Congenital disorders of bone and blood.

Bone and marrow are the two facets of the same organ, in which bone and hematopoietic cells coexist and interact. Marrow and skeletal tissue influence each-other and a variety of genetic disorders directly targets both of them, which may result in combined hematopoietic failure and skeletal malformations. Other conditions primarily affect one organ with secondary influences on the other. For instance, various forms of congenital anemias reduce bone mass and induce osteoporosis, while osteoclast failure in osteopetrosis prevents marrow development reducing medullary cavities and causing anemia and pancytopenia. Understanding the pathophysiology of these conditions may facilitate diagnosis and management, although many disorders are presently incurable. This article describes several congenital bone diseases and their relationship to hematopoietic tissue.

Prevalence Estimates of Rare Congenital Anomalies by Integrating Two Population-Based Registries in Tuscany, Italy.

BACKGROUND/AIMS: Population-based registries play a key role in the epidemiological surveillance of congenital anomalies (CAs). This study is aimed at improving the epidemiological surveillance and providing prevalence estimates of rare CAs using the Registry of Rare Diseases as an added data source to the Registry of Congenital Anomalies. METHODS: Cases of diagnosed rare CAs (2006-2013) were extracted from the Tuscany Registry of Rare Diseases and the Tuscany Registry of Congenital Anomalies in order to set up an integrated dataset. Prevalence (per 100,000 births; 95% confidence interval) was calculated for each rare CA. RESULTS: Overall, 56 rare CAs were analyzed including 656 cases, of whom 121 (18.4%) were retrieved from the Registry of Rare Diseases that provided a major contribution for rare CAs for which a prenatal diagnosis is difficult, or for CAs more easily diagnosed in the postneonatal period. After data integration, an increased prevalence estimate was observed in particular for atresia of bile ducts (6.24; 3.57-10.14), tuberous sclerosis (2.34; 0.86-5.10), Kabuki syndrome (1.95; 0.63-4.55), and some monogenic CAs. CONCLUSIONS: This study represents an example of integration of registries operating in the field of rare diseases. Providing the accurate prevalence of rare CAs is a key point to improving surveillance, supporting public health policies, and planning healthcare.

Successful haematopoietic stem cell transplantation in 44 children from healthy siblings conceived after preimplantation HLA matching.

Haematopoietic stem cell transplantation (HSCT) remains the best therapeutic option for many acquired and inherited paediatric haematological disorders. Unfortunately, the probability of finding an HLA matched donor is limited. An alternative technique is PGD combined with HLA matching, which offers the possibility of selecting unaffected embryos that are HLA compatible with the sick child, with the aim of possible use of stem cells from the resulting baby in future. Since the first successful report for Fanconi anaemia a decade ago, the therapeutic success of this technique was reported in a few cases and for a limited number of disorders. Here, we report full recovery of 44 sick children who received HSCT from healthy infants conceived after pre-implantation HLA matching for the following 10 indications; beta-thalassaemia, Wiskott-Aldrich syndrome, Fanconi anaemia, sickle cell anaemia, acute myeloid leukaemia, acute lymphoblastic leukaemia, Glanzmann's thrombasthaenia, Diamond-Blackfan anaemia, X-linked adrenoleukodystrophy and mucopolysaccharidosis type I. No serious complications were observed among recipients and donors. Graft failure occurred in four children with beta-thalassaemia where a second HSCT was planned. Preimplantation HLA matching is a reliable technique and provides a realistic option for couples seeking treatment for an affected child when no HLA-matched donor is available.

Non-cardiac manifestations of neonatal lupus erythematosus.

Neonatal lupus erythematosus (NLE) is characterized by the transplacental passage of maternal anti-Ro and/or anti-La antibodies and characteristic illnesses in the foetus/neonate. Most attention has focused on the most serious complication- cardiac involvement. This article will focus on non-cardiac involvement. Skin involvement (cutaneous NLE) is present in 15-25% of children with NLE. The rash of NLE tends to be photosensitive but may be present at birth or in non-sun exposed areas. It is most frequently seen around the eyes, not in the malar area, but also occurs in other parts of the body. The pathology resembles the rash of subacute cutaneous lupus erythematosus. Anti-Ro antibodies are present in >95% with the remaining mothers having anti-U1RNP antibodies only. Asymptomatic elevation of liver function tests, which may be associated with evidence of cholestasis, is seen in 10-25% of cases of NLE. Mild hepatomegaly and less commonly splenomegaly may be present. Liver involvement seen in isolation or associated with other features. The pathology resembles idiopathic neonatal giant cell hepatitis. Any haematological lineage, neutropenia and thrombocytopenia most commonly, may be affected by NLE. Haematological involvement is almost always asymptomatic. There are protean manifestations of neurologic involvement in NLE: hydrocephalus, non-specific white matter changes, calcification of the basal ganglia and a 'vasculopathy'. The most unusual feature of NLE is the radiographic finding of stippling of the epiphyses (chondrodysplasia punctata). Overall, non-cardiac involvement of NLE is more common than cardiac. The study of these manifestations may lead to new insight into how autoantibodies lead to disease.

Comparison of megadose methylprednisolone versus conventional dose prednisolone in hematologic disorders.

Glucocorticoids (GCs) are known for their clinically useful effects in immunologic and inflammatory disorders. Although there is a huge volume of knowledge concerning the cellular and molecular effects of GCs, statements regarding their effects in multiple diseases at variable doses are not clear-cut owing to pharmacogenetic differences. The main actions of GCs in hematologic disorders have been related to their differentiation-inducing and apoptosis-inducing effects, but modification of several steps of the hematopoietic and/or immune pathway has also been reported. In our clinic, mega-dose methylprednisolone (MDMP) has been successfully used for treatment of different hematologic diseases, such as leukemias, bone marrow failure in aplastic anemia, hypoplastic anemia, myelodysplastic syndrome, neutropenia, autoimmune diseases, and in some congenital hereditary diseases. Both clinical and experimental studies in our department revealed that MDMP was more effective than conventional dose steroids. It is interesting that MDMP can be curative in some congenital hereditary diseases such as Diamond-Blackfan syndrome. However, more research is required to clarify their roles in biology, physiology, and molecular genetics.

Hematología perinatal / Perinatal hematology

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Neonatal hematologic disorders.

Neonatal hematology is a complex subspecialty of pediatric hematology, combining the unique aspects of the maternal/fetal relationship, the delicate balance of coagulation factors, and the distinctive physiologic conditions of the newborn period. The objective of this article is to briefly review specific hematologic disorders that commonly present in the newborn period. Alloimmune cytopenias, polycythemia, thrombosis and bleeding associated with vitamin K deficiency will be discussed through a focus on pathophysiology, signs and symptoms, current treatment strategies, and implications for nursing care.

[Neonatal lupus: different clinical neonatal expression in siblings]. / Lupus néonatal: une fratrie de nouveau-nés avec différentes expressions cliniques.

Neonatal Lupus Syndrome is a rare disease caused by placental passage of maternal autoantibodies. Pathogenesis is partially unknown and many clinical manifestations are possible. We report on newborn siblings who presented with different symptoms of Neonatal Lupus Syndrome. One patient presented with congenital heart block and another with hepatic and haematologic involvement. Cases of Neonatal Lupus among siblings are very rare, because of the high risk of pregnancy in affected women. Various clinical expressions may be explained by a different specificity of Anti-Ro autoantibodies among siblings. The reported cases are commented with regard to recent literature, trying to explain their pathogenesis.

Gene therapy for inherited disorders of haematopoietic cells.

Over the last decade, the majority of inborn errors of haematopoiesis has been elucidated on a molecular level. For some of these diseases, gene transfer into transplantable cells offers new therapeutic perspectives. Improved retroviral or lentiviral techniques allow stable gene transfer in >10% of repopulating cells cultured in vitro. However, severe impediments are still encountered with respect to achieving sufficient and long-lasting transgene expression levels and appropriate numbers of transgenic cells in vivo. Improving the techniques for manipulation of stem cells in vitro, and the development of regimens promoting engraftment and selection of gene-modified cells are important areas of current research. Further activities address the level and persistence of transgene expression within individual cell clones, and the functional characteristics of progeny cells in vivo. Promises with respect to the potential impact of gene therapy for patients suffering from inherited disorders are often triggered by 'proof of concept' in preclinical disease models. However, recent observations of side effects related to random vector insertion or transgene expression indicate that even more careful quantitative and qualitative investigations of efficiency and toxicity may be needed for individual transgenes before approaching clinical trials.

In utero hematopoietic cell transplantation: what are the important questions?

The treatment of congenital hematologic disorders before birth by in utero hematopoietic stem cell transplantation remains a challenging goal. Although success has been achieved in X-linked severe combined immunodeficiency, the approach has failed in all other disorders attempted thus far. In this review, we examine relevant experimental data from the perspective of an analysis of why failure has occurred. We will also attempt to pose the important questions that will need to be answered prior to further clinical attempts to treat most target disorders by this approach.

Role of apoptosis in congenital hematologic disorders and bone marrow failure.

Apoptosis, the cell's intrinsic death program, plays a critical role in the regulation of tissue homeostasis, especially in cell systems with a high turnover rate such as hematopoiesis. Imbalances between survival, proliferation and death of precursor cells or mature cells may result in accelerated loss or impaired output or uncontrolled polyclonal or monoclonal expansion and may pave the way to the development of leukemia. Congenital hematologic disorders are characterized by disturbed growth control of hematopoietic cells. In the previous years, it has become clear that deregulated apoptosis contributes or is even a key determinator of the pathophysiology of diseases such as lymphoproliferation, aplastic anemia or chronic neutropenia. Hematopoietic growth factors have been shown not only to stimulate proliferation of hematopoietic stem cells and committed precursor cells, but also to act as survival factors protecting developing precursor cells from apoptotic signals. The molecular delineation of pathways of apoptosis signaling or survival in hematopoietic cells is expected to provide tools for molecular understanding of the pathophysiology of congenital and acquired hematopoietic disorders and to identify targets for therapeutic intervention strategies.

A K19E missense mutation in the plasminogen gene is a common cause of familial hypoplasminogenaemia.

The prevalence of familial plasminogen deficiency in Scotland has recently been calculated at 2.9/1000. However, little is known of the molecular genetic background and the frequency of plasminogen gene mutations in most cases of inherited plasminogen deficiency. Having previously identified 28 unrelated subjects with familial plasminogen deficiency from a cohort of 9611 blood donors, we have now reviewed 19 of these 28 subjects and screened the plasminogen gene in 15 subjects with hypoplasminogenaemia (plus five relatives) and four subjects with dysplasminogenaemia for mutations and polymorphisms. A missense mutation K19E in the plasminogen gene was found in 13 of the 15 propositi with hypoplasminogenaemia, in one of these in a homozygous manner. In two subjects with hypoplasminogenaemia, two new mutations (P353A and R471X) were identified. These three different mutations, if inherited in a homozygous or compound-heterozygous manner, may be associated with the development of ligneous conjunctivitis. In four subjects with dysplasminogenaemia, three heterozygous mutations (C548G, n = 1; A601T, n = 1; G693R, n = 2) were found. None of the propositi with plasminogen deficiency developed venous thrombosis at any time. In conclusion, the K19E mutation in the plasminogen gene is a common cause of hypoplasminogenaemia in Scotland, with an estimated prevalence of around 0.14%.

Testing for hematologic disorders and complications.

This review summarizes state-of-the-art and emerging techniques in the antenatal diagnosis of fetal anemia and hemoglobinopathies. Fetal anemia may result from hemolytic disease, hemorrhage, suppression of erythropoiesis, infection (eg, parvovirus B19), or trauma. The clinical laboratory plays an essential role in the evaluation of these disorders by way of the use of various hematologic, biochemical, serologic, cytometric, and molecular genetics methods. Hemoglobinopathies are the most common class of single gene disorders worldwide. The authors have used the example of homozygous alpha-thalassemia major (Hb Barts disease) as a paradigmatic case for antenatal hemoglobinopathy screening. Perhaps the most familiar indication for hematologic screening in pregnancy is HDFN, most commonly in pregnancies previously sensitized to the RhD antigen. All pregnant women, regardless of their past medical or obstetric history or previous antibody screens, should have ABO/Rh blood typing and a red cell antibody screen performed at the first prenatal visit. Long-established methods for assaying FMH (KB method), microcytosis (hemogram with red cell indices), and blood group incompatibility (direct antigen test, serologies) remain critical for rapid, sensitive diagnosis. Analysis of fetal free DNA in maternal plasma holds the promise for rapid, ultrasensitive, and noninvasive detection of many fetal hematologic disorders.

Genetic modification of hematopoietic stem cells: recent advances in the gene therapy of inherited diseases.

Hematopoietic stem cells constitute a rare population of precursor cells with remarkable properties for being used as targets in gene therapy protocols. The last years have been particularly productive both in the fields of gene therapy and stem cell biology. Results from ongoing clinical trials have shown the first unquestionable clinical benefits of immunodeficient patients transplanted with genetically modified autologous stem cells. On the other hand, severe side effects in a few patients treated with gene therapy have also been reported, indicating the usefulness of further improving the vectors currently used in gene therapy clinical trials. In the field of stem cell biology, evidence showing the plastic potential of adult hematopoietic stem cells and data indicating the multipotency of adult mesenchymal precursor cells have been presented. Also, the generation of embryonic stem cells by means of nuclear transfer techniques has appeared as a new methodology with direct implications in gene therapy.

[Congenital inborn diseases with disorders of neutrophil count]. / Wrodzone schorzenia przebiegajace z zaburzeniami liczby granulocytów obojetnochlonnych.

In the research we showed some inborn syndromes with disturbances of the neutrophils' number. The diseases were divided in the following categories: disturbed proliferation of myeloid stem cells, phenotypic anomalies, panmyelophtisis, neutropenia caused of marrow infiltration, neutropenia caused of agammaglobulinemia or dysgammaglobulinemia, metabolic disorders. The nowadays diagnostic possibilities and treatment in these cases were showed.

Intrauterine fetal diagnosis for hematologic and other congenital disorders.

Advances in prenatal diagnostic techniques allow for earlier, more rapid, and more effective detection of congenital disorders. The indications, diagnostic accuracy, and risks for invasive diagnostic techniques including amniocentesis, chorionic villus sampling, and fetal blood sampling are reviewed. Recent advances in non-invasive detection methods, such as fetal ultrasound and the isolation of fetal cells in the maternal circulation are discussed. Additionally, the intrauterine diagnosis of congenital infections and chromosomal and Mendelian disorders, as well as hematologic disorders are summarized.