Serum soluble interleukin-2 receptor, interleukin-6 and tumor necrosis factor alpha as markers of celiac disease activity.

OBJECTIVES: To evaluate the markers of lymphocyte activation (sIL-2R, IL-6 and TNF α) in the peripheral blood of newly diagnosed patients with celiac disease (CD) and patients with CD on Gluten free diet (GFD) for at least 2 y. The markers were correlated with conventional serological tests Anti-tissue transglutaminase (Anti-TTG) used for diagnosis and follow up of the disease; wherever possible. METHODS: Thirty newly diagnosed cases of CD (on the basis of histopathology and serology) not on GFD were enrolled as Group 1 of the study. Thirty age and sex matched controls from the Pediatric Surgery OPD formed Group 2. Thirty cases of CD on GFD for at least 2 y (Group 3) were also enrolled in the study. Upper G.I. endoscopy was performed in all Group 1 patients and cytokine levels assayed by ELISA on serum obtained from all patients in Groups 1, 2, 3. RESULTS: Mean sIL-2R level in Group 1(1498.1+/-1234.31 pg/ml) and Group 3 (488.78+/-396.18 pg/ml) were significantly higher than the controls (336.27+/-218.67 pg/ml p < 0.05). Among the patients with CD, mean serum levels in Group 1 were higher than in Group 3 (p < 0.05). sIL-2R levels showed good correlation with tTg levels in Group 1 patients (p < 0.000, r = 0.69). Mean IL-6 levels in Group 1 were significantly higher (28.43+/-28.32 pg/ml) than Group 2(15.03+/-7.72 pg/ml p < 0.05) and Group 3(11.26+/-5.13 pg/ml p < 0.05). IL-6 levels were comparable between Groups 2 and 3 (p > 0.05).IL-6 levels showed good correlation with tTg levels in Group 1(p < 0.008, r = 0.471). Mean TNFα levels in Group 1(179.66+/-102.93 pg/ml), Group 2 (153.16+/-27.02 pg/ml) and Group 3 (166.67+/-28.95 pg/ml) were comparable (p > 0.05). TNFα levels showed poor correlation with tTg levels in Group 1 patients (p > 0.604, r = -0.099). CONCLUSIONS: sIL-2R and IL-6 levels have a good correlation with CD activity and can be used as reliable markers for detecting minimal transgression from GFD.

Addition of cobalamin to iron and folic acid improves hemoglobin rise in nutritional anemia.

OBJECTIVE: To assess whether addition of cobalamin (cbl) to iron-folic acid will result in improved response in nutritional anemia. METHODS: This study included 150 children aged between 0.5-5 y having nutritional anemia. Anemia was categorized for severity and red cell morphology. Serum levels of ferritin were obtained in all cases while levels of cbl and folic acid (FA) were done only in children having macrocytic or dimorphic anemia. Children were randomized to receive either iron and FA (Group I) or iron, FA and cbl (Group II). Response to treatment was assessed at 2, 4 and 8 wk. RESULTS: Of all the 150 patients, iron deficiency was documented in 111 patients. Of the 41 cases in whom, Cbl and FA levels were done, 97.56% and 53.66% had deficiency of cbl and FA respectively. Patients in group II had higher Hb level at 2, 4 and 8 wk (significant at 4 and 8 wk). Percentage Hb rise from baseline Hb was significantly higher in group II (p 0.00). In group II, increase in Hb among cases with macrocytosis and others were similar although percentage increase in Hb was more pronounced among patients with macrocytic anemia or dimorphic anemia. However, this difference was statistically not significant (p = 0.18). CONCLUSIONS: Children receiving cbl in addition to iron and FA showed an improved hematological response.

Effect of iron deficiency anemia on audiovisual reaction time in adolescent girls.

Adolescent girls are at high risk of developing iron deficiency because of increased iron demands during puberty, menstrual losses, and limited dietary iron intake. This study was carried out to demonstrate the effects of Iron Deficiency Anemia on Audiovisual reaction time in adolescent girls. Adolescent girls between 17-19 years of age with similar socioeconomic background were recruited from college of nursing for the study. They were all screened and categorized into two groups depending on their haemoglobin status. Students having Hb > 12 gm/dl formed the control group i.e. Group I (n=30). All students having Hb < 12 gm/dl and S. Ferritin < 12 microg/dl formed group II i.e. iron deficient anemic (IDA) group. The following haematological parameters were studied Hemoglobin (Hb), MCV, MCH, MCHC (using Sysmex kx-21 Autoanalyser), Serum.Iron, TIBC (Spectrophotometry), Serum.Ferritin (ELISA). Auditory and Visual reaction time were measured by reaction time instrument supplied by Medicaid system, chandigarh. The mean Hb levels in Group I was 12.93 +/- 0.86 and Group II was 10.08 +/- 0.51 (P<0.001). The MCV, MCH, MCHC, S. Iron, S. Ferritin was also significantly less in group II as compared to group I (P<0.001). TIBC was significantly more in group II as compared to group I (P<0.001). Results showed that both ART and VRT were significantly increased (P<0.001) in iron deficient adolescents suggesting a deterioration in sensorimotor performance in anemics.

Evaluation of serum transferrin receptor and sTfR ferritin indices in diagnosing and differentiating iron deficiency anemia from anemia of chronic disease.

OBJECTIVE: The present study was conducted to assess the utility of serum transferrin receptor (sTfR) and sTfR ferritin indices to differentiate ACD from IDA and also to diagnose coexisting IDA and ACD. METHODS: The study group comprised of 30 IDA patients, 30 cases of ACD and 30 age and sex matched controls. Complete hemogram with peripheral smear examination, markers of ACD, iron profile including serum ferritin and serum transferrin receptor levels were done in all patients and controls. Serum TfR and ferritin indices were calculated. RESULTS: sTfR levels were significantly higher in the IDA group compared to ACD group (p<0.001). ACD group was further subdivided into two groups on the basis of sTfR levels (B1<3 microg/ml and B2 > or = microg/ml), suggesting coexisting IDA in group B2. sTfR/log ferritin index was > 1.5 in all cases of IDA and ACD with coexisting IDA while all pure ACD cases and control subjects had sTfR/log ferritin index < 1.5. All case in IDA group had log sTfR/serum ferritin index > 2.55 and all patients with ACD with or without associated iron deficiency had log sTfR/serum ferritin ratio < 2.55. CONCLUSION: The sTfR levels along with the above mentioned indices can be very useful in differentiating pure IDA, ACD and ACD with coexisting iron deficiency, thus providing a noninvasive alternative to bone marrow iron.

Clinico-haematological profile of acute megakaryoblastic leukaemia: report of five cases.

Acute megakaryoblastic leukemia (AMKL) is a rare subtype of acute myeloid leukemia. Although known as a distinct entity for a very long time, because of lack of distinct clinical features and morphological criteria, it is difficult to diagnose this variant correctly. We herein present the clinical, morphological, cytochemical, and immunocytochemical features of five cases of AMKL. Certain morphological features such as presence of abnormal platelet count, giant platelets, and cytoplasmic blebbing in blasts were found to be important pointers towards the diagnosis. However, none of the features were found to be consistent and thus morphological diagnosis has to be confirmed by cytochemistry and immunocytochemistry.

Etiological profile of stroke and its relation with prothrombotic states.

OBJECTIVE: To study the etiological profile of childhood stroke and its relation with prothrombotic states. METHODS: Children with acute stroke with no evidence of CNS infection or head injury were studied. Stroke was confirmed by CT scan and further evaluated by MRI. Cardiac status was assessed with transthoracic echocardiography. Test for hypercoagulable state (antithrombin III, protein C, protein S, anticardiolipin antibody IgG and IgM and lupus anticoagulant) were done in all patients. RESULTS: A total of 66 children were enrolled--36 cases and 30 controls. Presenting symptoms were motor deficit (72%), seizure (66%), altered sensorium (36%), aphasia (27%). Causes identified were antiphospholipid antibody syndrome (25%), Moya Moya disease (16.6%), cardiac disease (11.1%), vasculitis (5.5%), ATIII deficiency (5.5%), Protein C deficiency (2.7%). Etiology remained unknown in 25% of cases with infarction. Hemorrhage was seen in 8.2% of cases and they had DIC or liver disease as the underlying cause. CONCLUSIONS: Magnetic Resonance Angiography and ELISA for antiphospholipid antibody should be done in all patients with stroke without an obvious cause.

Antithymocyte globulin and cyclosporin in children with acquired aplastic anemia.

OBJECTIVE: To assess the responses to ATG and cyclosporin combination in patients of aplastic anemia. METHODS: Twenty three (17M: 6F) patients of aplastic anemia (11 very severe aplastic anemia (VSAA) and 12 severe aplastic anemia (SAA), were administered antithymocyte globulin and cyclosporin. RESULTS: The median age of patents was 8 years (range 6-12 years). Three patients died within 2 months of therapy. Twenty children (11 SAA and 9 VSAA) were finally analysed. Six months after the start of treatment, 8/20 (40%) patients responded-2 complete (CR) and 6 partial responses (PR). At the end of 1 year; 2 patients maintained CR and seven patients continued PR (overall responders 45%). The response was better in SAA (54.5%) with 2 CR and 4 PR; than in VSAA (33%) with 3 PR . Eleven (55%) children were alive without response. One patient developed AML 13 months later. CONCLUSION: We conclude that antithymocyte globulin and cyclosporin combination is an effective treatment for aplastic anemia patients who are ineligible for bone marrow transplantation.

Expression of apoptosis regulators Bcl-2 and Bax in childhood acute lymphoblastic leukemia.

Twenty-five children (19 M:6 F) with newly diagnosed ALL with median age of 5.5 years (1 month-12 years) were enrolled in the study. Apoptosis regulator proteins bcl-2 and bax were measured in all patients using alkaline phosphatase anti-alkaline phosphatase method. Twenty-one patients were positive for bcl-2 and 23 cases for Bax, although expression levels varied. Patients who presented with splenomegaly or hepatomegaly < 5 cm expressed significantly higher levels of bcl-2 and bax protein expression. Neither of age ( < or >10 years), sex, generalized lymphadenopathy, WBC ( < or >50,000/mul) or FAB subtype was associated with high levels of bcl-2 or bax protein expression. Patients with higher mean hemoglobin levels (p = 0.009), high blast % in bone marrow (p = 0.02), immature immunophenotype (p = 0.001) exhibited signifxicantly higher bcl-2 levels. Bcl-2/bax ratio correlated inversely with TLC at presentation (p = 0.022; r = - 0.456) and in B-lineage leukemic cells as compared to T-lineage cells (p = 0.002). Bcl-2/bax ratio did not correlate with any other variable measured. Bcl-2 and bax protein co-express in ALL and high bcl-2/bax ratio correlates with good prognosis features.

Lupus anticoagulant and anticardiolipin antibodies in polytransfused beta thalassemia major.

The currently used therapeutic strategies in beta thalassemia have prolonged the survival for many patients; this longer survival has been accompanied by the development of a number of unexpected complications, these include hemostatic derangements. The presence of anti-phospholipid antibodies (APA) (lupus anticoagulant, LA and anti-cardiolipid antibody, ACA) has recently been reported in polytransfused patients of beta thalassemia. In this study 50 patients with beta thalassemia major (beta-TM) who had received at least 20 transfusions were evaluated for presence of antiphospholipid antibodies and correlated with a number of clinical and hemostatic parameters. About 32% cases had developed a minor bleeding tendency and one also showed ecchymotic patch. None of the patients had thromboembolic episodes. LA was seen in 16% of cases. The mean age and number of transfusions were higher in LA positive patients as compared to LA negative patients however the results were not statistically significant. IgM ACA were detected in 6% of patients but no statistically significant correlation was found with age, number of transfusions, platelet count and coagulation parameters. IgG ACA were detected in 30% of cases and showed a significant correlation with number of blood transfusions (p = 0.016) and age (p = 0.031). Anti HCV antibodies were detected in 30% of patients out of which 1 had IgM ACA and 10 had IgG ACA. The latter showed a significant correlation with HCV infection. An increased incidence of LA and IgG ACA is found in polytransfused patients with beta-TM when compared to the normal healthy population but their clinical significance is yet not clearly understood.

Hemophagocytic syndrome associated with visceral leishmaniasis.

The present paper reports a case of 6-year-old male child, suffering from pallor, fever and hepatosplenomegaly. A clinical diagnosis of enteric fever with a second possibility of malaria was considered. Laboratory findings included bicytopenia, hyperbilirubinemia and raised liver enzymes. Bone marrow examination revealed active hemophagocytosis. On extensive search few amastigote forms of Leishmania donovani were seen. Patient was negative for other viral, bacterial and malaria infections. The final diagnosis of hemophagocytic syndrome associated with visceral leishmaniasis was made. There was response of anti-Leishmanial treatment with improvement in clinical condition.

Bleeding manifestations in severely thrombocytopenic children with immune thrombocytopenic purpura.

OBJECTIVE: To report the observations on various bleeding manifestations in children with immune thrombocytopenic purpura (ITP) having severe thrombocytopenia (platelet count (PC) < 20,000/microl) and to compare the differences in bleeding manifestations at levels of PC at < 10,000/microl compared with between 10,000 and 20,000/microl. STUDY DESIGN: It is a retrospective analysis of bleeding manifestations in children with ITP (n = 58) having severe thrombocytopenia recorded between July 1999 and June 2002. A total of 164 episodes of severe thrombocytopenia were observed. During 31 episodes (18.9%), no bleeding manifestations were observed. When bleeding was observed cutaneous bleeds were the commonest manifestations occurring in 124 episodes. Of these 124 instances, in 82 (66.1%) episodes only cutaneous bleeding was observed while in remaining 42 (33.9%) episodes cutaneous bleeding was associated with other bleeding sites. Other common bleeds observed included epistaxis 22 (13.4%), oral bleeding 21 (12.8%) and gastro-intestinal bleeding 5 (3.04%). Comparison of the bleeding manifestations during episodes when the PC was < 10,000/microl and those between 10,000 and 20,000/microl showed that in 76.6% episodes with the count at > 10,000/microl no or only cutaneous bleeds were observed (clinically mild disease) compared to 59.45% episodes with episodes having PC < 10,000/microl (z score 2.37, p < 0.05). There was no statistically significant difference in proportion of patients having clinically mild disease during acute or chronic phase of the disease. CONCLUSION: During episodes of severe thrombocytopenia, most children have clinically mild disease. When the PC is < 10,000/microl clinically mild disease is observed less often compared to episodes with PC 10,000-20,000/microl. Based on these observations, it can be recommended that during severe thrombocytopenia, particularly when the PC is between 10,000-20,22,000/microl, patients can be safely managed with watchful waiting without any specific therapeutic intervention.

Tremors and thrombocytosis during treatment of megaloblastic anaemia.

In developing countries, a deficiency of cobalamine and folate contributes significantly to megaloblastic anaemia. Neurological observations in infants and young children with megaloblastic anaemia have included hypotonia, developmental regression, tremors and other abnormal movements. Following therapy with vitamin B12, coarse tremors occurred in six of 51 patients (12%) with megaloblastic anaemia. The tremors, which were noticed initially in the hands and feet, gradually became generalised and disappeared during sleep. They subsided within 5-11 days. Thirteen of 25 (52%) patients developed thrombocytosis between day 3 and week 5 of follow-up. In one child, the platelet count increased to >1300 x 10(9)/L. The importance of recognising these clinical findings during treatment of megaloblastic anaemia is emphasised.

Thalassemia major-- on the verge of bleeding or thrombosis?

UNLABELLED: Thrombotic events have been reported in adult thalassemic patients. To investigate this further, we measured hemostatic parameters in thalassemic children to identify possible predisposing factors in early childhood. OBJECTIVE: To assess hemostatic derangements in polytransfused children with beta-thalassemia major (beta-TM). METHODS: Complete blood count, prothrombin time, activated partial thromboplastin time, protein C, protein S, Antithrombin III (AT III), fibrinogen, d-dimer assay, serum iron, serum ferritin and liver function tests were measured in 54 patients and 30 controls using standard lab methods. RESULTS: Sixteen patients exhibited bleeding manifestations. None of the cases had thromboembolic phenomena. The average pretransfusion haemoglobin in the cases studied was 8.45 +/- 1.6 g/dl, thrombocytopenia was seen in 33.3%, prolongation of prothrombin time was seen in 40.7% and prolongation of aPTT was seen in 46.3%. None of our patients had laboratory features of DIC. Protein C was low in 26.2%, protein S in 28.6% and AT III levels in 46.8% of cases. Mean fibrinogen levels and d-dimers were similar in cases and controls. Serum ferritin levels in the patients were high with a mean of 3,709 +/- 1,625 ng/ml. Serum ferritin had a significant positive correlation with PT (r = 0.382) and ALT (r = 0.315) and a significant negative correlation with protein S (r = - 0.376). Prolonged PT correlated with prolonged aPTT, low protein C, low protein S and serum ferritin levels. Protein C had a significant positive correlation with AT III. Low AT III activity correlated positively with age, aspartate transaminase and alanine transaminase. Average hemoglobin maintained correlated negatively with serum ferritin levels (r = - 0.540), and AST (r = - 0.417). Bleeding episodes correlated with age, liver size and number of transfusions. CONCLUSION: Significant alterations in the hemostatic system already exist in polytransfused children with beta-thalassemia that make it a high-risk condition for both hemorrhagic manifestations and future development of thromboembolic events.

Peroxidative stress and antioxidant enzymes in children with beta-thalassemia major.

OBJECTIVE: Regular blood transfusions and secondary iron overload make thalassemic erythrocytes prone to peroxidative injury. Although some reports suggest endogenous free radical damage in thalassemia, there remains discrepancy in the status of antioxidant enzymes. The aim of this study was to evaluate the extent of lipid peroxidation and status of antioxidant enzyme in children with beta-thalassemia. METHODS: Fifty transfusion-dependent beta-thalassemics were subjected to analysis of lipoperoxides as malondialdehyde (MDA), nitric oxide (NOx), superoxide dismutase (SOD), glutathione (GSH), and glutathione peroxidase (GPx) along with serum iron and ferritin, liver functions and uric acid. Plasma MDA was analyzed to indicate the oxidative parameters, whereas the erythrocyte SOD, GPx, and plasma NOx were measured to show the antioxidant status of the children. All these parameters in 30 non-anemic healthy controls attending the child health promotion clinic of hospital were also studied. RESULTS: All the patients were iron overloaded. Markers of free radical injury such as MDA and antioxidant enzyme SOD and NOx levels were significantly elevated in thalassemic children while mean GPx levels were decreased in patients compared to controls (P < 0.001). All these markers significantly correlated with serum ferritin levels. There was no significant difference in levels of GSH measured but it correlated with serum iron levels. CONCLUSION: Our study results suggest that iron overload causes peroxidative damage in beta-thalassemia and antioxidant systems try to compensate for reducing lipid peroxidation to lower tissue damage.

Diamond-Blackfan anemia: clinical features and treatment results in 4 cases.

Diamond-Blackfan anemia is a rare hematological disease characterized by selective marrow erythroid hypoplasia. We present the clinical and hematological profile and results of treatment in four children. The median age at presentation was 14 months with a median age of onset of pallor at 7.5 months. Mean Hb at presentation was 2.9 g/dl. All children were started on prednisolone with response in one child. One child was switched to dexamethasone and responded transiently relapsing in 4 months but responded to further dexamethasone. Two children required cyclosporin for 3 and 8 weeks for response. With median follow-up of 59 months, all four children continue in complete hematological remission with no further relapses.

Pancytopenia in children: etiological profile.

Pancytopenia is a common occurrence in pediatric patients. Though acute leukemias and bone marrow failure syndromes are usual causes of pancytopenia, etiologies such as infections and megaloblastic anemia also contribute. The aim of this study was to evaluate the clinico-hematological profile of varying degrees of childhood cytopenias with special reference to the non-malignant presentations. This is a retrospective study carried out in a tertiary care children's hospital. We retrospectively analyzed 109 pediatric patients who presented with pancytopenia for different etiologies. Acute leukemia (including ALL, AML and myelodysplastic syndrome) and aplastic anemia accounted for 21 per cent and 20 per cent cases respectively. Megaloblastic anemia was found in 31 (28.4 per cent) patients and was single most common etiological factor. Severe thrombocytopenia (platelet < or = 20 x 10(9)/l) occurred in 25.2 per cent of these patients. Various skin and mucosal bleeding occurred in 45.1 per cent of patients with megaloblastic anemia. Infections accounted for 23 (21 per cent) patients who presented with pancytopenia. Amongst infections, enteric fever occurred in 30 per cent patients. Malaria, kala-azar and bacterial infections were other causes of pancytopenia at presentation. The study focuses on identifying easily treatable causes such as megaloblastic anemia and infections presenting with pancytopenia. These conditions though look ominous but respond rapidly to effective therapy.

Hearing loss in chronic myeloid leukemia.

A 12-year-old girl presented with abdominal pain, fever, and hearing impairment of 6 months duration. She had massive hepatosplenomegaly and anemia. On the basis of her peripheral blood and bone marrow findings, she was diagnosed as chronic myeloid leukemia (CML) in chronic phase. Her hearing was assessed by brainstem evoked responses (BERA), which showed objective improvement in hearing with hydroxyurea. The rare occurrence of deafness in CML is reviewed and possible pathogenesis is discussed.

Clinico-hematological profile of congenital leukemia.

Congenital leukemia is a rare disorder that usually presents with extramedullary infiltrates and myeloid phenotype in 80% cases. The authors present 4 cases of congenital leukemia diagnosed over 11 year period, three of which were of acute lymphoid leukemia and one was of biphenotypic leukemia.

Serum prolactin in celiac disease.

Serum prolactin levels (SPL) were estimated in patients with celiac disease (CD), diagnosed as per ESPGAN criteria, on unrestricted gluten containing diet (group 1), as well as those consuming a gluten-free diet (GFD) (group 2). Forty-one children with CD, with 20 cases in group 1 (mean age 5.67 +/- 2.14, range 2.5-10.5 years) and 21 cases in group 2 (mean duration of follow-up 2 years, range 1-4 years), and 41 age- and sex-matched controls were studied. Hyperprolactinemia was defined as serum prolactin > 18 ng/ml in males and > 24 ng/ml in females. Upper gastrointestinal endoscopic biopsy was performed in both study groups for initial and follow-up evaluation. Hyperprolactinemia was detected in all the patients of group 1 and one patient of group 2 who had severe villous atrophy. The SPL in group 1 (mean 48.3 +/- 17.4; range 20-90 ng/ml) and group 2 (mean 18.3 +/- 6.9, range 10-39 ng/ml) was significantly higher compared with the controls (mean 9.3 +/- 4.5; range 2.4-20 ng/ml; p < 0.001). Among the patients with CD, mean SPL in group 1 was significantly higher than in group 2 (p < 0.001). In group 1, there was a positive correlation between SPL and duration of symptoms (p = 0.006, r = 0.768) and age of diagnosis (p < 0.001, r = 0.842). A positive correlation also existed in group 2 between SPL and degree of villous atrophy (p < 0.001, r = 0.71) and lamina propria infiltrate (p < 0.001, r = 0.568). Our results suggest that SPL has a significant correlation with activity of CD. Therefore serum prolactin estimation may provide an additional marker of disease activity in CD and may be a more viable option economically.

Clinical and nutritional profile of children with celiac disease.

This prospective study was aimed to evaluate the clinical and nutritional profile of children diagnosed as celiac disease (CD) as per the modified ESPGAN criteria, at the time of diagnosis and after institution of gluten free diet. Out of 65 enrolled cases of CD, 7 (10.8%) children did not follow a strict dietary compliance. Only 41 children with satisfactory dietary compliance on gluten free diet (GFD) who regularly attended the follow up for at least 6 months were evaluated for their nutritional and hematological status. Results were compared with age and sex matched controls. The mean age of diagnosis was 8.7 +/- 3.3 years. Diarrhea and failure to thrive were the most common presenting symptoms. At diagnosis, the nutritional and hematological indices were significantly lower in patients than in controls. Mean duration of follow up on GFD was 22 months (range 6-48 +/- 5.6 months). On follow up, height for age Z score was significantly lower, mean BMI was significantly higher, and weight for age Z score, weight for height Z score (%), mean triceps and biceps skin fold thickness, and mid arm circumference were comparable to controls. At diagnosis, 80% cases had microcytic hypochromic anemia and 20% had dimorphic anemia. On GFD for at least a period of more than 6 months, 19% had microcytic anemia and in 81% the hematological picture was normocytic normochromic. 60% cases had thrombocytosis at diagnosis in comparison to 2.3% after treatment. Institution of GFD leads to rapid improvement in clinical picture as well as most of the nutritional and hematological parameters.