: report of one case.

Isosexual precocious puberty in girls is not uncommon, but its association with craniopharyngioma and growth hormone deficiency is rarely reported. We present a patient with this combination. An 8-year-old girl developed breasts and then had menarche at 7 9/12 years old. Growth hormone deficiency was suspected due to inappropriate height and growth velocity in association with idiopathic precocity and a poor predicted adult height of 138.8 cm. Growth hormone deficiency was confirmed by clonidine and insulin stimulation tests. Intracranial lesion was suspected due to precocity associated with GH deficiency. MRI of the sella's region revealed a 1 cm mass in the hypothalamus. After surgical resection, pathology of the tumor disclosed a craniopharyngioma which has rarely been reported to cause precocious puberty. The precocious puberty regressed after surgery. Growth hormone deficiency persisted and GH therapy was given to improve growth. The growth rate of patients with both growth hormone deficiency and precocious puberty may be maintained within the normal prepubertal range by the effect of sex steroid. We suggest that in patients with central type precocity in association with an inappropriate growth status, physicians should investigate the underlying intracranial lesion, and the possibility of growth hormone deficiency.

The promoter region of the CTLA4 gene is associated with type 1 diabetes mellitus.

The CTLA4 (cytotoxic T lymphocyte associated antigen-4) gene encodes the T cell receptor involved in the control of T cell proliferation and mediates T cell apoptosis. C-T polymorphism is present at position -318 from the ATG start codon in the promoter region of the gene. We report a study on the polymorphism in 347 unrelated children with type 1 diabetes mellitus (DM) (age at diagnosis 7.2+/-3.8 years) and their 260 healthy siblings as controls. Genotype C/C conferred a risk of type 1 DM (RR = 2.02, 95% CI 1.32-3.10, pc = 0.0033). The gene frequency of the C allele was higher in patients (RR = 1.91, 95% CI 1.28-2.84, pc = 0.0026). The gene frequency and phenotype frequency of the T allele were negatively associated with type 1 DM (RR = 0.52, 95% CI 0.35-0.78, pc = 0.0026 and RR = 0.49, 95% CI 0.32-0.76, pc = 0.0022, respectively). The frequency of genotype C/T was lower in patients (RR = 0.50, 95% CI 0.32-0.78, pc = 0.0051). This study demonstrates that nucleotide -318 C-T polymorphism of the CTLA4 gene is associated with type 1 DM. The promoter allele -318 C confers a risk of type 1 DM but allele -318 T confers protection against this disease.

Transient neonatal hypoparathyroidism: report of four cases.

Neonatal hypocalcemia (NH) is common in the neonatal period. Its cause falls into one of two clinical categories, early NH occurs in first 24-48 hours of life; late NH is observed at the end of the first week of life. NH due to congenital hypoparathyroidism, either permanent or transient, is rare. They both present with hypocalcemia, low levels of intact parathyroid hormones, and hyperphosphatemia. In this paper we report on four cases of neonatal hypocalcemia due to transient hypoparathyroidism. They are all full-term infants with normal birth weights, carried by nondiabetic mothers. The age of onset was 6 days old to 17 days old, there were three male and one female. Seizure was the major symptom except for case 2, who had a high pitch crying, irritability and opisthotonus. Laboratory data revealed calcium: 4.7 to 6.3 mg/dl, phosphorus: 6.8 to 9.2 mg/dl, and magnesium: 1.2 to 2.8 mg/dl. The intact parathyroid hormone levels were abnormally low in two cases (<13 pg/ml and 5.7 pg/ml), yet only subnormal in the other two (25.2 pg/ml and 22.2 pg/ml). Further studies on these four babies showed no evidence of Di George syndrome. Interestingly, two patients' mothers were found to have hyperparathvroidism. In conclusion, in case of neonatal hypocalcemia, measurements of calcium, phosphorus, and intact-PTH in neonates are required to recognize hypoparathyroidism. Pediatricians should always check maternal parathyroid status to rule out maternal hyperparathyroidism.

Treatment results of the TPOG-NHL92 protocols for childhood non-Hodgkin's lymphomas in Taiwan: a report from the Taiwan Pediatric Oncology Group (TPOG)

A nation-wide chemotherapeutic trial for childhood non-Hodgkin's lymphoma (NHL) was conducted by the Taiwan Pediatric Oncology Group (TPOG). Four TPOG-NHL92 protocols based on stage and histology were activated in 1992: TPOG-92LD (treatment duration: 8 months) was used for localized (stages I/II) NHL with any histology, 92LB (2 years), 92SNC (5 months), and 92LC (1 year) for advanced (stages III/IV) lymphoblastic (LB), small non-cleaved cell (SNC), and large cell (LC) lymphoma, respectively. From January 1992 through June 1998, 200 children with newly diagnosed NHL from 13 member hospitals of TPOG were enrolled. There were 140 boys and 60 girls. Their ages at diagnosis ranged from 2.4 months to 18.3 years with a median of 8.2 years. There were 54 (27.3%) patients with LB, 94 (47.5%) with SNC including B-cell acute lymphoblastic leukemia (B-ALL), and 50 (25.2%) with LC. Stages I, II, III, and IV (including B-ALL) of the disease comprised 5%, 10%, 43%, and 42% of cases, respectively. There were 176 patients eligible for evaluation of treatment results. The remission rate of induction was 82.4%, induction failed in 22 (12.5%) patients, and nine patients died during induction. As of August 31, 1999, 26 patients relapsed, six died during remission, one patient developed secondary acute myelomonocytic leukemia, and 105 patients remained in continuous remission with a median remission duration of 49 months. The event-free survival (EFS) at 7 years was 63.5%, 61.5% and 65% for LB, SNC, and LC groups (P = 0.8298). The 7-year EFS for stages I/II, III, and IV of the disease was 73%, 68.9%, and 50.3% (P = 0.0212), respectively. We concluded that following the strategy of stratification of therapy, only disease stages had prognostic significance in this study. More efforts are needed to improve our treatment results.

Novel cystic fibrosis mutation (2215insG) in two adolescent Taiwanese siblings.

Cystic fibrosis (CF) is an autosomal recessive disorder that is rarely found in Asians. Only four cases of CF from four different families have been reported in Taiwan. We report two cases of CF involving two teenage siblings. Both presented with repeated airway infections, poor weight gain, clubbing of the fingers, hypoxemia, and obstructive ventilatory impairment. Multiple focal bronchiectases and emphysema were demonstrated on high-resolution computed tomography. Sweat chloride concentrations, as measured using the modified sweat chloride test in a closed space with a heater, were 327 mmol/L and 276 mmol/L, respectively. To confirm the CF diagnosis, DNA mutation analysis was performed. All 27 exons of the CF transmembrane conductance regulator (TR) gene and their flanking intron sequences were screened for nucleotide sequence alterations, and the mutations were then identified by direct DNA sequence analysis. Both siblings carried 1898 + 5G-->T; a mutation previously identified in Taiwan. In addition, the mutation analysis identified a new single-base-insertion mutation in exon 13 on the second CFTR allele of these patients. This mutation, named 2215insG, is expected to cause a significant disruption of CFTR function. The 1898 + 5G-->T/2215insG genotype is thus consistent with the CF diagnosis. A new missense mutation, S895N, in exon 15 of the CFTR gene, which cosegregated with 2215insG, was also identified in both of these patients.

Growth response and final height in Turner syndrome after combination therapy of growth hormone and anabolic steroid.

To improve the growth of Turner syndrome patients we administered human growth hormone (GH) combined with anabolic steroid. Thirty three patients completed at least one year of GH therapy. Daily GH injection was started at a dose of 1.0 IU/kg/wk at age 12.6 +/- 2.1 years when their heights were below -3.2 +/- 2.1 standard deviation, growth velocity was less than 4 cm/year and bone age (BA) was 9.9 +/- 1.7 years. Anabolic steroid was added at 14.3 +/- 1.3 years of age when their growth velocity slowed. Their consecutive annual growth velocities were: 7.40 cm/year; 6.15 cm/year; 5.47 cm/year; 4.74 cm/year and 4.05 cm/year respectively. Growth hormone therapy was discontinued when patients grew less than 4 cm/year, their BA reached 14 years or they were satisfied with their height. After combination therapy of GH for 3.0 +/- 1.1 years and anabolic steroids for 1.9 +/- 1.0 years, the final height of 17 patients was 150.3 +/- 4.1 cm. We compared our results with worldwide reports and analyzed demographic factors related to growth response and final height. We conclude that combination therapy of GH and anabolic steroid is effective in improving growth and final height of Chinese Turner patients.

Mutations of CTNS causing intermediate cystinosis.

Six patients with the intermediate form of cystinosis are described. Two have new mutations not previously described. The disease occurs due either to the combination of one mild mutation and one which is known to cause nephropathic cystinosis or to homozygosity for a predicted mild mutation. Partial phenotypic correction of cystinotic fibroblasts by transfection with normal cDNA or a cDNA derived from a mutation causing intermediate cystinosis is demonstrated.

The preliminary result of the training course of pediatric advanced life support.

To improve the preparedness of health care providers in pediatric resuscitation and to evaluate the effectiveness of the Pediatric Advanced Life Support course, we followed the standard guidelines of American Heart Association to conduct the first 10-hour course of Pediatric Advanced Life Support course in our hospital and designed this study. A total of 160 doctors and nurses were enrolled in the providers course held on Jan. 11, 1998. A pretest, posttest and survey questionnaire were given to each participant. One hundred and twenty-nine completed these tests. The average scores were 73.1 for the pretest and 86.8 for the posttest. The average scores on the pretest and posttest among doctors (n = 57) and nurses (n = 72) are 72.6, 86.7 and 73.5, 86.8, respectively (p < 0.001). In the participants with pretest score of less than 80 (n = 92), the mean values of pretest and posttest scores were 69.0 and 86.4. The participants with pretest scores higher than or equal to 80 (n = 37) had pretest and posttest mean values of 83.3 and 87.7. The participants with less background knowledge (pretest < 80) had better increment scores after this course (p < 0.05). The mean posttest scores in those working in private clinics and having 20 years of working experience are 74.0 and 72.0 (lower than the criteria for successful completion of written examination). We conclude that this provider course did increase the knowledge and skill pertaining to pediatric resuscitation personnel, particularly in participants with less background knowledge. The participants from private clinics or with working experience more than 20 years need a repeatedly educational PALS training course.

Identification of four novel mutations in the CYP21 gene in congenital adrenal hyperplasia in the Chinese.

Congenital adrenal hyperplasia (CAH) is a common autosomal recessive disorder mainly caused by defects in the steroid 21-hydroxylase (CYP21) gene. We have analyzed CYP21 gene sequences in 65 CAH families in Taiwan. All ten exons of the CYP21 gene were analyzed by differential polymerase chain reaction followed by single-strand conformation polymorphism electrophoresis and the amplification-created restriction site method. About 95% (123 chromosomes) contain mutations due to conversion of DNA sequences into its neighboring homologous pseudogene, CYP21P. Four novel mutations representing 5% of the total chromosomes have also been identified. The mutations were confirmed by sequencing an aberrant DNA fragment. These four mutations included a base change of the splicing donor site at intron 2 from GT to AT, a base substitution of C to T at codon 316, deletion of ten bases (TCCAGCTCCC) at codons 330-333 of exon 8, and duplication of 16 bases (CCTGGATGACACGGTC) at codons 393-397 of exon 9. The loss of the splicing donor site at intron 2 and the premature stop at codon 316 may result in aberrant splicing to reduce enzyme activity and a truncated protein with no enzyme activity, respectively. Likewise, both the duplication and the deletion forms create a frameshift and premature stop during translation. The resulting proteins lack the heme-binding domain and hence are expected to lose enzymatic activity. Since these mutations are not found in the neighboring CYP21P pseudogene, gene conversion should not be the cause of these novel mutations.

Mucopolysaccharidosis type II (Hunter's syndrome) in Taiwan.

The mucopolysaccharidoses are a group of inherited disorders of lysosomal storage of glycosaminoglycans. Among them, mucopolysaccharidosis (MPS) type II (Hunter's syndrome), caused by a deficiency in iduronate sulfatase, is the only one inherited in an X-linked recessive manner. We describe 12 Hunter's syndrome patients and seven carriers, with precise analysis of glycosaminoglycan content in urine and iduronate sulfatase activity in cultured fibroblasts and plasma. Their ages at the time of diagnosis ranged from 1 year 10 months to 11 years (mean 4.3 yr). The delay in diagnosis was from 1 month to 5 years (mean 2.1 yr) after the initial presentation. The most frequent initial complaints of the patients were delayed developmental milestones (75%) and speech (67%), although all patients were found to have coarsening of facial features at diagnosis. The difficulties in disease recognition allowed disease recurrence in four of the 11 families. Prompt clinical suspicion and referral will be important in genetic counseling for MPS type II and its management, if definitive therapy becomes available.

Genetic analysis of the insulin receptor gene in Chinese patients with extreme insulin resistance.

BACKGROUND: Many patients with extreme insulin resistance in combination with acanthosis nigricans are reported to have defective insulin receptor genes. Because acanthosis nigricans is commonly accompanied by severe hyperinsulinemia and obesity, and obesity is a major factor in insulin resistance, this study was initiated to assess the prevalence of mutations in the insulin receptor gene in Chinese patients with extreme insulin resistance defined by hyperinsulinemia, obesity and acanthosis nigricans. METHODS: Exons 1-22 of the insulin receptor gene were amplified by polymerase chain reaction (PCR) by from genomic DNA from 13 young subjects with clinical and metabolic features of extreme insulin resistance. They were also screened for nucleotide variation using single-strand conformation polymorphism (SSCP) combined with nucleotide sequence analysis. RESULTS: Variant SSCP patterns were detected in exons 1, 3, 6, 11, 12 and 17 of the insulin receptor gene. However, sequencing of amplified DNA fragments revealed that none of the variations were mutations. The SSCP variant in exon 1 was caused by a novel intron polymorphism (G-->T at position 13, 5' intron), while the SSCP variant in exon 12 was caused by a novel silent polymorphism Thr789 (ACG-->ACA). Variants in exons 3 and 17 corresponded to known silent polymorphisms: Gln276 (CAA-->CAG) and His1068 (CAC-->CAT), respectively. Another three variants in exons 3, 6 and 11 were also identified as known polymorphisms in the flanking introns. In addition, two alterations, a silent polymorphism Gly8 (GGA-->GGG) and a polymorphism in the 3' flanking intron (T-->G at position 74), were observed in exon 1 of the insulin receptor gene. CONCLUSIONS: Although the prevalence of insulin receptor gene mutations in this Chinese study population might be underestimated because of the sensitivity of SSCP, these results suggest that mutations at the insulin receptor locus are uncommon in subjects with features of hyperinsulinemia, obesity and acanthosis nigricans.

Familial primary hypomagnesemia complicated with brain atrophy and cardiomyopathy.

A 2 5/12-year-old Chinese boy was investigated for refractory seizures and psychomotor regression. His birth history was unremarkable. Generalized seizures occurred at 2 weeks of age with hypocalcemia. They recurred at 7 months of age and have become aggravated since. During hospitalization, in addition to hypocalcemia and hypomagnesemia, he was found to have hypoparathyroidism, cardiomyopathy, and brain atrophy. Excessive renal loss of magnesium, general intestinal malabsorption, or inadequate dietary intake of magnesium were excluded. He was successfully treated with oral supplements of 19-25 mmole/day of magnesium. Over a few months, he made a dramatic progress in development. His hypoparathyroidism and cardiomyopathy gradually resolved. However, intermittent seizures and psychomotor retardation persisted up to his present age of 6 3/12 years. At 4 months of age his younger sister also developed seizures and was found to have isolated hypomagnesemia. This was corrected by oral magnesium and followed by resolution of the seizure. She has developed normally up to her present age of 1 10/12 years. Both patients are currently maintained on oral magnesium oxide.

Primary intracranial germ-cell tumor in children.

BACKGROUND: Primary intracranial germ-cell tumors (GCTs) account for about 11.1% of all primary brain tumors of children in Taiwan. Because these tumors commonly involve the hypothalamus-pituitary gland regions and their biochemical secreting character, patients frequently display neuroendocrinological symptoms and signs. Endocrinopathy, if present, often occurs prior to other neurological or radiological manifestations. This article reviews experience here, with present results comparing them with previous reports. METHODS: Twelve children who were diagnosed with primary intracranial germ-cell tumors between 1983 to 1995 were studied retrospectively. Their clinical presentations, laboratory results and treatment modalities as well as the current status were collected for presentation here. RESULTS: There were seven boys and five girls. The age distribution was from 5 to 15 years old. The most common symptom was increased intracranial pressure (9/12), followed by diabetes insipidus (8/12), vision deficit (8/12) and sexual precocity in 3 boys. In 11 patients the tumors arose from the suprasellar or pineal regions. In two patients the tumors arose synchronously in the suprasellar and pineal regions. Pure germinoma was found in six patients. Only one had an elevated tumor marker. These six patients all received radiation with or without operation therapy, and all are still alive. Six patients, each with a non-germinomatous malignant germ-cell tumor, had a poorer prognosis. Although they received aggressive treatment, including operation, radiation and chemotherapy, three patients died, with a mean survival period of 3.3 years. CONCLUSIONS: In cases of diabetes insipidus in children or sexual precocity in boys, a thorough investigation for intracranial germ-cell tumors is recommended. The treatment and outcome are different for germinomas and non-germinomatous malignant germ-cell tumors. A thorough pathological diagnosis is recommended for planning of treatment protocol in order to improve prognosis.

Genetic analysis of the glucose-6-phosphatase mutation of type 1a glycogen storage disease in a Chinese family.

Type 1a glycogen storage disease (GSD) is an autosomal recessive metabolic disorder caused by a deficiency in glucose-6-phosphatase (G6Pase). Polymerase chain reaction (PCR) and nucleotide sequence analysis were used to identify the location and nature of mutations at the G6Pase locus in two siblings affected with type 1a GSD. Both patients are compound heterozygotes with two different single nucleotide substitutions in the two G6Pase alleles. A guanine to adenine transition was identified at base position 327 in the exon 2, converting an arginine to a histidine at codon 83. The second substitution was a thymine to adenine transversion at base position 1101 in the exon 5, converting an isoleucine to an asparagine at codon 341. Family study reveals that both parents are heterozygous carriers: the father with a mutant G6Pase allele at exon 2, the mother with another mutant G6Pase allele at exon 5. This is the first family study in Taiwan on type 1a GSD identified by molecular analysis. The mutations identified herein are novel substitutions in the G6Pase gene. In addition, an adenine to guanine substitution was observed at base position 653 in the exon 5 of G6Pase gene in both sibling patients and their parents, as well as in 15 normal Chinese subjects and three normal Caucasian subjects.

Alagille syndrome with interstitial 20p deletion derived from maternal ins(7;20).

We present a 6-year-old Chinese boy with Alagille syndrome and an interstitial 20p deletion, with a karyotype of 46,XY,der(20)dir ins(7;20)(q11.23;p11.23p12.2 or p12.2p13)mat. He had a peculiar face and suffered from congenital heart disease, growth retardation, severe cholestasis, hepatosplenomegaly, and impaired renal function. The karyotype of his mother showed a balanced translocation, 46,XX,dir ins(7;20)(q11.23; p11.23p12.2 or p12.2p13), and her phenotype was normal. His dead elder brother was highly suspected as another victim of Alagille syndrome. The findings in the present family suggested that if Alagille syndrome is a single gene defect, the putative gene responsible for the syndrome would not be located at the insertion breakpoints but located within the deletion extent.