Brno, 1. – 2. 7. 2011
International Scientific Advisory Board
András Arató (Hungary)
Nataša Marčun Varda (Slovenia)
Milan Bayer (Czech Republic)
Jan Janda (Czech Republic)
László Kovács (Slovakia)
Ingrid Brucknerová (Slovakia)
Susane Greber-Platzer (Austria)
Radvan Urbanek (Germany)
Gábor Kovács (Hungary)
Local Organizing Committee
against complement factor H in aHUS: 1 year follow up data from the
international Innsbruck HUS NET aHUS registry
Riedl M1, Giner T1,
Rosales A1, Jeller V1,
Würzner R2, Jungraithemayr T1
für Pädiatrie I, Medizinische Universität Innsbruck, Austria
für Hygiene, Mikrobiologie und Sozialmedizin, Medizinische Universität
Introduction: Antibodies against complement factor H (FH Ab) have
been reported in aHUS patients. The role of FH Ab in disease onset, progression
and treatment is of critical interest for physicians and patients dealing with
this unsolved problem. At present, evidence based therapy recommendations are
Methods: We comment on 16 patients with FH Ab associated aHUS from
the Innsbruck HUS-Net registry (www.hus-online.at). Patients were followed from
the beginning of the acute phase, with recording on patient’s therapy and
clinical progression over a period of 1 year.
Results: Patients show
a median age at disease onset of 7 years. All patients presented with
hemolytic anemia (mean hemoglobin: 5,8 g/l), thrombocytopenia (mean platelet
count: 33,2x109/µl) and elevated creatinine levels (mean: 458
µmol/l). Only 37% of the patients showed decreased C3 levels and 15% showed
decreased Factor H levels. Within the follow up period of 1 year 25% of the
patients developed renal insufficiency, 33% showed ESRD, and 67% showed at
least one disease recurrence. Using supportive therapy without plasmatherapy or
immunosuppression 2/2 patients showed disease recurrence, 6/7 patients recurred
under plasmatherapy without additional immunosuppression and only 2/7 patients
with plasmatherapy followed by immunosuppression developed recurrences.
Conclusion: CFH Ab positivity is
a distinct pathogenetic aHUS subgroup mainly of pediatric patients.
Testing for CFH Ab as soon as possible is mandatory, as in positive cases this
has important impact on prognosis and the recommended therapy. Following our
results and the literature a recommendation for the use of plasmatherapy
as induction therapy followed by a maintenance therapy using
immunosuppressive agents can be given. Nevertheless, treatment responses are
heterogeneous and the different alternative immunosuppressive agents, the used
dosages and the timing of initiation and withdrawal are still a matter of
Proteomic analysis of renal ischaemia/reperfusion injury: search for new targets
Himer L1,2, Kékesi KA3, Juhász
Simor A3, Gulyássy P3, Darula
Szebeni B1, Reusz G2, Szabó A5, Tulassay
1Research Group for Pediatrics and Nephrology, Semmelweis
University and Hungarian Academy of Sciences, Budapest, Hungary
2First Department of Pediatrics, Semmelweis University,
3Laboratory of Proteomics, Eötvös Loránd University,
4HAS Biological Research Center, Institute of
Biochemistry, Szeged, Hungary
Department of Pediatrics, Semmelweis University, Budapest, Hungary
Background: Ischaemia/reperfusion (I/R)
injury is a leading cause of acute kidney failure (ARF), which is observed
most frequently in patients after major surgery, burns, severe hypovolemia, and
renal transplantation. Mortality rate and treatment of ARF means a serious
problem in the intensive health care. Ischaemic preconditioning (IP) may induce
tissue adaptation to stress and protect it from a subsequent severe I/R
Aim: Because the complex molecular
pathomechanism of renal I/R injury is not fully understood, our present aim is
to analyse I/R and IP induced protein changes in the kidney to find potential
key molecules and therapeutic targets.
Methods: Kidneys of ischemized,
preconditioned/ischemized and control rats were analyzed using two dimensional
gel electrophoresis and mass spectrometry. Functional protein analysis was
performed by Pathway Studio software.
Results: 108 proteins were altered after
insult. They were ranked into functional groups: components of cytoskeleton,
elements of different metabolism, proteolysis, DNA/RNA processing, signaling
and miscellaneous. All proteins were manually validated and searched in the
literature. Some protein of interest were choosen for further experiments.
Conclusion: Here we investigate the
alteration in the complex interaction of different proteins of kidney during
ARF. Our results may help the identification of new biomarkers of I/R injury
leading to kidney damage. Determination of the protective IP induced proteomic
changes will help us to find new targets for therapeutic intervention.
Characterisation of uropathogenic escherichia coli from
children with urinary tract infection in different countries
Ramosa NL, Ngoc Dzung DT, Stopsack
K, Pourshafie MR, Katouli M, Kovács
L, Brauner A
Faculty of Science, Health and Education, University of the
Sunshine Coast, Maroochydore, Queensland, Australia
Department of Microbiology, Tumour and Cell Biology, Division of
Clinical Microbiology, Karolinska Institutet and Karolinska University
Hospital, Stockholm, Sweden
Department of Biochemistry, Hanoi Medical University and Hanoi
Medical University Hospital, Hanoi, Vietnam
2nd Department of Pediatrics, Comenius University Medical
School, University Children´s Hospital, Bratislava, Slovakia
Department of Microbiology, Pasteur Institute of Iran, Tehran,
Purpose: Uropathogenic Escherichia coli
(UPEC) carry many virulence factors, including those involved in long-term
survival in the urinary tract. However, their prevalence and role among UPEC
causing urinary tract infection (UTI) in children is not well studied. To
further understand the virulence characteristics of these bacteria, we
investigated the prevalence of antibiotic resistance, antigen 43 genes, curli
and cellulose among UPEC from children from different countries.
Methods: Isolates (n=337) from 5 countries
were tested for antibiotic susceptibility, phylogenetic groups, prevalence of
flu, fluACFT073, fluBCFT073, curli and cellulose.
Results: High prevalence of multidrug
resistance and extended spectrum beta lactamase production was found among
Iranian and Vietnamese isolates. Resistance was associated with phylogenetic
group D while group B2 was associated with fluACFT073 and fluBCFT073. Fewer
Iranian isolates carried fluACFT073, curli and cellulose. fluBCFT073 was most
prevalent among Slovak isolates.
Ampicillin and amoxicillin/clavulanic acid
resistance was prevalent among fluACFT073- and fluBCFT073-positive Australian,
Iranian and Swedish isolates. Lack of curli and cellulose was associated with
resistance among Vietnamese isolates.
Conclusions: We conclude that major
differences exist in the prevalence of antibiotic resistence among UPEC from
different countries. Associations observed between resistance and virulence
factors may, in different ways, promote the long-term survival of UPEC in the
Role of IL-17 in the pathomechanism of renal fibrosis
Szebeni B1, Himer L1, Sziksz E1, Saijo S2, Kis E3, Prókai Á3, Bánki NF3, Kardos M4, Degrell R5, Fekete A3, Rusai K3, Szabó AJ3, Szabó A6, Reusz G2, Tulassay
Laboratory of Paediatrics and Nephrology, Hungarian Academy of Sciences,
for Experimental Medicine, Institute of Medical Science, University of Tokyo,
Department of Paediatrics, Semmelweis University, Budapest, Hungary
Department of Pathology Semmelweis University, Budapest, Hungary
Department of Medicine and Nephrological Center, University of Pécs, Hungary
6Second Department of Paediatrics, Semmelweis University,
fibrosis is a typical example of organ fibrosis leading to end stage
kidney disease and increased morbidity and mortality. Regardless of the
initiating cause, the mechanism of organ fibrosis is similar in the different
chronic renal failures and always have a major inflammatory component.
Recently, a new Th cell lineage, termed Th17 cells, has been identified
based on their capacity to produce interleukin (IL)-17A but not the classic Th1
or Th2 cytokines. IL-17A recruits neutrophils and macrophages and stimulates
the production of pro-inflammatory cytokines. Interestingly, less attention has
been paid to the impact of Th17 cells on non immune cells such as epithelial
cells, although IL-17A receptors (IL-17RA) are intensively expressed in the kidney,
especially on the tubular epithelial cells.
Aims: Our present work investigates the role
of IL-17A on renal tubular epithelial cells and renal fibrosis.
Methods: We evaluated the renal level and
localization of IL-17A and IL-17RA in a mouse model of ureteric
obstruction (UUO). For this purpose real-time PCR, immunhistochemical staining
and flow cytometry were used. The role of IL-17A on epithelial to mesenchymal
transition (EMT) and on activated signaling pathways was tested in vitro
using HK-2 renal tubular epithelial cells by flow cytometry. The impact of the
selective modulation of IL-17A on fibrosis was studied in vivo by
Western blot determination of αSMA levels after UUO
using IL-17A knock-out and wild-type animals.
Results: The number of IL-17A producing
T-cells and IL17RA-positive epithelial cells elevated 5 days after UUO. After
IL-17A treatment of HK-2 cells we found increased phosphorylation of Erk1/2,
Jnk1/2, Smad2/3 signaling pathways. At the same time, we found increased number
of αSMA - positive HK-2 cells. Finally, after
UUO the level of αSMA was less increased
in the kidney of IL-17KO mice compared to that of control mice.
Conclusion: Our work contributes to the
better understanding of the role of IL-17A in renal fibrosis. Our results show
that IL-17A induces EMT through the activation of Erk1/2, Jnk1/2, Smad2/3
signaling pathways in vitro. IL-17A alters renal fibrosis in vivo as
well. However, further works are needed to elucidate its exact effects on renal
„In vitro“ effectiveness of probiotics on E. Coli in
comparison with commonly used antibiotics in treatment of urinary tract
infections in children
Popovič K1, Cencič A2,3, Ander
Eneko M2, Gorenjak M3, Gradišnik
Marčun Varda N1
1University Medical Centre Maribor, Department of
Paediatrics, Maribor, Slovenia
2University of Maribor, Faculty of Agriculture and Life
Sciences, Maribor, Slovenia
3 University of Maribor, Faculty of Medicine, Maribor,
The aim of the study: Management of
recurrent urinary tract infections (UTI) with antibiotic prophylaxis is well
defined. Because of rising resistance of bacteria to antibiotics, questionable
cost/effectiveness and parental dissaproval of long term antibiotic
prophylaxis, better options are looked for. One of the expanding areas of
research is possible preventive role of probiotics. The aim of our study was to
determine the inhibitory effect of some probiotics vs. antibiotics on E.
coli in preclinical study. Probiotic with the best inhibitory results will
be used in future clinical trial.
Methods: Clinical isolates of E. coli
and a control E. coli strain (ATCC 11105) were tested for inhibition
by probiotic strains and some antibiotics using well diffusion method. We
used L. plantarum strains (PCS20, PCS22, PCS25, PCS26) from
Slovenian local cheese and 3 commercial
probiotics (Probio Junior, Prolife and BioGaia) in comparison to the
widely used L. rhamnosus LGG strain (“the golden standard”). We
also tested gentamycin (40 mg/ml) and cefuroxime (100 mg/ml), two commonly used
antibiotics in treatment of UTI.
Results: We found out that all probiotics
have lower activity against E. coli (approximately 30% less) than both
antibiotics, cefuroxime and gentamycin. Most of the tested probiotic strains
exert resembling activity against uropathogenic E. coli. Prolife in
yeast potato dextrose broth, encouraging growth of yeasts, in this case Saccharomyces
cerevisae, produced significant inhibition of growth of most E. coli
strains, especially the ATCC control strain, and isolate 6497. Such activity
was comparable to that of gentamycin, but significantly lower than that of
Conclusion: Antimicrobial effects of some
probiotics on E.coli clinical strains show promissing results for
possible prevention of UTI. Although Saccharomyces cerevisae showed very
good results, we believe that yeasts as possible opportunistic pathogens should
not be used in clinical practice.
However, further validation is necessary.
NPHP1 homozygous deletion rate in Hungarian children with juvenile nephronophthisis
Kerti A1, Antalfi R1, Balogh E1, Bernáth M1, Moriniere
Szabó A1, Sallay P1, Wagner
Reusz G1, Saunier S2, Antignac C2, Tory
1Ist Department of Pediatrics, Semmelweis University,
2INSERM U983, Necker Hospital, University Paris
Descartes, Paris, France
3Department of Transplantation and Surgery, Semmelweis
University, Budapest, Hungary
Juvenile nephronophthisis (NPH) is
responsible for 6-10% of ESRD in childhood. The homozygous deletion of the
first nephronophthisis gene (NPHP1) is responsible for 22-45% of NPH
cases, but has not yet been screened in Hungary.
Within the cohort of 67 Hungarian children
treated at the Ist Department of Pediatrics, Semmelweis
University with cystic kidney disease or chronic renal failure without
hematuria, proteinuria or urinary tract malformation, 22 patients have been
diagnosed as NPH based on clinical symptoms, recessive inheritance and renal
morphology. Five of these patients presented with Joubert syndrome and 1
patient with Senior-Loken syndrome (SLS).
The 22 patients with NPH have been screened
for the NPHP1 homozygous deletion by the amplification of exons 7 and
19, and introns 2 and 18. An extragenic region was amplified as a control.
Eight of 22 patients with NPH (36%) have
been found to carry NPHP1 homozygous deletion. They have all developed
ESRD at the median age of 14 years (range: 13-18). Out of them, 4 patients
presented with isolated NPH, 2 patients with Joubert syndrome, 1 with SLS and 1
with NPH and sensorineural hearing impairment. The clinical phenotype was
particular in three cases. The retinopathy of the patient with SLS is more
severe than expected in patients with NPHP1 mutations; his visual acuity
at the age of 29 years is lost one one side and 0,25 on the other. One patient
with Joubert syndrome was treated with autism, which is not exceptional in
Joubert syndrome, but has not been reported in patients carrying NPHP1
mutations. Finally, one patient was treated with sensorineural hearing
impairment which is rarely associated to NPH.
The rate of NPHP1 homozygous deletion
is similar in Hungarian children to that found in world-wide cohorts. The
associated extra-renal symptoms can be more extreme than previously found.
Rapamycin sensitivity and mTOR activity in lymphoma/leukemia cells
Sebestyén A2, Nemes K1,2, Márk Á2, Hajdú M2, Kovács G1, Kopper L2, Csóka M1
12nd Dept. of Pediatrics, Semmelweis University,
Dept. of Pathology and Experimental Cancer Research, Semmelweis University,
Acute lymphoblastic leukemia (ALL) is the
most common malignancy diagnosed in children, representing nearly one third of
all pediatric cancers. Recently, the mammalian target of rapamycin (mTOR) has
gained more attention as a potential target in different tumors including
The serine-threonine kinase mTOR is
a central mediator of several signals, regulates cell growth, protein
translation, cellular proliferation and survival. mTOR can form two distinct
complexes termed mTORC1 and mTORC2 with different rapamycin sensitivity.
Molecular biological studies suggest that mTOR inhibition may be a useful
therapeutic strategy in different human malignancies. However, there are
limited data about the activity of mTOR in different lymphomas, specially in
In the present work we studied the
expression of mTOR activity in different lymphoma/leukemia cell lines, in bone
marrow/blood samples from pediatric ALL patients and in isolated normal PMNC-,
B- and T-cells. The expression of mTOR activity dependent proteins (p-4EBP1, p-
mTOR, p-S6, p-p70S6K) was examined. We statistically analyzed the expression
results in clinical samples during the therapy and at the possible relapses
based on minimum 2 years follow up. The effect of rapamycin treatment and the
expression of mTOR complexes were also studied by flow cytometry and
Leukemia and lymphoma cell lines showed
increased mTOR activity compared to normal lymphoid cells. More than 70 bone
marrow samples from pediatric ALL and from non leukemic patients were analyzed.
The p-4EBP1 expression was significantly higher (20–58x) in all ALL samples
than in normal cells. The p-4EBP1 expression level showed significant
correlation with the prognosis of the patients. According to the in vitro
rapamycin treatment and the mTOR related protein expression studies, in cases
where p-4EBP1 expression level was decreased by in vitro rapamycin treatment,
apoptosis induction could also be occured. We also found that rictor/raptor
expression can influence the rapamycin sensitivity of malignant lymphoid cells.
Our results confirm that pediatric ALL cells
have high mTOR activity. This could be detected by p-4EBP1 expression. The
recent results suggest that mTOR activity measurments could be useful method to
identify ALL patients with worse prognosis at diagnosis and to recognize early
relapses. However, further studies are required to define the best way to sort
ALL and other lymphoma patients for future rapalog treatments based on rapalog
Supported by OTKA K81624, K84262.
Absence of IDH polymorphisms in bone tumours
Amary MF2, Maggiani F2, Halai
1Second Department of Paediatrics, Semmelweis University,
2Histopathology, Royal National Orthopaedic Hospital NHS
Trust, Stanmore, Middlesex HA7 4LP, UK
The aim of the study:
The isoforms of isocitrate dehydrogenase (IDH), IDH1 and IDH2 are responsible
for α-ketoglutarate and
NADPH production as essential substrates for cell respiration. In the case of
somatic mutations, these enzymes dramatically change: their affinity for α-ketoglutarate decreases and as
a gain-function-event a new enzyme product, 2-hydroxyglutarate
appears in abundance. 2-hydroxyglutarate as an oncometabolite was shown led to
carcinogenesis through the altered DNA methylation profile and the stabilized
hypoxia-inducible factor 1 connecting an increased angiogenesis in cancers.
IDH1 R132, IDH2 R140 and R172 mutations were
found in 60-90% of secondary gliomas and 5% of primary gliomas. Other tumours
such as acute myeloid leukemias (12–18%), prostate cancers (3%), acute
lymphoblastic leukemias (2%) also harboured these polymorphisms. Since patients
with multiple enchondromas have occasionally been reported to have these
conditions, we hypothesized that the same mutations would occur in other
mesenchymal tumours such as PNET/Ewing sarcoma and osteosarcoma.
Methods: DNA was extracted from
a paraffin-embedded tumour, which was at least 60% tumour-rich. The
majority of the bone tumour samples had been decalcified in EDTA,
a minority in formic acid. Osteosarcoma samples from 222 patients, 19
osteosarcoma cell lines and PNET/Ewing sarcoma samples from 25 patients were
screened for IDH1 R132 mutations by Sequenom high-throughput MassARRAY
platform. 64.4% (143 samples) of the osteosarcoma samples were also analysed
for IDH2 R140 and R172 mutations by capillary sequencing. A cut-off of 10%
of allelic frequency was generally used. Looking for germline mutations,
non-neoplastic tissue (skeletal muscle, bone marrow, blood) from 30 patients
was investigated by restriction digestion and DNA sequencing.
Results: Neither IDH1 nor IDH2 mutations
were detected in osteosarcomas or in PNET/Ewing sarcoma samples. No germline
mutations were found.
Conclusion: IDH1 and IDH2 somatic mutations
did not contribute to the pathogenesis of osteosarcoma and PNET/Ewing sarcoma
suggesting the existence of a more complex regulation in the case of these
When thrombocytopenia is not immune thrombocytopenic
Pospisilová D, Flögelova H, Stejskalova
I, Novak Z, Hrachovinova I1
Department of Pediatrics, Faculty of Medicine of Palacky
University and University Hospital, Olomouc, Czech Republic
1Institute of Hematology and Blood Transfusion, Prague,
Introduction: Thrombotic thrombocytopenic
purpura (TTP) is a rare disease in childhood. Pathogenesis of TTP is
associated with deficiency of cleaving metalloproteasis known as ADAMTS 13 („a disintegrine-like and metalloprotease
with thrombospondine repeats“). In healthy individuals, this proteases degrades
ultralarge multimers of von Willebrand factor (vWF) into inactive monomers,
which are not able to react with platelets. The deficiency of ADAMTS 13 causes
abnormal platelet aggregation and results in microvascular thrombosis. TTP is
characterised by consumptive thrombocytopenia, microangiopatic hemolytic anemia
and organ dysfunction. We present an unusual manifestatation of TTP in 17 years
old girl with bruises and petechiae.
Case report: Seventeen years old girl was
admitted with severe thrombocytopenia (8x109/l platelets). In the previous year she underwent two courses of high
dose imunoglobulin and corticosteroid therapy for severe immune
thrombocytopenia. Remission lasted for 6 months in both cases. Four days after
admission, the patient developed headache, microangiopathic hemolytic anemia
(with high LDH and free hemoglobin levels) and deterioration of renal function
(serum creatinine and urea both increased to twice). The peripheral-blood smear
showed schistocytes – fragmented red blood cells. Diagnosis of TTP was made and
plasma exchanged therapy started. The patient underwent a total of 26
cycles of plasmapheresis. ADAMTS 13 activity was below 1% and a high titer
inhibitor of metalloprotease was found. Due to non-complete response to
plasmapheresis, vincristine and rituximab were added. Treatment was complicated
by recurrent allergic reactions to plasma and rituximab.
Conclusions: Thrombotic thrombocytopenic
purpura in children is extremely rare, but
serious disease. There are two forms of TTP: acquired and congenital.
The congenital form – also known as Upshaw-Schulman syndrom – is a less
common type. It is caused by mutation in ADAMTS 13 gene. The acquired type is
caused by anti-ADAMTS13 autoantibodies, which inhibit the cleaving function of
this metalloprotease. Patients with severe ADAMTS13 deficiency are at high risk
of relapse, so our patient must be still periodically observed.
The aim of this case report is to highlight
the wide spectrum of symptoms of TTP and to note, that not all diagnostic
kriteria are always present. In a retrospective view of previous attacs,
we found a mild anemia with hemoglobin 115 g/l. We suppose that the
previous episodes of thrombocytopenia have to be the first manifestation of
incompletely expressed TTP. Treatment of thrombotic thrombocytopenic purpura
can caused many complications and, in some cases, plasmapheresis only is not
able to induce a remission.
This work was supported by Internal grant of
the Faculty of Medicine, Palacky University, Olomouc, Czech Republic, no.
Extracorporal membrane oxygenation (ECMO) in
a pediatric intensive care unit
G¹, Beck C¹, Ojinaga V¹, Schönlaub J¹, Zimmerhackl LB¹, Geiger R¹, Schweigmann
U¹, Schermer E¹, Neu N¹, Frühwirth M¹
¹Department of Pediatrics, Medical University Innsbruck,
Extracorporal membrane oxygenation (ECMO) is an invasive supportive technique
used in patients with potentially reversible cardiac and/or respiratory failure
in whom conventional therapies have failed. Here we report the frequency of
usage, patient demographics, and outcomes in children treated with ECMO in our
pediatric intensive care unit (PICU).
Patients: 31 pediatric patients treated with
ECMO at the PICU of the Medical University Innsbruck, Austria between 1996 and
2010 were retrospectively analyzed. Indications for ECMO were either
hemodynamic (58,6%) or respiratory (41,6%) failure. 5 patients underwent ECMO
insertion under rescucitation.
Results: ECMO Duration was significally
higher in patients with respiratory support (9,3±6,3 d) than in patients with
hemodynamic support (3,6±3 d) and highest in oncologic patients with ARDS
(11,9±5,2 d). All but one (30/31) patient needed a mean of 2 vasopressors
(range: 2–4) during ECMO. Renal replacment therapy (RRT) is not performed routinely
with ECMO in our center. In 15 patients (48%) RRT had to be performed because
of fluid overload. Mean requirment of blood products was 12±9 Packed red blood
cells and 9±12 Platelet concentrates. Bleeding complications occured in 16
(52%) patients and was associated with the lenght of ECMO duration. Severe
bleedings occured in 6 patients (4 lung, 2 intracerebral haemorrhage). Overall
survival was 59% (18/31) and was significantly higher in patients with cardiac
disease (70,6%) and lowest in oncologic patients (40%). Bleeding complications
and need for RRT were associated with higher mortality.
Conclusion: In this analysis overall
survival is comparable to those in the literature and ECMO can be lifesaving in
these patients. Survival was best in patients with cardiac disease and worst in
oncologic patients with ARDS. Bleeding complications and need for RRT were
associated with higher mortality. According to the ILCOR guidelines on PALS
2010 Extracorporal cardiac life support (ECLS) may be considered in selceted
patients with cardiac arrest, if cardiac arrest occurs in an evironment with
appropriate expertise and protocols for ECLS.
The use of simple genetic methods as a second tier in the screening
for congenital adrenal hyperplasia screening is complicated
Malikova J1, Votava F2, Cinek O1, Lebl J1
1University Hospital Motol and Second Faculty of
Medicine, Charles University in Prague, Department of Pediatrics, Prague, Czech
2University Hospital Kralovske Vinohrady and Third
Faculty of Medicine, Charles University in Prague, Department of Pediatrics,
Prague, Czech Republic
Background: The neonatal screening for
congenital adrenal hyperplasia (CAH) leads to identification of a certain
proportion of newborns with moderately increased 17-hydroxyprogesterone
(17-OHP) who require a follow-up until normalization of 17-OHP. Among
these individuals, we aimed to assess the number of copies of the CYP21A2
gene and its pseudogene and the prevalence of point mutations.
Patients and methods: We analyzed 754
randomly chosen neonatal dried blood spots from subjects with moderately
elevated 17-OHP, who decreased to normal 17-OHP levels thereafter, 70 samples
with known genotypes and 191 control blood samples of healthy children. The CYP21A2
gene was sequenced. The copy number ratio between the CY21A2 gene and
its CYP21P pseudogene was tested by two methods utilizing the difference
in the sequence of exon 3 (8bp deletion): two-colored real-time quantification,
and fragment analysis. The samples clustered into four major clusters according
to the gene/pseudogene ratio, representative samples from each group were
analyzed by the multiplex ligation-dependent probe amplification (MLPA).
Results: Among the samples with moderately
elevated 17-OHP, we identified 22 (3%) subjects with a known heterozygous
point mutations and 10 (1.4%) samples with substitutions of unknown functional
significance. Furthermore, we observed high proportions of samples deviate from
the usual 1:1 ratio of the CYP21A2 to its pseudogene in dried blood
spots with moderately elevated 17-OHP and also in control blood samples. Over
66 samples (9%) could not be classified due to failure of one or more methods
because of the low quality of DNA obtained from the dried blood spots.
Conclusion: Using a second tier based
on detection of pathogenic CYP21A2 variants, we would exclude clinical
CAH caused by steroid 21-hydroxylase deficiency in 688 samples (91%). But the
efforts towards definite confirmation of no less than one functional allele of
the CYP21A2 gene would be far too costly and laborious as compared to
the now utilized recall measurements of 17-OHP.
Pre-term newborns bone metabolism
Pecková A1, Bayer M
Dept. of Paediatrics, Charles University, Medical Faculty,
Hradec Kralove, Czech Republic
1Dept. of Gynecology and Obstetrics, Charles University,
Medical Faculty, Hradec Kralove, Czech Republic
Introduction: Growth and development of bone
structure during intrauterine life have predictive quality for development
during childhood until the adulthood. From the studies with term borned
newborns we know that the leptin influence the maturation of chondrocytes and
osteoblasts. There is positive correlation between the cord blood level of
leptin and bone density (term newborns). There are little information about
pre-term newborns, who are in higher risk of low bone density.
Methods: Prospective study. We investigate
60 pre-term newborns (slight and mild immaturity). There was fill in the
questionnaire – medication during pregnancy, weight gain during pregnancy,
diabetes during pregnancy, smoking, meassuring of the placenta – average,
weight, longitude of umbilical, cord blood acid base balance, newborn - gestation
age, delivery type, time of delivery,
Apgar score, newborns weight and lenght, minerals in urine. Cord blood analyses
– Ca, P, ALP, AST, ALT, 25-OH D, leptin, osteocalcin. Hypothesis – there is
correlation between cord blood analytes and newborns an placental description
Results: Analyses of the results are still
running, preliminary results will be available at the time of the symposium.
Screening strategies for the identification of the first
degree relatives of T1D patients with the highest risk of progression to
clinical onset of type one diabetes
L, Vcelakova J, Stechova K, Lebl J, Vyhnankova M, Kolouskova S
Pediatric Dpt., University Hospital Motol, 2nd Medical Faculty,
Charles University, Prague, Czech Republic
Aim: The first degree relatives of patient
with T1D are at 4-8 fold increased risk for diabetes compared with the general
population. We asked whether combined examination of risk HLA genotype and
pancreatic islet autoantibodies considering their titer, type and the number of
them would improve the selection of the children under the highest risk for
clinical onset of T1D.
Methods: The siblings and offspring of T1D
patients were recruited by the Czech T1D Prediction Programme where they are
prospectively followed up for T1D development and which includes estimation of
risk HLA genotype (DQA1, DQB1) and regularly examination of T1D associated
autoantibodies (GADA, IA2A, IAA by radiobinding assay). In Ab positive children
under the high risk of T1D development we performed IVGTT (41 children).
Diabetes status of all siblings and offspring was defined.
Results: Of the 1062 first degree relatives,
152 (14,3%) were positive for at least one Ab and 53 (4.9%) developed diabetes
during follow up (median follow up 3 years, range 1–12). The prevalence of GADA
or IA2A or combination of GADA and IA2A in Ab positive children was 72 (47.3%),
34 (22.3%) and 43 (28.2%). The study showed a strong association among T1D
risk and HLA (p<0.05), Ab titer (p<0.01), Ab type (p<0.05) and Ab
number (p<0.01). The highest risk were connected with risk genotype
DQA1*05-DQB1*0201/DQA1*03-DQB1* 0302, high-titer of IAA, IA2A (p<0.01). We
proved association between FPIR and length of Ab positivity, but no association
between FPIR and Ab titers. As the secondary result MODY diabetes was proven in
13 cases of Ab negative diabetic patients.
Conclusion: HLA and Ab screening is able to
define children at actual risk of diabetes progression. On the other hand the
estimation of the period to T1D manifestation is very difficult because the
length of beta cells destruction is too variable as shown FPIR and we should
focused on the others cofactors.
Renin-Angiotensin-Aldosterone-System (RAAS) blockers in diabetic
Wagner L, Prókai Á, Vér Á, Vannay Á, Degrell P, Szabó AJ, Fekete A 1st
Dep. of Pediatrics, Semmelweis University, Budapest, Hungary
Dep. of Transplant Surgery, Semmelweis University, Budapest,
Dep. of Med. Chem. Mol. Biol. and Pathobiochem., Semmelweis
University, Budapest, Hungary
2nd Dep. of Internal Medicine and Nephrology Center, Pécs,
Objectives and study: Renal RAAS is clearly
activated in diabetes, which is the main cause of end-stage renal failure.
Previously in a rat model of DN we found impaired renal function parallel
with elevated expression and translocation of the renal Na/K ATPase (NKA).
Heat-shock protein (HSP) 72 stabilized membrane associated NKA and preserved
enzyme function. Here, we analyze the effect of various RAAS inhibitors on
diabetes or hyperglycemia induced renal damage.
Methods: In vivo – Diabetes was
induced in male Wistar rats with iv. Streptozotocin After 5 weeks of diabetes
rats were treated daily with ACE inhibitor enalapril, ARB losartan and aldosteron
antagonists spironolactone and eplerenone for 2 weeks p.o. Vehicle-treated
diabetic, and treated non-diabetic animals served as controls (n=6/group).
Renal histology, kidney function, protein levels and intrarenal localization of
NKA and HSP72 were evaluated. In vitro - HK-2 cells were cultured under
5mM (C) and 35mM (G) glucose concentrations and in 35mM mannitol (M). G
cells were treated with the same RAAS blockers for 72 hours. NKA and HSP72
protein levels were measured.
Results: Diabetes resulted in impaired renal
histological and functional parameters, elevated and translocated renal NKA and
HSP72. RAAS inhibitors ameliorated histological damage, while kidney function
was mostly preserved by aldosterone antagonists. Each RAAS treatment -except enalapril
- lowered renal NKA and HSP72 and prevented NKA translocation. Hyperglycemia
induced elevation of tubular NKA was decreased by each treatment, except
Conclusion: Aldosteron antagonists, even in
monotherapy might be beneficial in the treatment of DN beside ACE inhibitors
and ARBs. RAAS inhibitors might help to stabilize NKA and thereby sodium
homeostasis, which could be an additional explanation for their renoprotective
Supported by grants OTKA-NNF78846-K71730 and
Genetic deficiency of tartrate-resistant acid
phosphatase is associated with skeletal dysplasia, cerebral calcifications and
Lausch E1, Janecke A2, Bros M3, Unger S1,4,
Zabel B1, Superti-Furga A1,4
1Centre for Pediatric and Adolescent Medicine, University
of Freiburg, Freiburg, Germany
2Department of Pediatrics II and Division of Human
Genetics, Innsbruck Medical University, Innsbruck, Austria
3Department of Dermatology, University Medical Center of
the Johannes Gutenberg University, Mainz, Germany
4Department of Medical Genetics, Centre Hospitalier
Universitaire Vaudois, Lausanne, Switzerland
Aims: Monogenetic autoimmune diseases hold
the promise to elucidate complex dysregulation observed in common disorders
like systemic lupus erythematosus (SLE) and multiple sclerosis (MS). Vertebral
and metaphyseal dysplasia, spasticity with cerebral calcifications, and strong
predisposition to autoimmune diseases are the hallmarks of the genetic disorder
Methods and results:
We mapped a locus in five consanguineous families to chromosome 19p13 and
identified mutations in ACP5, which encodes tartrate-resistant
phosphatase (TRAP), in 14 affected individuals and showed that these mutations
abolish enzyme function in the serum and cells of affected individuals.
Phosphorylated osteopontin, a protein involved in bone reabsorption and in
immune regulation, accumulates in serum, urine and cells cultured from
TRAP-deficient individuals. Patient-derived dendritic cells exhibit an altered
cytokine profile and are more potent than matched control cells in stimulating
allogeneic T cell proliferation in mixed lymphocyte reactions.
Conclusions: These findings shed new light
on the role of osteopontin and its regulation by TRAP in the pathogenesis of
common autoimmune disorders. Pharmacologic modulation osteopontin may thus
provide a novel therapeutic angle for diseases like SLE and MS.
A novel mutation of the 25-hydroxyvitamin D-1 alpha
hydroxylase gene (CYP27B1) in a boy with vitamin D-dependent
rickets type 1
Ertl A1, Streubel
Zeitlhofer P2, Raimann
Sagmeister S1, Haeusler G1
1Medical University of Vienna, Department of Paediatrics
and Adolescent Medicine, Department of Pediatric and Adolescent Medicine, Div.
of Pediatric Pulmonology, Allergology and Endocrinology, Austria
2Medgen Vienna, Austria
3Medical University of Vienna, Clinical Institute for
Pathology and Genetics, Austria
Case report: A male patient (parents
unrelated) presented at one year of age with radiological and biochemical signs
of rickets despite regular prophylactic administration of 25-hydroxyl-vitamin
D3 (25-OH VitD3). Whereas 25-OH VitD3 administration failed to improve severe
hypocalcaemia, therapy with 1,25 (OH)2- cholecalciferol and calcium was followed
by rapid improvement of clinical and biochemical findings. During childhood,
serum calcium levels were stable, but during adolescent growth, very high
levels of parathormone (298 ng/ml, normal 10-60 pg/ml), with normal serum
calcium and alkaline phosphatase indicated the need for dosage adjustment.
Interestingly, the patient was completely asymptomatic during a period of
severe hypocalcaemia, which can be attributed to his chronic adjustment.
Genetic analysis had not been available at the time of presentation, and was
performed by sequencing analysis of the CYP27B1 gene. Our patient proved
to be compound heterozygous for two new mutations, namely
NM_000785.3:c.[217G>A];[790+2T>G] (nt 1 corresponds to the A of the
ATG initiation codon). The first one is located in exon 2 and causes the amino
acid substitution p.Gly73Arg, whereas the second one is a potential splice
site mutation (intron 4).
Discussion: Vitamin D-dependent rickets type
1 is an extremely rare disorder (36 mutations in 54 patients reported), usually
found in consanguineous families. In our patient, the asymptomatic parents had
a heterozygous mutation, each of which has so far not been described to
lead to functional defects.
Perspective: In order to test the relevance
of the mutations, we will first use a structure prediction program
(PSIPRED, Protein Structure Prediction Server) to predict the change of protein
secondary structure, and, afterwards, we will characterize the functional
consequence of these mutations on 1 alpha-hydroxylase activity in cell culture.
Heparin Co-Factor II Thrombin Complex (HCII-T) –
a new biomarker for MPS
Clarke L, Herkner K, Kasper
D, Kircher SG, Konstantopoulou V, Moeslinger D, Pollak A
Medical University of Vienna, Department of Paediatrics and
Adolescent Medicine, Austria
The mucopolysaccharidoses are
a heterogeneous group of multisystemic and progressive lysosomal storage
disorders caused by a deficiencies of specific enzymes in the
Storage of glycosaminoglycans also
influences physiological processes within the body like inflammatory reactions
or haemostasis. The pathological storage leads to an activation of serine
protease inhibitors, like Heparin Co-Factor II. Due to activation HCII inhibits
thrombin by forming a covalent linkage.
Randall et al. discover a correlation
between the well known influence of GAGs to the formation of HCII-T-complex and
MPS. A 630 fold increase of the HCII-T complex level was demonstrated in
the mouse model.
In patients suffering from MPS I/ MPS II/
MPS VI it was also possible to demonstrate an elevated HCII-T level.
Langford- Smith et al. inject dermatan
sulfate (MPS I/ MPS II/MPS VI) into a mouse and observe an increase of
Neither injections of heparan sulfate (MPS
III) nor of keratan sulfate (MPS IV) provoke an increase of HCII-T.
Interestingly, in samples from patients suffering from MPS III and MPS IV the
HCII-T level was increased.
We did measurements in 7 male patients
suffering from MPS II before and during enzyme replacement therapy. Before
starting the ERT the HCII-T level was highly elevated and dropped down during
In our group it was not possible to find
a correlation between the level and the severity of the disease.
Hereditary pancreatitis in children – possibilities of
Töröková K, Čierna
I, Kovács L
2nd Department of Pediatrics, Comenius University Medical
School, University Children´s Hospital, Bratislava, Slovakia
Hereditary pancreatitis is a very rare
disease with early onset, slow progress and variable clinical presentation.
Inheritance is autosomal dominant with incomplete, approximately 80 percent
penetrance and variable expressivity. Mutation of the PRSS1 gene
(cationic trypsinogen gene) increases the autocathalytic conversion of
trypsinogen to active trypsin that increases the autodestruction of the
pancreas leading to chronic inflammatory changes. Other genes associated with
chronic pancreatitis are PRSS2 (anionic trypsinogen gene), SPINK1
(serin protease inhibitor – Kazal type 1) and CFTR (cystic fibrosis
transmembrane conductance regulator).
Our aim is to point out the therapeutical
pitfalls and possibilities of genetic diagnosis with case studies of three
patients with chronic pancreatitis. The onset of the disease was at ages 8, 14
and 16 with strong abdominal pain from acute exacerbation of until that time
asymptomatic chronic pancreatitis. Chronic inflammatory changes led to
pancreatic fibrosis, pseudocysts and calcifications in the parenchyma and along
the pancreatic duct. All of them required Sumery according to fulminant course
of the acute exacerbation. DNA analysis was indicated to confirm the inherited
form of chronic pancreatitis with autosomal dominant inheritance from mutations
in genes PRSS1 and SPINK1. One of the patients had mutation of PRSS1
gene – R122H and in two patiens mutation of SPINK1 gene – N34S in
heterozygous form was revealed.
These case studies draw attention to the
importance of diagnostic of inhereted forms of chronic pancreatitis. After
exclusion of other causes included cystic fibrosis, the indication for PRSS1
and SPINK1 mutation testing in symptomatic patients should be one of the
a) recurrent unexplained attacks of acute
pancreatitis and a positive family history (in two of our patients acute
pancreatitis appeared in a first-degree family members in young
adulthood), b) unexplained chronic pancreatitis and a positive family
history, c) unexplained chronic pankreatitis without a positive family
history after exclusion of other causes, d) unexplained pancreatitis episode in
Patients with confirmed hereditary
pancreatitis are at risk for developing exocrine and
endocrine insufficiency and are at 50-fold
increased risk of pancreatic cancer; therefore the prevention of the
complications is possible with early diagnostic, follow-up and education of
DNAH5 and DNAI1 mutations in patients with primary
ciliary dyskinesia detected by sequencing of selected exons
Djakow J1, Svobodová
Cinek O1, Uhlík
1Department of Pediatrics, 2nd
Faculty of Medicine, Charles University in Prague and University Hospital
Motol, Prague, Czech Republic
2Department of Histology and Embryology, 2nd
Faculty of Medicine, Charles University in Prague, Czech Republic
Introduction and the aim of the study:
Primary ciliary dyskinesia (PCD) is a rare genetically heterogenous
condition. Mutations in DNAH5 or DNAI1 genes can be found in about a third
of the patients with PCD. Frequent mutations were described in some exons of
these structurally complicated genes. The objective of the study was to
determine a prevalence of the DNAH5 or DNAI1 mutations in the patients
with PCD using sequencing of selected exons and to evaluate whether this
approach can be used as a first-step genetic testing.
Methods: Based on clinical findings and
diagnostic tests on the ciliated epithelium, 31 paediatric patients with PCD
were identified. Twenty-six patients from 23 families agreed on genetic
testing. Direct sequencing of 9 exons of DNAH5 and 4 exons of the DNAI1 was
Results: In total, 6 mutated alleles were
found in 5 of the patients. One
patient, a 17-year old male with PCD caused by outer dynein arm (ODA) defect
and completely immotile cilia, was a compound heterozygote for DNAH5
mutations, while in other four individuals we found only one mutation. Four of
the mutations found were previously described, two mutations were novel
Conclusions: Selected exon sequencing is
likely to detect at least one mutated allele in most of the patients who are
expected to carry DNAH5 or DNAI1 mutations. Targeted and tiered genetic testing
may be a reasonable approach to detect mutations in PCD patients, especially
if their phenotype is taken into account.
Genetic, epigenetic, RNA and protein analysis of
myocardial tissue samples in congenital heart defects – recommendation on
preparation and long-term storage
Diener K-H1, Dangl A2,
1Division of Pediataric Pulmonology, Allergology and
Endocrinology, Medical University of Vienna, Department of Paediatrics and
Adolescent Medicine, Austria
2Division of Pediatric Cardiology, Medical University of
Vienna, Department of Paediatrics and Adolescent Medicine, Austria
Aim of the study: In congenital heart
defects (CHD) several mutations in different cardiac specific genes are
discussed to increase the risk for malformations of the heart during
embryogenesis. This can cause deficiency, absence or malfunction of the
produced protein leading to disruption of the normal function of
cardiac-specific pathways in the developing heart.
Therefore we plan to analyze genetic
sequences of cardiac specific genes in myocardial tissue of patients with CHD.
Afterwards, for better understanding of the disordered function, mRNA
expression, epigenetic evaluation and analysis of protein quantity and quality
of genes with detected mutations should be performed. Myocardial samples are
taken during cardiac surgery after informed consent of the patients with CHD or
To ensure a maximum stability of RNA,
DNA and protein in myocardial tissue, optimal procedures of handling and
storage are required. With this study, the best practices for handling and
storage of the extracted myocardial samples should be worked out to guarantee
best quality and quantity for a long time.
So we compared the conventional technique of
myocardial samples storage at -80°C for DNA analysis and at liquid nitrogen for
measurements of RNA and proteins with a new stabilizing reagent (QIAGEN
AllProtect) to improve storage condition and duration at -80°C for all tissue
Methods: Immediately after surgical
extraction the myocardial samples are divided in small, equally sized pieces,
which are used to analyse baseline levels of RNA, DNA and protein in freshly
drawn specimen and for further storage using the conventional technique or
after treatment with the stabilizing reagent at -80°C. Further analysis will be
performed after 4, 12 and 24 months storage. Isolation is prepared by QIAGEN
AllPrep DNA/RNA/Protein-Mini Kit, which allows the extraction out of one
myocardial piece. Quantification and qualitative analysis are performed by use
of the Nanodrop Spectrophotometer ND-1000 and Agilent Bioanalyzer.
Severity of hypertension in obese children and adolescents
Babinská K1, Kovács L1, Jankó V1,
Dallos T.1, Vitáriušová E1, Feber J2
12nd Department of Pediatrics, Comenius University
Medical School, University Children´s Hospital, Bratislava,
2Division of Nephrology, Department of Pediatrics,
Children’s Hospital of Eastern Ontario, Otawa, Canada
The aim of the study:
Childhood obesity represents a major problem, at present time affects in
Slovakia 15% children and is characterized with early occurrence of
complications, including hypertension. The ambulatory blood pressure monitoring
(ABPM) enables precise detection of arterial hypertension, assessment of blood
pressure load and blood pressure dipping during the night. The goal of our
study was to analyze the impact of obesity on blood pressure, detect the
severity of hypertension and characterize the type of hypertension in obese
children and adolescents.
Methods: Blood pressure was assessed with
ambulatory blood pressure monitoring. The severity of hypertension was
determined according the BP load and corrupted night blood pressure dipping.
One hundred-nine patients with primary obesity aged 7 to18 years (mean±SD age =
14.1±3.1) were enrolled in the study. Patients were divided into3 groups according to BMI
Z scores: Group 1 (n=27): BMI >1.65 and <3.28 SDS; Group 2 (n=55):
BMI >3.29 and <4.91 SDS; Group 3 (n=27): BMI >4.92 SDS.
Anthropometric, laboratory and blood pressure data were analyzed.
Results: Only 26 patients (24%) had
ambulatory normotension, 27 (25%) had ambulatory prehypertension, 3 (3%) had
hypertension and 53 (48%) had severe ambulatory hypertension. The severity of
hypertension increased significantly with the degree of obesity (Chi square
test for trend, p=0.0027). Daytime systolic, diastolic and mean arterial
pressures (SBP, DBP, MAP) increased significantly with increased BMI (shift to
the right), whereas the nighttime pressure remained elevated regardless of the
degree of obesity. Isolated nighttime hypertension was observed in 25% of
patients, 38% were classified as non-dippers.
Conclusion: Almost 50% of children with
obesity and hypertension suffer from severe ambulatory hypertension detected on
ABPM. Obesity has a major impact not only on incidence but also on the
severity of hypertension. Nighttime blood pressure is elevated in early stage
of obesity, in severe obese patients raises the daytime blood pressure.
Assessment of arterial stiffness in hypertensive
children and adolescents
Miksić M, Gregorič A, Marčun Varda N
Department of Paediatrics, University Medical Centre Maribor,
The aim of the study: The important part of
investigations in hypertensive children is to establish the effects of elevated
blood pressure on the hypertensive target organs. One potential early marker of
this damage is the increase of arterial stiffness now recognized as
a major driver of cardiovascular disease. The aim of our study was to
investigate if there are any differences between normotensive and hypertensive
children according to the measures of arterial stiffness.
Methods: Twenty normotensive and 20
hypertensive children of both sexes, matched by age and sex, were included in
the study. Carotid-radial pulse wave velocity (PWV) was measured in
hypertensive children as an index of arterial stiffness using the applanation
tonometry-SphygmoCor and compared to the values in normotensive children.
Central aortic systolic pressure (AoSP), aortic pulse pressure (AoPP),
augmentation pressure (AP) and the augmentation index (AIx@HR75) were also
compared between the two groups.
Results: The hypertensives presented higher
mean values of PWV (6.30 m/s), AoSP (131.9 mmHg), AP (0.35 mmHg) and the
AIx@HR75 (2.80) than the controls (PWV (6.09 m/s), AoSP (125.5 mmHg), AP (-2.30
mmHg) and the AIx@HR75 (-0.75)). The AoPP was higher in the normotensive group
(55.9 vs. 51.1 mmHg). No significant differences in PWV (p=0.57), AoSP
(p=0.24), AP (p=0.37), the AIx@HR75 (p=0.34) and AoPP (p=0.26) were found.
Conclusion: We found no significant
differences of arterial stiffness between normotensive and hypertensive
children. Nevertheless, we believe that with increasing size of studied
population the difference would become more significant.
Nonalcoholic fatty liver disease (NAFLD) in children and adolescents
Nováková B², Schuszter A¹, Kuchta M¹
¹IInd Department of Children and Adolescents, Children Faculty
Hospital, P. J. Š. University, Košice, Slovakia
²IIIrd Internal Clinic, University Hospital of L. Pasteur,
Non-alcoholic fatty liver disease is now considered as one of the commonest liver
diseases in developed countries. It is recognised as an increasing clinical
problem in children and adolescents. Risk factors include obesity, insulin
resistance, and disorders of lipid metabolism.
The aim: of our study was to evaluate basic
characteristics of NAFLD – its prevalence, diagnosis based on laboratory
parameters and ultrasound examination of the liver among children and
adolescents with identified disorder of lipid metabolism.
Methods: The retrospective study included 50
children and adolescents (27 mail and 23 female) aged from 1 to 19 years (mean
age was 12,5±4,48) with impaired lipid metabolism. Serum aminotransferases,
total bilirubin, glucose levels and parameters of lipid metabolism were
analyzed from fasting blood samples. Ultrasound examinations were realized on
ACUSON Sequoia Echo C512, using convex probe. In order to achieve greater
objectivity of ultrasound evaluation, ultrasound images were quantified by
programe Adobe Photoshop 5.5 function Histogram.
Results: Antrophometric parameters (body
weight, BMI, waist circumference, hip circumference and WHR – waist to hip
ratio) were significantly higher in the group of children with NAFLD, compared
with the group without NAFLD. There was a significant association between
activity of aminotransferases (AST and ALT) and body weight, BMI and level of
triglycerides in the group with NAFLD. Patients with NAFLD had significantly
higher echogenity of liver parenchyma, what was objectivised and quantified by
the density of pixels in usg image. There was a statistically significant
correlation between PO index (ratio: liver parenchyma/cortex of the right
kidney) and antrophometric parameters (body weight, BMI, waist, hip
Conclusions: Non invasive diagnostic
methods, such as measurement of antrophometric parameters, ultrasound
examination – mainly objectivisation of the currently used ultrasound liver
examination by using the Adobe Photoshop quantification utility, allow to
predict presence of nonalcoholic fatty liver disease.
Improvement in biomarkers of bone formation during
54-week infliximab therapy in pediatric patients with Crohn´s disease
K1,2, Szabó D1, Kővári É1, Vannay Á2, Dezsőfi A1, Arató A1, Tulassay T1, Veres G1
1First Department of Pediatrics, Semmelweis University,
2Research Group for Pediatrics and Nephrology, Semmelweis University and Hungarian
Academy of Sciences,
The aim of the study: Treatment with
infliximab (IFX) may improve growth and disturbed bone metabolism in pediatric
patients with Crohn disease (CD), but the characteristics of bone formation and
resorption factors under IFX treatment are not well known. This study examined
changes in bone formation (osteocalcin/OC, bone-specific alkaline
phosphatase/bALP) and resorption (beta-crosslaps/bCL) under IFX treatment.
Moreover, associations between bone biomarkers, and CRP, vitamin D level,
disease activity index (Pediatric Crohn’s Disease Activity Index, PCDAI), and dual
energy x-ray absorptiometry (DEXA) after 54 weeks of IFX therapy were analyzed.
Methods: Twenty-eight subjects with moderate
to severe CD received IFX induction (5 mg/kg/dose) at weeks 0, 2, and 6.
Maintenance therapy was given all patients every 8 weeks. Serum OC, bCL, bALP,
and vitamin D were collected at baseline, 6 weeks, 30 weeks and 54 weeks, in addition CRP and PCDAI were
determined. DEXA z-scores were assessed at baseline, 30 weeks and 54 weeks.
Results: Serum levels of bone formation OC increased
significantly after IFX induction treatment. bALP increased significantly
between baseline and weeks 6 (mean, 110U/L, 161U/L, respectively, P=0.002).
There were no significant differences concerning bCL and vitamin D at different
time points. Nevertheless, both z-score of the lumbar spine and femoral neck
improved after 54 weeks when compared with baseline respectively. Increment of
bone forming OC correlated negatively with decrement of CRP and PCDAI (week 0
vs. weeks 6, week 30, and weeks 54).
Conclusion: Clinical response to IFX therapy
was associated with an increased level of bone forming osteocalcin in pediatric
patients with 54-week treatment of IFX. Bone resorption marker (bCL) was not
increased suggesting a bone forming effect of IFX treatment.
An interventional study on mass hysteria in children
Sharma1, Ajaya Kumar Jha2, Anish Joshi2, Ritesh
1Department of Psychiatry
2Department of Paediatrics, Dhulikhel Hospital, Kathmandu University Teaching
Background: A Mass conversion
dissociative disorder, also known as “Mass hysteria”, has become a common
phenomenon in rural and urban school going children. This study has been
carried out to find out the socio-demographic pattern of this disorder, explore
factors that may be contributory to this problem and the utility of
psychological intervention, carried out on the affected children, their family
members and teachers, on the recurrence of this disease.
Materials and methods: This is
a retrospective study of 67 children, who suffered from episodes of
pseudo-seizures in the community school. A detailed questionnaire form was
used, which was specifically prepared to evaluate these children. Detailed
mental status examination was performed by a psychiatrist. Psychological
intervention was done in which group therapy and individual counseling were
After six months of prospective follow up,
all children who had recurrence of the episode were re-interviewed. Similar
type of group therapy and individual counseling were carried out in children
with repeated attacks. In both the occasions, in addition to the children,
teachers and parents were also counseled separately.
Results: Most of the affected children were
in the 12 to 14 years age group and majorities (91%) were females and were from
6th to 9th grades. Family history of similar attacks was found in 25% of the cases.
Prevalence of the attack was found to be commoner in children with lower
socio-economic status. Some form of mental illness like anxiety, depressive
disorder was found in 13% of cases. These were all determined by using the
criteria in DSM IV. Alcohol abuse and disturbed family dynamics were associated
in 33% of the cases. Majority of the affected children were found to have poor
scholastic performance. More than 50% of the children with attack were found to
have witnessed or been involved in violent activities and in 15% of the cases
there was a history of corporal punishment.
After six months of prospective follow up,
nearly 20% had recurrent episodes of the pseudo-seizure while 80% had no
recurrence. All children who had a repeat-attack were females. School
dropout was found in 5% of the cases. Overall outcome after psychological
intervention was found to be satisfactory and it was found to be very effective
in decreasing the recurrence of pseudo-seizures.
Conclusion: Effective intervention and
prospective follow up has shown to be very cost effective in decreasing the
recurrence of mass pseudo-seizures. We recommend comparison of similar problems
in rural versus urban areas. Broader
community participation and prolonged follow up is strongly suggested.
Barorefles sensitivity and analysis of pulse wave in
young diabetic patients
Šťastná J1, Petrová A2, Pekař M2, Nováková Z2, Brázdová
Pejchlová M1, Hrstková H1, Závodná E2, Honzíková N2,1
11st Department of Paediatrics, Faculty Hospital in Brno
and Faculty of Medicine, Masaryk University, Czech Republic
2Department of Physiology, Faculty of Medicine, Masaryk
University, Brno, Czech Republic
3Merciful Brothers’ Hospital in Brno, Czech Republic
The aim of the study: Type 1 diabetes
mellitus is a chronic endocrine and metabolic disease, which usually
starts in childhood. The insufficient compensation of glycaemia may result in
cardiovascular disorder. The aim of the study was to evaluate the baroreflex
sensitivity (BRS) and the pulse-wave velocity (PWV) and augmentation index
(AIx) in young diabetic patients.
Methods: We examined 15 patients with type 1
diabetes mellitus without clinical signs of an autonomous disorder (group D,
age: 15±3.2 yrs, duration of the disease 6.33±2.94 years, glycated haemoglobin
HbA1c 7.29±1.35%) and 18 healthy individuals (group C, age: 16.7±0.5 years). We
used a 5-min continuous non-invasive blood pressure (BP) measurement
(Finometer, FMS, The Netherlands). BRS was calculated by beat-to-beat values of
BP and inter-beat intervals by spectral analysis and expressed in ms/mmHg. The
applanation tonometry was used for detection of pulse-wave velocity, the
augmentation index was estimated by pulse-wave analysis (Sfygmocor,
AtCorMedical, Australia). The Mann‑Whitney
test was used for statistical evaluation (STATISTICA 9.CZ, StatSoft).
Results: Comparing group D with group C, we
found a significant increase of the PWV values (D vs. K: 7.33±0.60 vs. 6.36±0.53 m/s;
p<0.05), AIx values (D vs. K: 0.30±10.35 vs.-1.63±1.42 %; p<0.05) and
heart rate (76.65±10.35 vs. 66.76±8.50 bpm, p<0.05), and a significant
decrease of the BRS (7.84±4.11 vs. 11.91±4.72 ms/mmHg; p<0.05).
Conclusion: The study showed that an
increase of pulse-wave velocity, augmentation index and a decrease of
baroreflex sensitivity can be found in young patients with type 1 diabetes
mellitus who do not have any clinical signs of an autonomous disorder during
some years of duration of this disease.
Supported by grant: MSM 0021622402.
Neonatal abstinence syndrome – our experience
Brucknerová I, Červeňová O
1st Department of Paediatrics, Medical School, Comenius
University, Bratislava, Slovakia
In infants, who were exposed to addictive
substances during pregnancy, neonatal abstinence syndrome (NAS) can develop.
Distinctive signs and symptoms of central and autonomic nervous system
regulatory dysfunction are presented.
The aim of the study: To present
a group of neonates with NAS, who were admitted at the Neonatology Unit of
1st Department of Paediatrics between January 1st, 2000 and December 31st, 2010. Risk factors, complications, treatment and
consequences are evaluated.
Methods: Group of 76 neonates (35 males and
41 females) with NAS were analyzed. Drug abuse mothers in 95% of cases were
positive and maternal anti-epileptic drugs and iatrogenic in 5%. The
most frequent drugs were heroin (57%), methadone (53%) and others (marijuana,
methamphetamines, benzodiazepines, barbiturates). 28% of mothers smoked.
After delivery 7 neonates
were asphyxiated (Apgar score ≤7), 18 children were small for gestational age and 30 children were premature.
Results: During the first day of life, 78%
of cases were admitted. For initial therapy in 4% of patients oral morphine
solution was administered. Other options as chloral hydrate and phenobarbital
were also used. 9% of all newborns were without any therapy. These high risks
children are threatened with transplacentally transmitted infectious diseases.
In our group 3 cases of hepatitis C infection have occured. In other cases
passively transferred antibodies were noted (HCV-44, HBV-4, BWR-20, CMV-5). 15%
of children had neurological consequences. After complete social investigation
68% of children were discharged home and 4% were moved to regional hospital.
24% from all of them were placed in children’s home and only 4% in foster care.
Conclusion: Drug abuse during pregnancy may
lead to fetal damage and have consequences for growth and development of the
children. Comprehensive care for newborns includes non-pharmacologic therapy
and supportive treatment based on evaluation of the Finnegan Neonatal
Abstinence Scoring System. All risk newborns require complex approach involving
some professionals and social workers. The most important is to identify the
most appropriate social environment.
Succinate activates the collecting duct
Burford J1, Gevorgyan H1, Péterfi
Vargas SL1, Peti-Peterdi J1
1Department of Physiology and Biophysics and Department
of Medicine, Zilkha Neurogenetic Institute, University of Southern California,
Los Angeles, California, USA
21st Department of Pediatrics, Semmelweis University,
Objectives and study: The novel metabolic
receptor GPR91 controls renin release, the rate-limiting step of RAS.
Furthermore, the renal collecting duct (CD) is the major source of (pro)renin
in diabetes. Since the highest GPR91 expression was found in the CD, this study
investigated whether succinate, the ligand of GPR91 regulates the local CD RAS.
Methods and results: Western blot analysis
of succinate-treated M1 cells (CD cell line) showed a dose-dependent,
2-2.5-fold elevation in pERK½, pp38, COX2, renin, prorenin and its receptor [(P)RR]. In WT and GPR91-/- control and STZ-diabetic (DM) mice, CD pERK1/2 (by immunofluorescence)
and urinary PGE2 excretion (measured by ELISA) increased
4-20 fold in DM mice and were GPR91-dependent. Medullary (pro)renin and
(P)RR protein expression (by immunoblotting) and renin activity in the CD
tubular fluid (visualized in vivo using multiphoton microscopy and
a fluorogenic renin substrate delivered by renal micropuncture) increased
4-5 fold in WT DM vs. control mice, which was completely abolished in
GPR91-/- DM mice.
Conclusions: This is the first, direct
demonstration of CD renin activity in vivo. Succinate accumulation and
GPR91 signaling are novel (patho)physiological regulatory mechanisms that
activate the local RAS in the CD via MAP kinases and COX2, PGE2 release, and increased (pro)renin and (P)RR synthesis. Succinate and
GPR91 may be important regulators of the local CD RAS in DM and may serve
as new therapeutic targets in diabetic nephropathy.
Supported by grants from NIH DK064324; AHA
EIA 0640056N; Council on International Educational Exchange (CIEE) and
REG_KM_09-1-2009-0016 BAROSS, OTKA NNF78846, Semmelweis University
Familial cases of complete androgen insensivity: germ
cell survival and pathology
Oosterhuis JW2, Stoop H2, Bruggenwirth H3, Drop SLS4, Snajderova M1, Lebl J1, Looijenga
1Department of Pediatrics, Charles University, 2nd
Faculty of Medicine, Prague, Czech Republic
2Department of Pathology, Josephine Nefkens Institute,
Erasmus University Medical Center, Daniel den Hoed Cancer Center, Rotterdam,
3Department of Clinical Genetics, Erasmus University
Medical Center, Rotterdam, The Netherlands
4Division of Pediatric Endocrinology, Eramus University
Medical Center, Rotterdam, The Netherlands
Background: Germ cell decline in gonads of
patients with complete androgen insensitivity
syndrome (CAIS) is probably not only dependent on the abdominal location
of the testes, but also on the present androgen receptor (AR) mutation. Germ
cells with fetal features can be frequently found among cells which are able to
survive. These are suspicious for being at risk for malignant transformation,
resulting in germ cell cancer.
Aim of the study: To explore whether there
might be a link between a level of androgen receptor functionality
and germ cell survival and/or abnormal development in CAIS.
Methods: We evaluated gonadal histology
focusing on germ cells in four affected sibling pairs. In three families the
pathogenic AR mutation resulted in frame-shift, and therefore in
a non-functional receptor. In the fourth family point mutation led to
residual receptor activity. To further assess germ cell characteristics,
immunohistochemical detection of OCT3/4 and KITL was performed.
Results: Germ cells were present in seven
out of eight patients, but only in four of them number of settled seminiferous
tubules could be calculated (Family 1 with frame-shift: Subj A (1.3 yr) 50
% and Subj B (6 yr) 18%; Family 2 with residual AR activity: Subj A (9.5
yr) 44% and Subj. B (16.5 yr) 20%), in others the number was too small. Germ
cells with signs of malignancy (positive for OCT3/4, located within KITL
positive area), were identified in four patients from both groups with and
without residual activity of AR.
Conclusion: Lesser decline of germ cells was
observed in gonads in case of residual AR activity. However, persistence of
OCT3/4 positive germ cells is likely influenced by other factors as well,
because these cells were detected in gonads of both patients with and without
residual AR activity.
Effect of second-generation antihistamines on lymphocyte
ABCB1 protein expression
Kopřiva F, Džubák P, Kratochvílová
R, Radová L, Mihál V, Hajdúch M
University Palacky in Olomouc, Faculty of Medicine/Department
of Paediatrics, Czech Republic
The aim of the study: The purpose of this
initial study was to compare expression levels of ABCB1 protein in blood
lymphocytes in the course of antihistamines therapy. ABCB1 protein (MDR1
protein or P-glycoprotein), member of the ATP-binding cassette (ABC)
transporters family, is a transmembrane efflux pump for removal of
xenobiotics from the intracellular compartment, such as drugs. The target group
was pediatric patients with allergic disease treated by second-generation
antihistamines and healthy paediatric patients who did not use any drugs.
Methods: The evaluation of lymphocyte ABCB1
protein expression was performed on samples of 20 children (14 girls and 6
boys) aged 2–16 years (median 7) with mild, intermittent allergic rhinitis
(classification of allergic rhinitis as per ARIA 2008) and no other, treated by
cetirizine or levocetirizine (n=10), loratadine or desloratadine (n=10) for at
least 3 months, used once or twice a day in an amount recommended by the
producer, depending on their age and weight. Reference of lymphocyte ABCB1
expression values were obtained from a group of 45 healthy children
without therapy (34 boys and 11 girls) aged 0.2–15 years (median 3). The
expression of lymphocyte ABCB1 was determined on fixed and permeabilized blood
mononuclear cells using indirect immunofluorescence staining technique by flow
Results: Based on the
weighted medians for ABCB1 expression in peripheral blood lymphocytes data
showed a statistically significant increased expression of ABCB1 in the
group treated by second-generation antihistamines compared with the healthy
control group without treatment (p<10(-6)).
Conclusion: Second-generation antihistamines
therapy can lead to overexpression of ABCB1 proteins on the surface of
lymphocytes and thus it can reduce accumulation of concomitant drugs in
lymphocytes. But only these drugs that are substrates of ABCB1 protein.
Incidence of diarrheal disease and associated risk factors among under 5 years old children in Kathmandu University
Department of Paediatrics, Dhulikhel Hospital, Kathmandu
University Teaching Hospital, Nepal
Background: Five million children under the
age of 2 years die from diarrheal disease in developing countries each year and
rotavirus infections account for about 20% of these deaths. In Nepal, due to
lower socio-economic status and poor hygienic condition of the people,
intestinal parasitosis is very much prevalent and intestinal pathogens are
important causative agents of diarrhea and are one of the major public health
problems of the country. Since few community based studies have addressed the
epidemiology or etiology of this condition, this study will undertake
prospective diarrheal surveillance among children less than 5 years of age
presenting in Kathmandu University Teaching Hospital (KUTH). The result of this
study is expected to encourage the health care professionals in terms of
diagnosis and treatment plan of childhood diarrhoea.
Materials and methods: This study will be
a hospital based, prospective, non-interventional study carried out in
KUTH, Department of Paediatrics. All children under 5 years presented with
acute onset of watery diarrhoea with or without nausea and vomiting seen in
outpatient and those admitted in Inpatient department will be enrolled in the
study. Data collection for the study will be over 6 months period.
During the study period the parents will be
asked to respond questionnaires to record their age, sex, family size,
educational status, mother’s employment and knowledge of Oral Rehydration
Solution, clinical history including duration of illness, fever, antibiotics
used prior to reporting to the hospital, water source and sanitation, personal
hygiene and food habit. Socio-demographic condition, anthropometry, clinical
status, degree of dehydration, duration of hospital stay and treatment outcome
will also be recorded.
Specimen analysis: The fresh stool specimen
will be sent for analysis in the laboratory of Dhulikhel Hospital, KUTH. The
specimen will be subjected to naked eye examination for consistency, colour,
and atypical components (mucus, blood and parasites), then sample will be examined
microscopically for the leucocytes, macrophages, RBCs, mucus, reducing
substance, fat droplets and parasitic ova and cysts and then the sample will be
proceeded by standard microbiology method for culture in order to look for
common pathogens. However till date we have not been able to diagnose the viral
cause of diarrhoea (eg. Rotavirus). Rotavirus and other viral antigen will be
detected using commercially available ELISA kits supported by the Department of
Microbiology and Virology from the Medical University of Innsbruck.
Conclusion: The result of this study would
help us to understand the etiology of the increasing childhood diarrhea in our
hospital and in the surrounding community. This will also help us in the
further management of viral diarrhea and also to think about the need of
rotavirus immunization in a developing country like Nepal.
Cartilage hair hypoplasia – new station
Charles University, Medical Faculty in Hradec Kralove, Czech
1CHUV Lausanne; Switzerland/Dept. of Paediatrics;
Introduction: Cartilage-hair Hypoplasia is
a multi-systemic disorder characterized by short stature, blond fine
sparse hair, but this may be quite variable, and defective cellular immunity
predominantly affecting T-cell mediated responses. Patients may have severe
combined immunodeficiency, requiring bone marrow transplantation or they may be
asymptomatic. Gastrointestinal dysfunctions are frequently observed such as
mal-absorption or Hirschsprung´s disease.
The adult height ranges between 111 and
151 cm in males and between 104 and 137 cm in females. Around 20% of
Cartilage Hair Hypoplasia patients exhibit recurrent to severe infections.
RMRP gene is localized 9p21-p12. RMRP is the
RNA component of the RNase MRP protein complex.
It functions as a RNA and is not translated into a protein.
The RMRP gene is transcribed by the DNA
dependent RNA polymerase III. In bone is more strongly expressed in
hypertrophic chondrocytes and pericondrium than in the zone of proliferating
chondrocytes. There is also very strong expression in the epiphysis.
Methods: There was analysed DNA from 3
patients (and their parents) with Cartilage-hair Hypoplasia phenotype. There
were used following laboratory techniques – DNA amplification by PCR, gel
electrophoresis of PCR product, sequencing reactions with fluorescent dyes,
capillary elecrophoresis of sequencing reaction product.
Results: There were found mutation and
polymorphysm in all 3 families. There were described one new mutation
(g.162-166 dup TATCC). There was patient with short statue, seizures, friable
hair, dry skin, deep set eyes, epicantic fold.
Translational research in medulloblastoma: impact for oncoming clinical trials
Zitterbart K1, Filkova H2, Zambo I3, Kren L4, Pavelka Z1, Kuglik P2,5,
Hermanova M3,4, Veselska R1,5,
1Department of Pediatric Oncology, University Hospital
Brno, Czech Republic
2Department of Medical Genetics, University Hospital
Brno, Czech Republic
31st Institute of Pathologic Anatomy, St. Anne’s
University Hospital and School of Medicine, Masaryk University, Brno, Czech
4Institute of Pathology, University Hospital Brno and
School of Medicine, Masaryk University, Brno, Czech Republic
5Institute of Experimental Biology, School of Science,
Masaryk University, Brno, Czech Republic
The aim of the study:
Medulloblastoma (MB), an embryonal neuroectodermal tumor of the cerebellum, is
the most common form of malignant brain tumor of childhood. Identification of
biological prognostic markers and cellular targets results in risk-adapted
treatment, which is crucial for improving cure rates and reducing long-term
Methods: We review the current knowledge of
the biological prognostic markers in MB and show the results of our research in
Results: Several prognostic biomarkers that
were identified in retrospective cohorts of medulloblastoma, including MYCC
and MYCN amplification, nuclear b-catenin accumulation, and chromosome
17 aberrations, have now been validated in clinical trials as SIOP PNET MB 5
& 6 studies. University Hospital Brno is the National coordinating centre
and the National reference centre for biology (MYC status and
beta-catenin examination) in these trials.
In our cohort of MB, we revealed limited
copy number changes of MYC loci and DeltaNp73 protein overespression as
biomarkers associated with poor outcome of patients (Zitterbart et al., Acta
Neuropathol 2007, Zitterbart et al., J Neuro-oncol 2011).
Conclusion: We illustrate the importance of
further investigations in multicenter trials to better refine the emerging
genomic-based prognostic stratification in MB.
We also suggest creating a tissue
microarray from a large cohort of MB from Central European region to
facilitate translational research that would provide robust data.
Acknowledgments: This study was supported by
grant IGA MZCR NS10218-3/2009.
Case report: Patient with Down syndrome with Transient
Myeloproliferative Disorder complicated with liver fibrosis
Foralová R1, Mendelová
1Dept. of Pediatric Oncology, University Children´s
Hospital in Brno, Czech Republic
2Dept. of Pediatric Hematology, University Childrem´s
Hospital in Brno, Czech Republic
Introduction: Transient myeloproliferative
disorder (TMD) is a rare diagnosis of neonates with apparent trisomy of
21st chromosome or its mosaicism, ring formation, Robertsonal translocation and
isochromosome 21. TMD occurs in approximately 10% of patients with Down
syndrome (Morbus Down - MD) and its usual manifestation hyperleucocytosis and
thrombocytopenia, other cytopenias are uncommon. In peripheral blood analysis,
the leukemic blasts are present and GATA 1 gene mutation can be demonstrated by
molecular methods. In MD spontaneous remission frequently occurs within 3 to 6 months. Unfortunately, 20 to 30% of
patients with TMD do not achieve remission or develop Acute Megakaryocytic
Leukemia (AMKL- AML/M7) in a few years of their lives. In few cases of TMD
or AMKL patients, they develop a rare complication – liver fibrosis, based
on expression and secretion of platelet- derived growth factor (PDGF),
transforming growth factor beta (TGFβ)
and tumor necrosis factor alpha (TNFα)
of megakaryoblasts, which is fatal in most cases. The fibrosis can occur even
in other organs.
Case report: Our patient was a preterm
newborn girl from the 5th pregnancy (2 aborts, 3rd delivery) with no
complication, born in the 36th week of pregnancy. The delivery was spontaneous
with turbid amniotic fluid, with good postnatal adaptation, Apgar score:
9-9-10, birth weight: 2950 g, birth length 46 cm. The clinical examination
brought findings of characteristic stigmatization for Down syndrome and very
slight dyspnea, liver and splenic enlargement. The Cardiology showed normal anatomy and the picture of slight
pulmonary hypertension. The 1st postnatal day were found hyperleukocytosis of
140x 109/l and anemia in the peripheral blood, high
lactate dehydrogenase and markers of liver function in the biochemistry. The
peripheral blood smear (PBS) with 39,7x109 leukocytes with 72% of blast cells led to the suspected diagnosis of
transient myeloproliferative disorder (TMD)/AML in Down syndrome with the
flowcytometric correlate. In the bone marrow aspiration the infiltration with
the blast cells could be detected. The blasts cell count was lower than in the
PBS. The diagnosis of TMD was confirmed from PBS in Hannover faculty of
medicine- centre of TMD Prevention 2007 study; and the biological marker of
GATA1 mutation was confirmed there too. Our patient was enrolled into the TMD
Prevention 2007 study and a close follow-up according to the study was
recommended. The spontaneous decrease of leukocytes number was visible. The
trisomy of the 21st chromosome was confirmed by karyotype: 47,XX+21; and CGH:
rev is henh(21)(q11.1qter). 3 weeks later the patient developed the 2nd attack
of hyperleukocytosis with 61,5% of blast cells presence in PBS together with
liver impairment as hepatomegaly and liver dysfunction. The therapy with low
dose ara-c was started - 3 cycles of cytarabine 1,5 mg/kg daily for 7 days was
administered. The 1st therapeutic response was shown at week 16 of the study
when the cytomorphologic remission was markable, but MRD was still positive.
Unfortunately the liver enlargement and even liver dysfunction with obstructive
jaundice slowly progressed during the treatment to the life- threatening
impairment – suspected liver fibrosis. The dyspnea with pulmonary hypertension
got worse and partial respiratory insufficiency and even global respiratory
insufficiency occurred. Because of the patient bad general condition there were
no liver biopsy had taken.
And because of supposed poor prognosis of
liver impairment the life- selvage therapy by corticoids was decided. Patient
got 7 pulses of methylprednisolone 5 mg/kg daily, followed by continual therapy
with prednisone with dosage of 1 mg/kg. In few days an improvement in overall
condition and regression of liver dysfunction was observed. During the next few
weeks the patient recovered liver function to normal. The therapy with
corticoids was discontinued after 11 weeks of administration. During
corticosteroids administration patient surprisingly achieved not only the cytomorphologic remission (gained after
3. cycle of ara-c) but even the imunophenotypic remission and GATA1 negativity.
The patient remains still in complete cytomorphologic, imunophenotypic and
molecular remission and her disease free survival is now 28 months.
Conclusion/Discussion: TMD in Down syndrome
is a rare diagnosis with supposed good prognosis – 70–80% subsequent
remission. An organ impairment – especially liver or pulmonary impairment, with
tendency to develop fibrosis decrease outcomes of TMD because the impairment is
mostly fatal. The possibilities of reverse of the progressive organ impairment
in TMD are practically minimal. As an
inhibitor of PDGF-Rβ receptor for PDGF the imatinib (Gleevec®, Glivec®) was considered for our patient. Actually the corticoids were
prioritized because of bad condition of the patient and supposition of poor
life expectance. A rapid response in liver and pulmonary function helped
to return to good overall condition. There still remains a question of
corticoids influence for remission attainment. Did we see just the delayed
spontaneous remission or the real response to corticoids?