Molecular basis of thalassemia syndromes in Serbia and Montenegro.

This study reports the molecular characterization of thalassemia syndromes in Serbian and Montenegrin populations. We identified eight beta-thalassemia mutations [codon 39 (C-->T), IVS-I-110 (G-->A), IVS-II-745 (C-->G), codon 44 (-C), -87 (C-->G), IVS-II-1 (G-->A), IVS-I-6 (T-->C), IVS I-1 (G-->A)] in 70 members of 29 families using polymerase chain reaction, reverse dot blot, amplification refractory mutation system and direct sequencing analysis. Hemoglobin (Hb) Lepore was found to be the most common cause of the thalassemia phenotype. Hb Sabine and alpha-thalassemia were detected as well. We also studied beta-globin gene cluster haplotypes and their association with the most common mutations. A novel haplotype associated with the Hb Lepore gene was identified. The results presented herein allowed the implementation of a prenatal diagnosis program in Serbia and Montenegro.

[Primary myelodysplastic syndrome in children]. / Sindrom primarne mijelodisplazije kod dece.

Primary MDS is a group of heterogenous clonal haematopoetic disorders. In a third of patients MDS terminates as acute myeloid leukaemia, usually resisitant to treatment, while the others succumb due to infections and haemorrhage. Conservative managements of MDS (chemotherapy, haematopoetic growth factors, modulation of cytokine network) are unsuccessful, while the bone marrow transplantation is the only definite treatment. We reviewed clinical and haematological presentations, frequency of dysplastic features, histological and cytogenetic findings in 29 children with primary MDS. Indications for haematological evaluation in our patients were symptoms and signs of isolated or combined cytopenias, fever of unknown origin and frequent infections. Hepatosplenomegaly was found in 19 (65%) patients, while this pattern was found in 10% of adult patients. Normochromic anaemia was found in 25 (86%) patients and thrombocytopenia in 23 (76%). Patients presenting pancytopenia had the lowest probability of survival. Degree of dysplasia, histology and kariotype of bone marrow had no influence on survival rates. Prognostic factors in paediatric MDS are of limited significance, as MDS in children is an absolute indication for bone marrow transplantation.

[Molecular characteristics of the thalassemia syndrome and prenatal diagnosis in a high risk family]. / Molekularna osnova sindroma talasemije i dijagnostika kod deteta pre rodjenja u porodici s visokim rizikom.

The diagnosis of thalassaemia maior has been established in a 6 months old infant by screenig tests. The sick child and his parents were included in the study. Reverse dote blot and allelle-specific PCR confirmed that the mother was heterozygous for mutation in the first intone of beta-globin chain at position 110-beta-IVSI-110. By gap-PCR it was established that the father was heterozygous for haemoglobinopathy Lepore. The child was double heterozygous for both mutations. During the next pregnancy, in the 11th week, faetal DNA was extracted from chorion villous. Fetus was heterozygous for haemoglobinopathy Lepore and carried the same mutation as the father. The parents the accepted information that the second child will be a silent carrier of mutation.

Glomerular involvement in myelodysplastic syndromes.

Several reports have documented various forms of glomerular diseases in adults with myelodysplastic syndromes (MDS), but similar reports in children are lacking. We describe two children with MDS-associated steroid-responsive nephrotic syndrome (NS). Patient 1, who had MDS with myelofibrosis, presented with hepatosplenomegaly, pancytopenia, chronic hepatitis, moderate proteinuria, hypocomplementemia and elevated ANA titer. During initial prednisone treatment proteinuria markedly diminished and partial but transient hematological improvement occurred. Relapse subsequently occurred that manifested by overt NS and pancytopenia. High doses of prednisolone led to remission of the renal disease, but hematological remission did not occur. Persisting pancytopenia and repeated infections terminated in sepsis, 2 years after the onset of the MDS. Patient 2, who had refractory anemia with clonal monosomy 19, presented with bowel disease, hepatosplenomegaly, anemia and non-organ-specific autoantibodies. Prednisone led to both clinical and hematological remission. The hematologic disease relapsed 12 months later, when nephrotic-range proteinuria, hematuria and mild azotemia were also found. Corticosteroid treatment led to long-lasting renal and hematologic remission, maintained by a small dosage of prednisone. In both patients, renal biopsy findings were consistent with those seen in idiopathic NS. A Medline search disclosed 16 cases of glomerulopathy in the course of MDS in adult patients. Clinical features included NS, usually accompanied by renal insufficiency with acute, chronic, or rapidly progressive glomerulonephritis. On biopsy, membranous nephropathy, crescentic or mesangial proliferative glomerulonephritis, and AL amyloidosis were found. We conclude: (1) that glomerular disease may be present and should be searched for in patients with MDS and (2) that MDS can be added to the list of rare conditions associated with corticosteroid-responsive NS in children.

Haploidentical bone marrow transplantation in leukemia and genetic diseases.

From 1986 to June 2000, sixty children suffering from acute and chronic leukemia (n = 42, 33 of which in resistant relapse), genetic diseases (n = 11), aplastic anemia (n = 2, one of which with platelet refractoriness and bleeding), myelodysplasia (n = 5) received an haploidentical bone marrow, mismatched for 2-3 HLA loci. The donor's marrow was treated in vitro with vincristine and methylprednisolone to obtain a functional T depletion (MLC and CTL inhibition, functional blockade of Th1 and Th2). The prevalence of infectious complications and GVHD was similar to that recorded in matched unrelated donor (MUD) transplants. In situations of high risk of rejection (chronic leukemia, genetic diseases) we infused immediately one half of the harvest and then frozen aliquots from the second week. Of the 25 ALL and 8 AML in resistant relapse, 3 survived, disease-free at 14, 8 and 1 years respectively. Of the 3 ALL, transplanted during remission, 1 is surviving at 18 months. Of the 6 CML, 1 had fractionated bone marrow and is surviving at 3 years, and 5 had standard single dose infusion and died of progression of their disease after rejection of the graft (4) or blast crisis after complete engraftment (1). The 2 patients with aplastic anemia, those with myelodysplasia, and 6 of the 10 with genetic disorders died of transplant-related complications or disease progression. 4 patients with osteopetrosis (n = 2), MLD (n = 1), Wiskott Aldrich dis. (n = 1) survive at 8, 2, 5 and 1.5 years respectively. In patients transplanted with fractionated marrow GVHD > 2nd grade occurred in 15%. Only one patient rejected the graft. Compared with MUD transplantation, mismatched BMT whenever performed in patients in good conditions provides similar outcome and widens the donor availability.

[Congenital mesoblastic nephroma]. / Kongenitalni mezoblastni nefrom.

Four children with congenital mesoblastic nephroma were treated at the Children's University Hospital in Belgrade, between 1979 and 1990. In relation to the total number of children cured from renal tumours (44), diagnosis of congenital mesoblastic nephroma was confirmed in 9% of all cases with renal tumours. The age of all diagnosed patients was under one year. Three patients developed unilateral and one patient bilateral congenital mesoblastic nephroma. The authors also stress the importance of differential diagnosis between congenital mesoblastic nephroma and other renal tumours, since therapy and prognosis of these tumours are different. In a case of bilateral congenital mesoblastic nephroma that later relapsed with malignant alteration, it is questionable whether bilateral nephrectomy was the most appropriate treatment.

[Major and minor congenital anomalies in children with Wilms' tumor]. / Kongenitalne major i minor anomalije kod dece sa Wilm'sovim tumorom.

Wilms's tumour is a paediatric tumour of hereditary origin in 40% of cases. In children with Wilms's tumour associated congenital anomalies are frequent, particularly congenital anomalies of the kidney and urogenital tract. Over the period from 1972 to 1987 the authors carried out a prospective study and systematically investigated congenital major and minor anomalies in 24 children with Wilms's tumour. They revealed the presence of aniridia, bilateral cataract and cryptorchidism in 1/24 children, mental retardation, small stigated congenital major and minor anomalies in 40 chidism in 1/40 children, mental retardation, small stature and a cystic kidney in 1/40, mental retardation in 3/40. A detailed investigation of minor anomalies confirmed the presence of 2 to 3 anomalies in all observed children. Cytogenetic investigation was performed in all children. Only in a child with aniridia Wilms's tumour a cytogenetic anomaly, 11p deletion, was found.

[Clinical manifestations of neuroblastoma in children and their effect on prognosis]. / Klinicke manifestacije neuroblastoma kod dece i njihov uticaj na prognosu.

There are many prognostic factors in neuroblastoma. In this paper we analyzed the prognostic importance of some clinical factors like age, stage of disease, primary localization and neurological manifestations in children with neuroblastoma. We analyzed 58 children with neuroblastoma who were treated from 1970 to 1988 at the Haematology Department of Children's University Hospital in Belgrade. According to statistical evaluation presence of neurological manifestations and age were not important prognostic factors in children with neuroblastoma. Only primary localization of the tumour and stage of the disease had significant influence on prognosis.

[The May-Hegglin anomaly]. / May Hegglin-ova anomalija.

The paper presents a patient J.S., aged 2 1/2 years, with thrombocytopenia, presence of giant thrombocytes and basophile inclusions in the granulocytes. The same lesions were found in the child's father, followed by increased tendency to bleeding also confirmed in other four family members. Familiar character of the disease and morphologic anomaly of thrombocytes and leucocytes were the basis in passing the diagnosis of May-Hegglin anomaly. The specific features of the case are the child's age and the appearance of hemorrhagic syndrome in infancy.

[Disseminated intravascular coagulation (D.I.C.) and fibrinolysis in patients with acute leukemia (author's transl)]. / Coagulation intravasculaire disséminée et fibrinolyse au cours des leucémies aiguës.

Biological symptoms of D.I.C. were investigated in 43 patients with acute leukemia. Ten of them were found to be positive either at the onset or at the relapse of the disease and in some cases D.I.C. was triggered by chemotherapy. Among the ten positive cases 3 patients had an acute promyelocytic leukemia, 4 had an acute lymphoblastic leukemia, 2 a myeloblastic and 1 a monoblastic leukemia. D.I.C. was found either in patients with an hypercellular form of the disease or in patients with a normal or low white cell count. Symptoms of D.I.C. in acute leukemia must be systematicaly sought at the onset and during treatment by chemotherapy and treated with heparin and platelet transfusions as it is now admitted for acute promyelocytic leukemia.

[Burkitt's lymphoma]. / Burkittov limfom.

The paper presents two patients with malignant lymphoma of Burkitt's type. Initial localisation of the disease on the mandible, early dissemination in the central nervous system and bone marrow infiltration with appearance of characteristic Burkitt's type blast cells enabled us to bring the diagnosis. Rapid fatal evolution of the illness in spite of the applied therapy point of the diagnosis of this rare type of malignant lymphoma.

[Disseminated intravascular coagulation (D.I.C.) and fibrinolysis in patients with acute leukemia (author's transl)]. / Coagulation intravasculaire disséminée et fibrinolyse au cours des leucémies aiguës.

Biological symptoms of D.I.C. were investigated in 43 patients with acute leukemia. Ten of them were found to be positive either at the onset or at the relapse of the disease and in some cases D.I.C. was triggered by chemotherapy. Among the ten positive cases 3 patients had an acute promyelocytic leukemia, 4 had an acute lymphoblastic leukemia, 2 a myeloblastic and 1 a monoblastic leukemia. D.I.C. was found either in patients with an hypercellular form of the disease or in patients with a normal or low white cell count. Symptoms of D.I.C. in acute leukemia must be systematically sought at the onset and during treatment by chemotherapy and treated with heparin and platelet transfusions as it is now admitted for acute promyelocytic leukemia.

[Erythropoietin in congenital anemias in children]. / Eritropoetin u urodenim anemijama dece.

The results of the erytropoietin level determination in serum and urine of patients with congenital anemias are presented and compared to the results obtained in children with acute aplastic anemias. Three patients with congenital hypoplastic anemia Diamond-Blackfan, two with Fanconi's anemia, one with congenital pancythopenia with hyperplastic marrow and five patients with acute aplastic anemia were studied. The increased serum erythropoietin level was found in every patient whose blood hemoglobin was less than 12g%. Erythropoietin was detected in nonconcentrated urine when serum erythropoietin level was higher than 0,5 units/ml. The statistically significant negative correlation between the serum erythropoietin level and blood hemoglobin concentration was found. In two patients suffering from congenital anemias, in whome the significantly increased erythropoietin level (about 1.0 units/ml) was detected, increased ammount of hemoglobin F in peripheral blood as well as increased MCV--signs of so called "stress" erythropoiesis-were noted. The results presented, together with the results obtained by other authors, indicate that congenital anemias studied here are not due to the disturbance in erythropoietin production.

Juvenile nephronophthisis associated with retinal pigmentary dystrophy, cerebellar ataxia, and skeletal abnormalities.

A boy aged 9 3/4 years with interstitial nephritis, retinal pigmentary dystrophy, cerebellar ataxia, and skeletal abnormalities is described. The association may be due to a new genetic disorder, since 2 similar cases have been reported.