PURPOSE: The MRE11-RAD50-NBN (MRN) complex plays a key role in recognizing and signaling DNA double-strand breaks. Pathogenic variants in NBN and MRE11 give rise to the autosomal-recessive diseases, Nijmegen breakage syndrome (NBS) and ataxia telangiectasia-like disorder, respectively. The clinical consequences of pathogenic variants in RAD50 are incompletely understood. We aimed to characterize a newly identified RAD50 deficiency/NBS-like disorder (NBSLD) patient with bone marrow failure and immunodeficiency. METHODS: We report on a girl with microcephaly, mental retardation, bird-like face, short stature, bone marrow failure and B-cell immunodeficiency. We searched for candidate gene by whole-exome sequencing and analyzed the cellular phenotype of patient-derived fibroblasts using immunoblotting, radiation sensitivity assays and lentiviral complementation experiments. RESULTS: Compound heterozygosity for two variants in the RAD50 gene (p.Arg83His and p.Glu485Ter) was identified in this patient. The expression of RAD50 protein and MRN complex formation was maintained in the cells derived from this patient. DNA damage-induced activation of the ATM kinase was markedly decreased, which was restored by the expression of wild-type (WT) RAD50. Radiosensitivity appeared inconspicuous in the patient-derived cell line as assessed by colony formation assay. The RAD50R83H missense substitution did not rescue the mitotic defect in complementation experiments using RAD50-deficient fibroblasts, whereas RAD50WT did. The RAD50E485X nonsense variant was associated with in-frame skipping of exon 10 (p.Glu485_545del). CONCLUSION: These findings indicate important roles of RAD50 in human bone marrow and immune cells. RAD50 deficiency/NBSLD can manifest as a distinct inborn error of immunity characterized by bone marrow failure and B-cell immunodeficiency.

Neuroblastoma (NB) is a neural crest-derived malignant tumor which is diagnosed during infancy in approximately 40% of cases; spontaneous regressions are observed, but there are varying degrees of severity. Treatment is indicated if an infant's condition is at risk of deterioration. Herein, we report the case of a 42-day-old boy who presented with hepatomegaly and was diagnosed with stage MS NB. A pathological diagnosis of "poorly differentiated neuroblastoma with low mitosis-karyorrhexis index, favorable histology" was made; his tumor cells were hyperdiploid and MYCN was not amplified. Because he had respiratory distress caused by the rapidly evolving hepatomegaly, two cycles of chemotherapy containing vincristine and cyclophosphamide were administered in the second and fourth weeks of admission; however, his abdominal tumor did not shrink. In the sixth week of admission, chemotherapy was revised to pirarubicin and cyclophosphamide, and the tumor began to shrink. After discharge, there was no re-elevation of tumor markers; after 1 year, the hepatomegaly and liver metastases disappeared. During the 5-year follow-up, his growth and development were normal and he progressed without sequelae. A regimen that includes pirarubicin could merit further study in the treatment of early infants with stage MS low-risk NB who are at risk of complications.

The breakthrough effects of tyrosine kinase inhibitors (TKIs) have lessened indications for allogeneic hematopoietic stem cell transplantation (HSCT) in chronic myeloid leukemia (CML). However, HSCT is still attractive for children and adolescents/young adults (AYAs) requiring lifelong TKI therapy. Nevertheless, little has been reported on the outcomes of large clinical studies of HSCT targeting these age groups. This study aimed to identify prognostic factors for the outcomes of HSCT, including reduced-intensity conditioning (RIC)-HSCT, for children and AYAs with CML in the TKI era. We performed a registry analysis for 200 patients with CML aged <30 years who underwent pretransplant TKI therapy from the observational nationwide database established by the Japanese Society for Transplantation and Cellular Therapy. The patients received bone marrow (BM), peripheral blood (PB), or cord blood (CB) from either related or unrelated donors. The indication for HSCT for individual patients was determined by the institution according to European LeukemiaNet recommendations and other guidelines. The 5-year overall survival (OS) rates for patients with chronic phase (CP) (n = 124), accelerated phase (AP) (n = 23), and blastic phase (BP) (n = 53) at diagnosis were 82.8%, 71.1%, and 73.3%, respectively, with no significant difference (P =.3293). The strongest predictor of engraftment was transplant source, with CB (hazard ratio [HR], 0.33) and PB (HR, 2.00) (compared with BM) being independent unfavorable and favorable predictors, respectively. Transplant source was also an independent predictor of chronic GVHD, with PB (HR, 1.81) and CB (HR, 0.39) (compared with BM) being unfavorable and favorable predictors, respectively. The strongest predictor of OS rate for patients with CP at diagnosis was disease phase at HSCT, with second or greater CP, AP, or BP (HR, 2.81) (compared with first CP [CP1]) being an unfavorable predictor. In addition, patients with CP at diagnosis who had major and complete molecular responses at HSCT had excellent outcomes, with 5-year OS rates of 100% and 94.4%, respectively. The 5-year OS rate was compared between RIC (n = 31) and myeloablative conditioning (MAC) (n = 58) in patients with CP1, both of which were 89.3%, with no significant difference (P = .9440). On univariate analysis for the RIC cohort with CP at diagnosis, the age at HSCT (HR, 1.27) (increase per year) and the time from diagnosis to HSCT (HR, 1.83) (increase per year) were significant predictors for OS. Our study demonstrates that RIC may be an appropriate alternative to MAC for children and AYAs with CP1. As for the transplant source, we recommend first selecting BM because of a higher engraftment rate compared to CB and a lower incidence of chronic GVHD compared to PB. Although HSCT in the status of a major molecular response is desirable, it is not advisable to continue TKI pointlessly long because age at HSCT and timing of HSCT are prognostic factors that determine survival. The decision to perform RIC-HSCT instead of continuing TKI should be carefully made, considering the possibility of transplant-related complications.

非典型溶血性尿毒症症候群(atypical hemolytic uremic syndrome:aHUS)は補体制御因子の異常による血栓性微小血管症で,生命予後に影響する腎外病変に対する関心が集まっている.症例は3歳女児.血尿,蛋白尿,浮腫を主訴に当院へ紹介され,精査によりaHUSと診断された.臨床経過中に消化管出血,難治性高血圧,肺水腫,そして可逆性の脳萎縮といった多彩な腎外病変を呈し,特に重篤な消化管出血と難治性高血圧の管理に難渋した.病初期におけるaHUSに対する血漿交換療法とエクリズマブの併用療法に加えて,難治性高血圧に対してレニン・アンジオテンシン系阻害薬,そして虚血性腸炎の体液管理に酢酸オクトレオチドがそれぞれ奏功した.多臓器にわたる腎外病変を有するaHUSは重症例が多く,適切な治療を行わなければ致死的な経過をたどる可能性があるため,集学的治療による全身管理が生命予後の改善に重要である.(著者抄録)

ABSTRACT: Recent data suggest that programmed cell death -1 (PD-1) and programmed cell death ligand-1 (PD-L1) are involved in the pathogenesis of Langerhans cell histiocytoma (LCH); however, their contributions are not well established. Also, the involvement of PD-1/PD-L1 molecules in musculoskeletal LCH remains particularly unclear. The current study aims to characterize the involvement of PD-1/PD-L1 immune checkpoint system in the pathogenesis of musculoskeletal LCH. PD-1/PD-L1 expression was evaluated in 6 patients, 3 men and 3 women with a mean age of 13.5 years, with musculoskeletal LCH who were treated at Kindai University Hospital and Osaka Women's and Children's Hospital between November 2005 and December 2020. The median follow-up period for all patients with musculoskeletal LCH was 41 months. We surveyed symptoms, number of lesions, treatment modality, and outcomes. Immunostaining for CD4, CD8, PD-1, and PD-L1 was also performed on pathological specimens obtained by biopsy. Multiple lesions were observed in 5 cases, and a single lesion was observed in 1 case. The chief complaint in 5 cases was pain. Four patients underwent spontaneous regression. The other 2 patients received chemotherapy. The outcomes included continuous disease-free (n = 5) and alive with the disease (n = 1). The CD4-, CD8-, PD-1-, and PD-L1-positive rates among all specimens were 100%, 100%, 16.6%, and 83.3%, respectively. The CD4/PD-L1, CD8/PD-L1, and PD-1/PD-L1 positive rates in all the specimens were 83.3%, 83.3%, and 16.6%, respectively. We believe that the PD-1/PD-L1 immune checkpoint molecules may play some role in the microenvironment of musculoskeletal LCH.

小児・思春期・若年成人(Adolescent and Young Adult,AYA)世代のがん患者および家族には,幅広いライフステージにおける多様なニーズが存在する.本研究では,現在の小児がん医療に対する患者家族のニーズを把握するための横断的質問紙調査を実施した.対象は,大阪府小児がん連携施設連絡会参加の9病院において,2015年から2018年までに小児がんの治療を受けた,20歳未満の患者の家族で,調査内容は,(1)参加者の基本情報(2)治療前の情報提供(3)支持療法・疼痛緩和・精神的苦痛の軽減(4)多職種連携・相談支援(5)療養環境(6)サバイバーシップ(7)小児がん医療全般についてとした.249人にアンケート調査票を配布し,200人の回答を得た(回収率80%).多くの患者が納得のいく治療を選択していた一方で,晩期合併症,生殖機能への影響についての説明状況は,診療病院によってばらついていた.治療による生殖機能への影響については,約半数(95人)が説明を受けておらず,うち8割(76人)が説明を希望していた.全体として,きょうだい支援,病院食,付き添い家族の生活環境,情報提供,医療費制度の手続きの改善などへのニーズが高いことが明らかとなった.具体的なニーズを各診療病院・行政にフィードバックし,対策を検討することで,今後の小児がん医療提供体制の改善につながると考える.(著者抄録)

Background and Objectives: Langerhans cell histiocytosis (LCH) is a rare disease characterized by the infiltration of one or more organs by Langerhans cell-like dendritic cells. LCH often involves the bone, and its clinical evidence is limited. The purpose of this study is to report on the treatment of LCH at our institution and to add to the evidence for LCH. Materials and Methods: We reviewed six cases of LCH treated in our hospital between November 2005 and February 2016. Patient age at the first visit, sex, site of origin, symptoms, image tools used for diagnosis, biopsy site, complications, treatment, and final clinical outcome were evaluated. The median follow-up period was 41 months. Results: The median patient age at the first visit was 13.5 years. Three male and three female individuals were enrolled. Multiple lesions were observed in five cases, and a solitary lesion was observed in one case. Pain was the chief complaint in five cases. Radiography was the most commonly used imaging tool. Bone scintigraphy or magnetic resonance imaging and positron emission tomography-computed tomography were also used to diagnose systematic LCH. Biopsy of the femur was performed in two cases, and biopsy of the tibia, lumbar vertebrae, rib, and radius was performed in one case each. Regarding comorbidities, one case of hepatitis B and one case of autism were observed. Chemotherapy was initiated in two patients. The other four patients were observed naturally. Continuous disease-free survival was observed in five patients. One patient remained alive but not without disease during the final follow-up examination. Conclusion: LCH should be diagnosed as early as possible to treat it appropriately.

Germline GATA2 heterozygous mutations were identified as complex immunodeficiency and hematological syndromes characterized by cytopenia (monocytes, B-cells, NK-cells), susceptibility to mycobacterium, fungus, or Epstein-Barr virus (EBV) infection, and myelodysplastic syndrome (MDS)/acute myelogenous leukemia (AML) development. Herein, we report a patient with AML who had a fatal infection after allogeneic hematopoietic stem cell transplantation (HSCT) due to impaired immune reconstitution associated with GATA2 mutation. A 15-year-old man was diagnosed with AML with monosomy 7. His family history was negative for immunodeficiency and hematological disorders. He attained complete remission after HSCT from an HLA-identical sister. Post-HSCT examinations performed 15 months later revealed pancytopenia, especially monocytopenia and the absence of B and NK cells, resulting in the occurrence of donor-type MDS. Twenty-one months after HSCT, he developed central nervous system aspergillosis and finally died of the disease. Two months later (24 months after PBSCT), the donor was diagnosed with persistent EBV infection accompanied by MDS with multilineage dysplasia. Genetic analysis of GATA2 revealed a novel heterozygous mutation (c.1023_1026dupCGCC) in both siblings. GATA2 mutations were highly prevalent among adolescent MDS/AML patients with monosomy 7. Therefore, the screening of GATA2 mutations in relatives is necessary when performing HSCT from a relative donor.

Monosomy 7 (-7) occurs in various types of paediatric myeloid disorders and has a poor prognosis. Recent studies have demonstrated that patients with germline gain-of-function SAMD9/9L variants and loss-of-function GATA2 variants are prone to developing myelodysplastic syndrome (MDS) associated with -7. However, the prevalence of the genetic variants among paediatric haematologic disorders with -7 is unknown. The present study screened germline variants of GATA2 and SAMD9/9L in 25 patients with various types of paediatric haematological disorders associated with -7. The diagnoses of the 25 patients included MDS (n = 10), acute myeloid leukaemia (AML) and myeloid sarcomas (n = 9), juvenile myelomonocytic leukaemia (n = 3) and other disorders (n = 3). Seven patients with a germline pathogenic GATA2 variant were found. For SAMD9/9L screening, next-generation sequencing was used to detect low-abundance variants and found four novel germline variants. Functional analysis revealed that three out of the four variants showed growth-restricting capacity in vitro and thus, were judged to be pathogenic. Cases with GATA2 mutation tended to be older, compared to those with SAMD9/9L mutations. In conclusion, GATA2 and SAMD9/9L were sequenced in 25 patients with paediatric haematologic disorders associated with -7, and 40% of them were found to have some pathogenic germline variants in the three genes.

X-linked lymphoproliferative syndrome type 1 (XLP1) is a rare congenital immunodeficiency disease. We report the case of an 18-year-old male who developed hemophagocytic lymphohistiocytosis (HLH) with neurologic complications after primary Epstein-Barr virus (EBV) infection and subsequently developed EBV-related central nervous system lymphoma (CNSL). Given the vulnerability to EBV, he was finally diagnosed with XLP1 and treated with whole-brain irradiation along with chemotherapy and subsequent allogeneic hematopoietic stem cell transplantation from a SH2D1A wild-type sibling donor. Although the prognosis for CNSL is generally dismal, reconstitution of the immune system from a normal donor contributed to the patient remaining in remission for 30 months.

終末期に家族と共に自宅で暮らすという願いを叶えることは、小児がん患者においても重要な取り組みである。症例は3歳の男児。左胸腔内の巨大腫瘤で発症した胸膜肺芽腫で、外科療法や自家末梢血幹細胞移植を含む化学療法で治療を終了した後早期に再発した。再発後は治療抵抗性で胸腔内腫瘍の急速な増大により呼吸不全状態となった。Irinotecanとcisplatinの胸腔内投与が奏功し、腫瘍摘出術と放射線照射後に退院が実現できた。しかし、照射野外の横隔膜下面より腹腔腫瘍で再々発した。家族の希望により急遽在宅緩和ケアに移行したため、移行時の連携準備不足で在宅ケアの継続が一時危ぶまれた。その後、病院主治医と在宅医相互の情報共有により役割分担を明確にすることで、最終的に自宅での看取りに至った。終末期を自宅で過ごす患者と家族の願いを叶える上で、在宅医療関係者との密な連携を速やかに構築することが重要であると考えられた。(著者抄録)

終末期に家族と共に自宅で暮らすという願いを叶えることは、小児がん患者においても重要な取り組みである。症例は3歳の男児。左胸腔内の巨大腫瘤で発症した胸膜肺芽腫で、外科療法や自家末梢血幹細胞移植を含む化学療法で治療を終了した後早期に再発した。再発後は治療抵抗性で胸腔内腫瘍の急速な増大により呼吸不全状態となった。Irinotecanとcisplatinの胸腔内投与が奏功し、腫瘍摘出術と放射線照射後に退院が実現できた。しかし、照射野外の横隔膜下面より腹腔腫瘍で再々発した。家族の希望により急遽在宅緩和ケアに移行したため、移行時の連携準備不足で在宅ケアの継続が一時危ぶまれた。その後、病院主治医と在宅医相互の情報共有により役割分担を明確にすることで、最終的に自宅での看取りに至った。終末期を自宅で過ごす患者と家族の願いを叶える上で、在宅医療関係者との密な連携を速やかに構築することが重要であると考えられた。(著者抄録)

We describe our experience with a 12 year-old girl with kaposiform hemangioendothelioma accompanied by Kasabach-Merritt phenomenon with exacerbation of the disease 10 years after the initial diagnosis. Kaposiform hemangioendothelioma infiltrated into the subcutaneous tissue of the facial skin with deterioration of coagulopathy despite conventional therapies including corticosteroid, vincristine, and propranolol. Sirolimus, a mammalian target of rapamycin inhibitor, produced rapid and dramatic improvement of the Kasabach-Merritt phenomenon and kaposiform hemangioendothelioma shrinkage. Eventually, multifocal lesions of kaposiform hemangioendothelioma disappeared on the images of magnetic resonance imaging and have remained in remission for 27 months after sirolimus cessation. We demonstrated that the AKT/mammalian target of rapamycin signaling pathway played a pivotal role in the kaposiform hemangioendothelioma growth. Sirolimus must be a strong candidate for molecular therapy targeting kaposiform hemangioendothelioma.

We herein reported a 4-month-old boy with transplantation-associated atypical hemolytic uremic syndrome (TA-aHUS) who was successfully treated with eculizumab. The patient diagnosed with type 3 of familial hemophagocytic lymphohistiocytosis underwent cord blood transplantation. After transplantation, he developed TA-aHUS, but plasma exchanges were unsuccessful. We identified deletions in CFH-related gene 1 (del-CFHR1) by the multiplex ligation-dependent probe amplification testing procedure and CFH autoantibodies. Eculizumab has been administered to the patient, with a marked improvement being achieved in thrombocytopenia. He has been well except for the persistent microhematuria for a year after transplantation. Uncontrolled complement activation might be involved in the pathophysiology of TA-aHUS.

<p> A 12-year-old boy with aplastic anemia underwent allogeneic bone marrow transplantation (BMT) from an HLA-identical sister when he was 8 years old. After BMT, grade Ⅲ acute graft-versus-host disease (GVHD) involving the intestinal tract, in particular gut symptom was refractory to the therapy. During the therapy, transplantation-associated thrombotic microangiopathy occurred on day 268. Twenty-three months after BMT, he presented with psoriatic skin eruptions on his extremities, suggesting the development of chronic GVHD owing to several positive autoantibodies such as rheumatoid factor or anti-nuclear antibody. Therefore, he was treated with PSL. He complained of dysphagia and ptosis and was diagnosed with myasthenia gravis (MG) based on the findings of positive anti-acetylcholine receptor antibodies and the edrophonium challenge test. In addition to PSL, he then received pyridostigmine and cyclosporine. The symptoms associated with MG finally dissolved after treatment with intravenous high-dose immunoglobulin. According to previous studies, the clinical features of MG post-BMT are universal and are associated with decreasing immunosuppression during chronic GVHD, most often occurring in patients with aplastic anemia, the absence of thymoma, and the presence of specific HLA antigens.</p>

Transient abnormal myelopoesis is mostly self-resolving and has a good prognosis, but some patients subsequently die of liver fibrosis. We report the case of an infant with Down syndrome who developed life-threatening liver fibrosis at the same time as the blasts were about to disappear. This patient also had a marked increase in eosinophils, which were possibly harboring a GATA1 mutation and were expressing a high level of platelet-derived growth factor-B mRNA; these may have been involved in the development of liver fibrosis. Low-dose cytosine arabinoside therapy effectively treated both hypereosinophilia and liver fibrosis.

Background: In 2004, the Japanese government halted the 6-month mass screening program for neuroblastoma. We investigated whether its cessation had led to an increase not only in mortality due to this disease but also in the incidence of advanced-stage disease among older children. Methods: Study subjects were neuroblastoma patients retrieved from the population-based Osaka Cancer Registry. Trends of incidence and mortality from neuroblastoma were analyzed by calendar year and birth cohort. Prognostic factors, including stage and v-myc avian myelocytomatosis viral oncogene neuroblastoma derived homolog (MYCN) oncogene status, were compared before and after the cessation of mass screening. Results: Age-standardized incidence rates in 2005-2009 (the cessation period of mass screening; 11.1 per million) were similar to those in 1975-1979 (the pre-screening period; 8.6 per million). Age-standardized mortality rates tended to decrease from 1975-1979 (4.0 per million) to 2005-2009 (2.7 per million) in parallel with the improvement in survival. Analysis by birth cohort indicated that the mortality rates in 2004-2005 (after cessation) for children 0-4 years of age were lower than those in 1975-1979 (O:E ratio 0.25; 95% confidence interval, 0.03-0.90). For children 1-9 years of age, there was a not significant difference in the distribution of stage, MYCN oncogene status, and DNA ploidy between 1991-2003 (the mass screening period) and 2004-2008 (after cessation). Conclusions: The cessation of mass screening for neuroblastoma does not appear to have increased mortality due to this disease or incidence of advanced-stage disease among older children.

ネフロン癆は, 小児の末期腎不全の原因のうち, 約4～5％を占める重要な疾患である. この研究では, 本邦において, 臨床・組織学的にネフロン癆が疑われた35名の患者について, 発見動機, 腎症状の特徴, 腎外症状の分析ならびにNPHP遺伝子解析を実施した. 疑い例を含む患者発生状況は, 47都道府県から大きな偏りなく患者が発生しており, 地域偏在性はなかった. また, 男女比についても, 明らかな性差はなかった. 同胞での発症は3家系に認められた. 患者年齢の中央値は, 12.5歳であった. 発見動機は, 学校検尿などのマススクリーニング検査によるものの頻度は低く, 他の疾患での検査時, あるいは健診で, 偶然腎機能障害が発見されたものを含めても全体の50％以下であった. また発見の引き金となった症状も, 腎に関連する症状よりもむしろ, 身体発育不全や貧血といった腎外症状を呈するものが多かった. 尿異常の特徴としては, 低比重尿や低分子蛋白尿の頻度が高かった. 腎組織所見としては, 腎髄質を中心とする尿細管の囊胞様拡張, 尿細管基底膜の不規則性変化は高頻度に存在していた. NPHP遺伝子解析と日本人の特徴としては, NPHP1異常が最も多く, large deletionが多かった. また, NPHP1, NPHP3, NPHP4 の各遺伝子にヘテロの異常を１個ずつ有する複合型ヘテロ接合体が, 欧米と同じくわが国にも存在することが明らかとなった.

Background. Cyclosporine A (CsA) is used widely for graft-versushost disease (GVHD) prophylaxis in hematopoietic stem cell transplantation (HSCT); however, the optimal schedule of its administration has not been established. Although comparative studies of adult patients undergoing HSCT have demonstrated enhanced efficacy and safety of twice-daily infusion (TD) compared with continuous infusion (CIF) of CsA, to our knowledge, similar studies have not yet been performed in pediatric groups. Procedure. A self-administered questionnaire was used to retrospectively compare the clinical outcome and incidence of CsA-associated adverse events of 70 pediatric acute myelogenous leukemia patients who were receiving CsA by TD (n = 36) or CIF (n = 34) as GVHDprophylaxis for their first allogeneic HSCT. Results. The cumulative incidences of grade II-IV acute GVHD and chronic GVHD, as well as the overall survival and event-free survival rates, did not differ significantly between the TD and CIF groups; however, the incidence of severe hypertension was significantly higher in the CIF group than the TD group. Conclusions. The analysis presented here indicates that TDand CIF administration of CsA have similar prophylactic effect on pediatric GVHD and suggest that TD is associated with a lower rate of toxicity than CIF in pediatric patients undergoing HSCT. (C) 2014 Wiley Periodicals, Inc.

Juvenile myelomonocytic leukemia (JMML) is a mixed myeloproliferative and myelodysplastic disorder that occurs in early childhood. The clinical course of JMML is highly variable. A third of patients follow a relatively indolent course, although approximately 15 % cases are thought to develop acute myeloid leukemia, referred to as blast crisis. The etiology and clinical characteristics of blast crisis remain unclear. We document the case of a 27-month-old boy who presented with hepatosplenomegaly, skin rash, and lymphadenopathy. An initial diagnosis of acute erythroid leukemia was made according to the French-American-British classification. Following estimation of hypersensitivity to GM-CSF and genetic analysis of PTPN11, he was diagnosed with JMML in the blast crisis phase. Although he had several poor prognostic factors, including monosomy 7 and high HbF percentage, he achieved partial remission after treatment with acute myeloid leukemia-oriented chemotherapy followed by allogeneic hematopoietic stem cell transplantation.

Development of both Crohn disease and Guillain-Barre syndrome likely involves autoimmunity associated with excessive inflammatory cytokines. We treated a girl who developed Guillain-Barre syndrome during the course of Crohn disease. Although high-dose -globulin therapy administered initially for Guillain-Barre syndrome was ineffective, plasmapheresis ameliorated her acute neuropathic symptoms. Crohn disease was managed with Salazopyrin administration and enteral feeding. Chronic inflammation of the intestinal mucosa caused by Crohn disease can allow presentation of microbial intestinal antigens normally hidden from the immune system. Such presentation could incite an extraintestinal immune response on the basis of molecular mimicry, leading to activation of systemic autoimmunity against the nervous system. Accordingly, concurrence of Guillain-Barre syndrome and Crohn disease in our patient appeared to result from shared autoimmune mechanisms and systemic and local increases in cytokine concentrations. The patient also developed erythema nodosum and gall stones, relatively common complications of Crohn disease. However, Guillain-Barre syndrome is rare.

Alport syndrome (AS) is a renal disorder caused by a genetic abnormality of type IV collagen alpha 3 and alpha 4, or alpha 5 genes and shows a poor prognosis. Since the defect of type IV collagen synthesis disturbs the maturation process of the glomerular capillary loop, residual immature glomeruli persist after birth. The therapeutic efficacy of cyclosporin A (CyA) for AS patients seems to be controversial. We recently noted that renal specimens obtained from a child with AS who was treated with CyA and then developed CyA nephropathy included an increased number of undifferentiated embryonic-type glomeruli. We analyzed renal histologic and immunohistologic findings in children with AS who did (n = 3) or did not (n = 2) develop CyA-induced nephropathy despite appropriately low serum CyA concentrations (< 100 ng/mL) being maintained over a period of 2 years. To discriminate embryonic-type from mature glomeruli, staining for type IV collagen alpha 1, laminin beta 1, and laminin beta 2 accompanied by light microscopic observation were employed. Staining patterns were used to semiquantitatively assess glomerular immaturity (glomerular immaturity index, or GII). In initial biopsy specimens, residual embryonic-type glomeruli were observed in each patient. Patients with early-onset CyA nephropathy had a high GII (median value 2.91 vs 1.23 +/- A 0.62 normal kidney tissues). In the follow-up biopsy after CyA treatment, surviving embryonic-type, collapsing embryonic-type, and sclerotic glomeruli that had failed to differentiate were observed. Taken together, the number of these glomeruli essentially equaled the total number of embryonic-type glomeruli in specimens obtained before CyA treatment. Our findings indicate a need for caution in CyA therapy for patients with AS, even for a relatively short course of administration, because some patients may have an unexpected number of embryonic-type glomeruli that predispose to CyA nephropathy.

Alport syndrome (AS) is a renal disorder caused by a genetic abnormality of type IV collagen alpha 3 and alpha 4, or alpha 5 genes and shows a poor prognosis. Since the defect of type IV collagen synthesis disturbs the maturation process of the glomerular capillary loop, residual immature glomeruli persist after birth. The therapeutic efficacy of cyclosporin A (CyA) for AS patients seems to be controversial. We recently noted that renal specimens obtained from a child with AS who was treated with CyA and then developed CyA nephropathy included an increased number of undifferentiated embryonic-type glomeruli. We analyzed renal histologic and immunohistologic findings in children with AS who did (n = 3) or did not (n = 2) develop CyA-induced nephropathy despite appropriately low serum CyA concentrations (< 100 ng/mL) being maintained over a period of 2 years. To discriminate embryonic-type from mature glomeruli, staining for type IV collagen alpha 1, laminin beta 1, and laminin beta 2 accompanied by light microscopic observation were employed. Staining patterns were used to semiquantitatively assess glomerular immaturity (glomerular immaturity index, or GII). In initial biopsy specimens, residual embryonic-type glomeruli were observed in each patient. Patients with early-onset CyA nephropathy had a high GII (median value 2.91 vs 1.23 +/- A 0.62 normal kidney tissues). In the follow-up biopsy after CyA treatment, surviving embryonic-type, collapsing embryonic-type, and sclerotic glomeruli that had failed to differentiate were observed. Taken together, the number of these glomeruli essentially equaled the total number of embryonic-type glomeruli in specimens obtained before CyA treatment. Our findings indicate a need for caution in CyA therapy for patients with AS, even for a relatively short course of administration, because some patients may have an unexpected number of embryonic-type glomeruli that predispose to CyA nephropathy.

Malignant peripheral nerve sheath tumor (MPNST), very rare in childhood, is a highly aggressive soft-tissue tumor. We experienced a case of a 7-year-old boy with MPNST who was treated with imatinib mesylate (imatinib) after the identification of platelet-derived growth factor receptor expression in his tumor. We were unable to observe clinical benefits of imatinib in this patient. Therefore, cellular reactions of imatinib were investigated in vitro using 3 MPNST cell lines. Imatinib induced cytotoxicity in vitro with variable IC50 values (11.7 to >30 M). Induction of apoptosis was not a pivotal mechanism in the inhibitory effects. We found that the treatment of MPNST cell lines with imatinib induced autophagy. Suppression of the initiation of autophagy by 3-methyladenine or small interfering RNA (siRNA) against beclin-1 attenuated the imatinib-mediated cytotoxicity. In contrast, blocking the formation of autophagosomes or the development of autolysosomes using siRNA against microtubule-associated protein light chain 3B, bafilomycin A1, chloroquine, or an MEK1/2 inhibitor (U0126) enhanced the imatinib-induced cytotoxicity in MPNST cells. Our data showed that the imatinib-mediated autophagy can function as a cytotoxic mechanism and that appropriate modulation of autophagy may sensitize MPNST cells to imatinib, which in turn may be a novel therapeutic strategy for MPNST.

[抄録] リコンビナントトロンボモデュリンは, トロンビンと結合し, その凝固活性を阻害するだけでなく, プロテインＣの活性化, high mobility group box-1を吸着することによる抗炎症作用を有し, 新しい血液凝固調節作用により播種性血管内凝固（DIC）を改善させる. これまで小児においての使用報告は少なく, 当科におけるリコンビナントトロンボモデュリンの使用経験を検証したので報告する. 対象は当科で治療した基礎疾患を有するDICの患者とした. 日齢11～18歳の９症例（男児３例, 女児６例）に, のべ14回の投与を行い, DICスコアーの改善により有効性を評価した. 基礎疾患は急性骨髄性白血病が３例, 一過性骨髄異常増殖症，神経芽腫, EBウイルス関連血球貪食症候群, Kasabach-Merritt症候群, フィラデルフィア染色体陽性急性リンパ性白血病，Ｔ細胞性リンパ芽球性リンパ腫が各１例ずつであった. 14回中11回（78.6％）で改善を認め, その中には移植関連微小血管障害に合併したDIC症例も含まれ, DICの改善のみならず微小血管障害の改善も認めた. 14回中３回で出血のため投与を中止したが, 出血以外の有害事象は認めなかった. 今回の成績は, これまでに報告されている成績とほぼ同等であり, リコンビナントトロンボモデュリンは小児においても有効であった.

小児の濾胞性リンパ腫は稀で、成人例とは典型的な(14;18)転座は認めなかったり、びまん性に増殖した組織が含まれたりと、異なる点がある。症例は10歳の男児で、B細胞性悪性リンパ腫の化学療法施行後16ヵ月で再発し、再発時の組織学的所見より日本小児白血病リンパ腫研究グループ(JPLSG)病理委員会で濾胞性リンパ腫(grade 3b)と診断された。その後、R-ICE(rituximab、ifosfamide、carboplatin、etoposide)やR-FCM(rituximab、fludarabine、cyclophosphamide、mitoxantrone)により治療後、臍帯血移植を骨髄非破壊的前処置法(TBI 3Gy/fludarabine 180mg/m2/cyclophosphamide 50mg/kg)により施行した。現在、移植後50ヵ月を経過し晩期障害を認めず寛解を維持している。(著者抄録)

Minimal-change nephrotic syndrome has recently been attributed to an immature, dysfunctional T-cell population. A woman, now 23 years old, developed nephrotic syndrome when she was 6 years old. Despite treatment with steroids and immunosuppressants such as cyclosporine, mizoribine, mycophenolate mofetil, and tacrolimus, the patient relapsed 14 times. At the age of 19 years, she developed chronic myelogenous leukemia, against which imatinib achieved cytogenetic remission. The patient received an allogeneic bone marrow graft transplantation from an unrelated marrow bank donor, with an uncomplicated recovery and molecular genetic remission. Immunosuppressants were withdrawn within 6 months. The patient is now without drug treatment. Complete remission of nephrotic syndrome has also been maintained for over 4 years without any drug administration. The patient's course supports suggestions that immunological dysfunction in nephrosis is associated with abnormality of immature, relatively unclassified T cells (CD34(+)) representing hematopoietic stem cells, as opposed to mature T cells (CD34(-)).

Aim: We investigated efficacy and therapeutic mechanisms of tonsillectomy for intractable childhood IgA nephropathy. Five patients refused tonsillectomy. Among 25 patients, 19 patients were able to evaluate histological findings before and after surgery. Patients with poor (n = 7) or relatively poor (n = 18) histologically determined prognosis and an age of at least 7 years, together with proteinuria of at least 0.3 g/day or severe persisting despite ongoing drug treatment, are candidates for surgery. Patients were grouped by interval between diagnosis of IgA nephropathy and tonsillectomy (within 3 years; early group vs 3 years or later; later group). Patients underwent kidney biopsy shortly before and 1 to 2 years after tonsillectomy. Results: Proteinuria was reduced after tonsillectomy over 2 years of follow-up in both early and later groups compared with proteinuria in the 6 months preceding surgery. Complete remission was achieved in 10 patients, most often among those having surgery within 3 years, while patients refusing surgery failed to attain complete remission of urinary findings. Histological activity decreased in both groups, significantly when surgery was early. Complement component C3 deposition and activated macrophages in glomeruli decreased after tonsillectomy, especially with early surgery. Conclusion: Tonsillectomy improved clinicopathological features in relatively severe paediatric IgA nephropathy, especially with the early-surgery group. Therapeutic mechanisms may include inhibition of complement activity in glomeruli and glomerular infiltration by activated macrophages.

Venous thrombosis is a well-known complication of nephrotic syndrome (NS), while arterial thrombosis is rare. We know of no reports of children with this complication. Here we report a case of 14-year-old girl with NS, who complicated with renal and cerebral infarctions resulting from arterial thrombosis. Urinary examination showed heavy proteinuria. She had intravascular dehydration. Serum albumin was 0.9 g/dL. Contrast-enhanced computed tomography (CT) showed a low-attenuation area in the right kidney. Decreased blood flow in the right middle cerebral artery was observed on MRA and also on multi-detector-row head CT. Urokinase and heparin were given. Cerebral infarction was treated neuroprotectively by i.v. infusion of edaravone. Comprehensive assessment of intravascular dehydration and the coagulationfibrinolysis system is needed to guide decisions concerning prophylactic anticoagulation therapy. Better understanding of NS and its risks, as well as the necessity of drug therapy, may help teenagers to accept and cooperate with treatment.

症例報告：急性骨髄性白血病で縦隔腫瘤合併例は稀である．また，その予後は不良とされる．染色体検査で5q欠失の染色体異常を持ち，初期治療への反応は良好であったが，強化療法中に5q欠失クローンから骨髄・髄外再発した臨床経過を報告したもの．

Background: In addition to the urinary abnormalities, symptoms of left renal vein entrapment between the aorta and superior mesenteric artery (left renal vein entrapment syndrome, LRVES) may include abdominal and flank pain as well as chronic fatigue. We investigated various LRVES symptoms in this study. Methods: In 53 pediatric LRVES patients treated at our department, 22 had a score of 5 points or higher on orthostasis. Initial evaluation of LRVES by abdominal ultrasonography showed a stenotic-to-prestenotic vein diameter ratio of 0.2 or less. Definitive diagnosis was made by computed tomography and magnetic resonance angiography. Cortisol, catecholamine (CA), and brain natriuretic peptide (BNP) were also measured. Results: The frequency of LRVES was 2.5 times higher in girls than in boys. Low or very low body mass indexes were seen in both sexes. The most common initial finding was urine abnormalities, followed by dizziness and malaise. In 6 patients, orthostasis precluded school attendance. Ten patients had orthostasis scores above 12. Patients unable to attend school had either low levels of plasma or urinary cortisol. Midodrine significantly decreased orthostasis scores. Some patients required treatment with fludrocortisone. Plasma CA, renin, and BNP levels were all normal. Conclusions: Locally excessive venous pressure may cause reversible adrenal dysfunction with transitory Addisonian symptoms. Children with cryptogenic malaise or severe orthostasis should be evaluated for LRVES. World J Pediatr 2012;8(2):116-122

Introduction: Imbalance between T-helper 1 (Th1) and 2 (Th2) lymphocytes and effects of reactive oxygen species (ROS) upon glomerular capillary walls have been implicated in minimal change nephrotic syndrome (MCNS). Methods: By polymerase chain reaction and comparative genomic hybridization, we evaluated mutations of the GSTT1 gene (GSTT1), a member of the glutathione S-transferase (GST) supergene family associated with both protection of cells from ROS and control of allergic reactions and serum immunoglobulin (Ig) E. Results: Among 15 children with MCNS, IgE elevation (over 2,000 IU/l) and GSTT1 deletion was found in 2 who showed severe allergic symptoms. Serum ROS concentrations in these 2 patients were significantly higher than in healthy controls or other MCNS patients. In addition, a Th2 shift caused by increased serum interleukin (IL)-4 was observed. Conclusion: These results suggest presence of a GSTT1 abnormality in some children with MCNS having marked serum IgE elevations and various allergic complications. Defective ROS degradation and Th1/Th2 imbalance caused by GSTT1 abnormality could initiate proteinuria leading to MCNS.

In two patients with steroid-resistant nephrotic syndrome (SRNS), we investigated the relationship between clinical findings during immunosuppressive therapy and multiple drug resistant gene-1 (MDR-1) expression. MDR-1 was detected by real-time polymerase chain reaction (PCR). In a boy who initially developed SRNS at 3 years, we observed MDR-1 expression over 3 years. Maximal and minimal MDR-1 expression were 90 000 and 7800 copies/mu g RNA, respectively. In a 4-year-old boy who initially developed SRNS at 3 years, we determined MDR-1 expression over 2 years. Maximal and minimal MDR-1 expression were 42 000 and 6900, respectively. MDR-1 evaluation requires determination of MDR-1 expression at several time points in a clinical course. Establishment of a normal expression may be needed for each individual patient. Increasing MDR-1 during remission was followed soon by recurrences, an observation that may be a guide for therapeutic choice. LDL influences a humoral factor involved in MDR-1 expression. Both patients responded to LDL adsorption therapy because of elevated LDL levels. While cyclosporine A therapy gradually decreased MDR-1 expression, LDL adsorption therapy decreased expression sharply. Based on the results of the present study, LDL adsorption therapy could contribute to the amelioration of drug sensitivity for immunosuppressants including corticosteroids via inhibitory effects on MDR-1 expression.

Introduction: We analyzed renal histologic and immunohistologic findings in children with nephrotic syndrome (NS) who did (n = 5) or did not (n = 17) develop cyclosporine A (CyA) nephropathy despite appropriately low serum CyA concentrations being maintained over 2 years. Methods: To discriminate embryonic-type from mature glomeruli, we performed staining for type IV collagen alpha 1, laminin beta 1 and laminin beta 2. Staining patterns were used to semiquantitatively assess glomerular immaturity (glomerular immaturity index, or GII). Results: In follow-up biopsy specimens, residual embryonic-type, collapsed embryonic-type and sclerotic glomeruli that had failed to differentiate were observed. Patients with early-onset CyA nephropathy had a high GII. In patients with a high GII, arteriopathy developed early in CyA treatment. Arteriopathy was observed mostly near embryonic-type glomeruli. Taken together, these glomeruli (surviving embryonic-type, collapsing embryonic-type, and sclerotic glomeruli) essentially equaled the total number of embryonic-type glomeruli in specimens obtained before CyA treatment. Conclusion: Our findings indicate a need for caution in CyA therapy for patients with NS, even for a relatively short course of administration, because some patients may have embryonic-type glomeruli or immature arterioles that predispose them to CyA nephropathy.

Aim: The relationship between abnormalities of tubular architecture and tubulointerstitial nephritis antigen (TIN-ag) in juvenile nephronophthisis (J-NPH) was evaluated. Methods: Sixteen J-NPH patients were examined. Nephrocystin-1, TIN-ag, type IV collagen, Fas antigen and the C5b-9 complement complex were stained by immunohistochemical methods. Results: Renal tubules of patients with J-NPH showed morphological abnormalities of tubular basement membranes (TBM) and frequent apoptosis of tubular epithelial cells. Additionally, the C5b-9 complement complex was deposited within the TBM in the absence of immunoglobulin deposition, suggesting complement-dependent TBM injury. Localization of TIN-ag in the TBM of J-NPH patients disclosed a partial defect or discontinuity in 14 of the 16 patients, while type IV collagen immunoreactivity was relatively preserved. These findings suggest that tubulogenesis is disturbed during nephronogenesis in J-NPH patients because of a defect in nephrocystin, an NPHP gene product. TBM defects induce further morphological abnormalities such as cystic dilation of tubules; as tubular function impairment advances, the incomplete tubules may be injured by C5b-9 complement complexes, followed by apoptotic cell death. Conclusion: TIN-ag, which is important in early nephrogenesis, lacks normal activity, and vulnerable and incomplete tubules with deficient TIN-ag expression are formed. Removal of these defective tubules by apoptosis combined with the C5b-9 complement complex could be the primary reason for progression to end-stage renal disease in J-NPH patients.

Introduction: We analyzed renal histologic and immunohistologic findings in children with nephrotic syndrome (NS) who did (n = 5) or did not (n = 17) develop cyclosporine A (CyA) nephropathy despite appropriately low serum CyA concentrations being maintained over 2 years. Methods: To discriminate embryonic-type from mature glomeruli, we performed staining for type IV collagen alpha 1, laminin beta 1 and laminin beta 2. Staining patterns were used to semiquantitatively assess glomerular immaturity (glomerular immaturity index, or GII). Results: In follow-up biopsy specimens, residual embryonic-type, collapsed embryonic-type and sclerotic glomeruli that had failed to differentiate were observed. Patients with early-onset CyA nephropathy had a high GII. In patients with a high GII, arteriopathy developed early in CyA treatment. Arteriopathy was observed mostly near embryonic-type glomeruli. Taken together, these glomeruli (surviving embryonic-type, collapsing embryonic-type, and sclerotic glomeruli) essentially equaled the total number of embryonic-type glomeruli in specimens obtained before CyA treatment. Conclusion: Our findings indicate a need for caution in CyA therapy for patients with NS, even for a relatively short course of administration, because some patients may have embryonic-type glomeruli or immature arterioles that predispose them to CyA nephropathy.

Focal segmental glomerular sclerosis (FSGS) is a leading cause of the nephrotic syndrome and characterized by the sclerosing lesions that affect one or more segments of some glomeruli. We encountered a female patient with a partial deletion of chromosome 6p, who presented proteinuria at age 3 years. Detailed chromosomal analysis disclosed an interstitial deletion of 6p: del(6)(p22.1p22.3). No abnormality such as hydronephrosis or renal agenesis was disclosed by imaging, but FSGS was present in a renal biopsy specimen. The patient is currently 11 years old and shows mental retardation with mild deterioration in the renal function. To address the defective genes in the present patient, we carried out comparative genomic hybridization (CGH), showing that E2F3 on chromosome 6p is absent in this patient. E2F3, a member of the E2F family transcription factors, inhibits expression of vascular endothelial growth factor (VEGF) and induces apoptosis during vascular development. The deletion of E2F3 was also detected by employing a PCR method, suggesting that glomerular architecture had been compromised in this patient. Serum VEGF concentrations were elevated to 177 +/- 21.4 pg/mL (upper limit of 33.3 pg/mL), when she was 6 years old, associated with the enhanced expression of VEGF in glomeruli. These findings suggest that the dysregulation of VEGF synthesis caused by the deletion of E2F3 may be associated with development of FSGS. In conclusion, among patients with idiopathic FSGS, an abnormality of E2F3 may exist on chromosome 6p. Therefore, one might consider chromosomal analyses in children with FSGS who have mental retardation.

We encountered a boy with periodic fever, aphthous-stomatitis, pharyngitis, adenitis syndrome, complicated by a papular rash representing pityriasis lichenoides et varioliformis acuta. Proinflammatory cytokines have been implicated in both diseases and may represent the underlying common immunologic mechanism causing the two diseases.

Since we reported the first successful case of allogeneic hematopoietic SCT (allo-HSCT), we have performed allo-HSCT for 29 patients with chronic active EBV infection (CAEBV), using either myeloablative conditioning (MAC) allo-HSCT (MAST) or reduced-intensity conditioning (RIC) allo-HSCT (RIST). In this retrospective analysis we compared the outcomes after MAST and RIST to identify the optimal conditioning for patients with CAEBV. Of 29 patients, 11 underwent allo-HSCT with MAC, consisting of TBI (12 Gy), etoposide (900 mg/m2) and CY (120 mg/kg) or melphalan (210 mg/m2), and the remaining 18 patients received allo-HSCT after RIC, consisting of fludarabine (∼180 mg/m2) and melphalan (140 mg/m2) or CY (120 mg/kg), with/without antithymocyte globulin and low-dose irradiation. Donor sources were 8 related BM, 2 related peripheral blood, 5 CD34 selected cells from HLA-haploidentical donors, 8 unrelated BM and 8 unrelated cord blood. The 3-year-EFS rate was 54.5±15.0% for MAST group and 85.0±8.0% for RIST group, and the 3-year OS rate was 54.5±15.0% for MAST group and 95.0±4.9% for RIST group (P=0.016). Allo-HSCT after RIC seems to be a promising approach for the treatment of CAEBV. © 2011 Macmillan Publishers Limited All rights reserved.

We evaluated and treated a girl with Henoch-Schonlein purpura (HSP), who initially developed redness, swelling, and pain in all 4 limbs accompanied by Raynaud syndrome and then had convulsions and disturbance of consciousness. HSP was diagnosed based on later findings of purpura in both legs and a decrease in factor XIII activity not accompanied by thrombocytopenia. She was normotensive. A skin biopsy specimen showed small-vessel vasculitis accompanied by immunoglobulin A deposition. The cause of erythema and limb pain, convulsions, and disturbed consciousness presumably was vasculitis. The possibility of HSP should be considered in patients with limb pain despite initial absence of purpura and in patients with central nervous system symptoms such as convulsions.

小児血液腫瘍に対する化学療法ならびに自家/同種造血幹細胞移植の合併症である侵襲性真菌感染症invasive fungal infection(IFI)は死亡率が高い。われわれは新規抗真菌薬micafungin(MCFG)のIFI予防薬としての安全性と有効性を,従来の標準予防薬のプロドラッグfosfluconazole(FF)との無作為割り付けにより比較検討した。細菌感染症はcefpiromeで予防し,発熱性好中球減少症にはmeropenem+minocyclineで早期治療した。IFI予防にMCFG2mg/kg/day(最高100mg/day),FF10mg/kg/day(最高400mg/day)とも安全性が高く,予防成功率も高く(MCFG94.4%,FF94.3%),有意差はなかった。小児の真菌感染症の予防薬としてMCFGは優れた薬剤であると考えられた。(著者抄録)

Newly diagnosed children with ALL (n = 32) were treated on a protocol incorporating minimal residual disease (MRD)-based treatment decisions. MRD was monitored at 4 time points by semi-quantitative PCR detection of antigen receptor gene rearrangement, flow cytometry, quantitative RT-PCR detection of chimeric gene transcripts and overexpressed WT1 mRNA. Four patients positive for MRD at week 5 were treated with an intensified regimen. Median follow-up was 5.0 years (range 3.8-6.6 years) with a 4-year event-free survival rate of 93.8 +/- 4.3%. This MRD-based treatment strategy seems to be highly successful and may improve the outcomes of children with ALL A large study is warranted. (C) 2009 Elsevier Ltd. All rights reserved.

We report an unusual case of severe skeletal muscle damage during the administration of 5-ASA for ulcerative colitis. The specific pathogenesis of this muscle damage is unknown. Additionally a hypersensitive reaction to 5-ASA was also suggested.

小児科クリニカル・クラークシップにポートフォリオを導入し、その結果をアンケート調査した。小児科でのクリニカル・クラークシップは5年生、6年生ともに好評であり、ポートフォリオを用いることにより、日々の目標と達成度が明確となり、クリニカルクラークシップを終了した時点での充実度が高まると考えらた。

急性リンパ性白血病の維持療法中にパルボウイルスB19の持続感染により赤芽球ろうのみならず汎血球減少を来した症例の臨床経過報告．治療を継続していく上で，パルボウイルスB19のリアルタイムPCR法による遺伝子定量が有用であった．また，ウイルスの中和にガンマグロビリン投与が有用であった．

Purpose: The purpose of this study is to evaluate the safety and efficacy of cancer immunotherapy with WT1 peptide for the treatment of children with refractory hematological and solid malignancies. Methods: The major eligible critria were the expression of the WT1 gene in affected tissues or leukemic cells, and the HLA type of the patients (and donors) being A2402. Vaccination using high-affinity WT1 peptide (CYTWNQMNL) with adjuvant (montanide ISA51) was performed every week for a tatl of 12 times. Results: 15 cases (16 courses) were enrolled. No side effects other than local skin reactions were observed. Out of the 10 cases (11 courses) having measurable residuals, clinical effects were observed in 3 cases, and there was complete remission in 1 case. Massive residual tumors or hematological leukemic burden were correlated with failure in the current setting. Conclusions: WT1 peptide vaccination was performed without serious complications in the present phase I/II study. In order to improve outcomes, WT1 peptide vaccination should be started at the earliest stages of the disease so that there are minimal lingering effects after successfully compteting therapy.

We encountered an example of a diagnosis of anaplastic large cell lymphoma (ALCL), i.e. a fourteen-year-old-boy with persistent spike fever for 2 months who was found to have an osteolytic lesion. At the time of admission, when the first biopsy was performed, an osteolytic lesion in his lumbar vertebra (L1) was revealed, and the finding was a pathological diagnosis of osteomyelitis. Then, as the high fever still persisted with increasing serum levels of C-reactive proteins and the soluble form IL-2 receptor despite performing antibiotic therapy, a second examination was carried out 2 months later and found additional osteolytic lesions located in the right ilium and lymphadenopathy in the pelvic cavity. The second biopsy specimens from the lymphadenopathy were positive for CD30 and anapestic lymphoma kinase. Chemotherapy, which was conducted according to ALCL99, resolved his symptoms. At the time of admission, IL-6 was high, hypercytokinemia, spike fever and bone lesions occurring before ALCL developed. Therefore, these findings suggest that the prior occurrence of hypercytokinemia such as IL-6 plays an important role in the development of ALCL.

Invasive fungal infection (IFI) is a serious complication of chemotherapy for hematological malignancies and autologous/allogeneic hematopoietic stem cell transplantation in children and shows a high mortality rate. We performed a randomized trial comparing micafungin (MCFG), a new anti-fungal agent, with fosfluconazole, a prodrug of fluconazole (FF) conventionally used as a prophylactic agent, for prophylaxis against IFI. Cefpirome was administered as prophylaxis against bacterial infection, and meropenem+minocycline as an empiric window therapy for febrile neutropenia. MCFG 2 mg/kg/day (max 100 mg/day) and FF 10 mg/kg/day (max 400 mg/day) were both safe and effective (event free ratio of IFI, MCFG 94.4% vs FF 94.3%) without significant difference. Thus, MCFG is safe and can be used for prophylaxis against IFI in children.

Chronic active Epstein-Barr virus (CAEBV) infection is characterized by a status of lymphoproliferative disease of EBV-infected cells, resulting in chronic or recurrent infectious mononucleosis-like symptoms. CAEBV is always accompanied by life-threatening complications. We report the case of a 2-year-old female patient with CAEBV who subsequently developed Langerhans cell histiocytosis (LCH) presenting with bilateral exophthalmos, bone, and skin involvement. In situ hybridization for EBER revealed EBV-infected B-cells present in lesional tissue implying that interactions between EBV-infected B-cells and lesional Langerhans cells may be associated with the development of LCH.

Chronic active Epstein-Barr virus (CAEBV) infection is characterized by a status of lymphoproliferative disease of EBV-infected cells, resulting in chronic or recurrent infectious mononucleosis-like symptoms. CAEBV is always accompanied by life-threatening complications. We report the case of a 2-year-old female patient with CAEBV who subsequently developed Langerhans cell histiocytosis (LCH) presenting with bilateral exophthalmos, bone, and skin involvement. In situ hybridization for EBER revealed EBV-infected B-cells present in lesional tissue implying that interactions between EBV-infected B-cells and lesional Langerhans cells may be associated with the development of LCH.

We report the results of 39 children who underwent cord blood stem cell transplantation (CBSCT) at our institute during the period from February 1996 to July 2005. The patients consisted of 9 with non-malignant disease, 26 with malignant disease and 4 with Epstein-Barr virus (EBV) associated disease. The median age of the patients was 4 years and 8 months (range, 6 months to 16 years 2 months). The median infused cell dose was 4.9 (range, 1.7∼11.4)×10⁷/kg. Thirty-four transplants were from HLA-mismatched donors, and 33 patients underwent a tacrolimus-containing regimen for GVHD prophylaxis. As for CBSCT as the first transplant, 3 out of 4 children with non-malignant disease achieved engraftment after CBSCT with the use of a reduced-intensity conditioning regimen. For acute leukemia, 3 patients out of 5 in their first remission and 2 out of 9 in advanced stage at CBSCT continue in remission at the time of writing. Fourteen patients received CBSCT as a second or a third transplant. None of 4 patients who underwent CBSCT as rescue therapy after rejection/graft failure achieved engraftment. It should be emphasized that EBV-associated disease seems to be a suitable disease for CBSCT, because all of the 4 patients who underwent CBSCT are still in CR.

7歳のレックリングハウゼン氏病の児に悪性神経鞘腫を合併した症例を経験した.頚部腫瘤として発症し,完全摘出後のわずか5か月後に局所再発した.化学療法や大量化学療法(ifosfamide+L-PAM)は部分的に奏功したが,臨床経過で腫瘍は再燃した.FDG-PET検査は悪性診断に有用であった.本腫瘍は,これまでの報告から予後不良であり,発症機序の解明による新規治療の開発が必要であると考えられた.

Background. Neonatal leukemia characterized by early stem cell origin and extramedullary infiltration in the first 4 weeks of life is rare. We analyzed the features and outcome of neonatal leukemia in Japan to establish an appropriate treatment strategy for this rare disorder. Procedure. Patients with infant leukemia registered and treated in the Japan Infant Leukemia Study between 1996 and 2001 were analyzed. Results. Among 162 infant leukemia patients, I I exhibited neonatal leukemia; frequencies for all infant leukemias were 6.9% (8/116) for acute lymphoblastic leukemia (ALL) and 7.3% (3/41) for acute myeloid leukemia (AML). Positive MLL gene rearrangement was observed in all eight patients with ALL; a single patient with AML displayed germline configuration. Acute monoblastic leukemia was apparent in all three patients with AML (M5a in the FAB classification). Most of the patients demonstrated hepatoplenomegaly and hyperleukocytosis at diagnosis. Cutaneous and central nervous system involvement were detected in half of the patients. Four patients (one with AML, and three with ALL) have survived following stem cell transplantation (SCT); however, growth impairment related to SCT was observed in these patients. Conclusions. These results suggest an improvement attributable to treatment of neonatal leukemia. International-based collaborative studies are necessary to investigate the biology of this condition and to establish appropriate therapeutic strategies.

Epstein-Barr virus (EBV) occasionally infects T and NK cells and causes EBV-infected T/NKcell lymphoproliferative disease (LPD), which comprises chronic active EBV infection, EBV-associated hemophagocytic syndrome, mosquito allergy, hydroa vacciniforme, aggressive NK-cell leukemia, and NK/T-cell lymphoma. The diagnosis is proven by the monoclonal proliferation of EBV-infected T or NK cells, which is a time-consuming and complicated method. T-cell monoclonality is helpful for the screening of EBV-infected T-cell LPD in patients with EBV-genome burden and is easily shown with T-cell-receptor rearrangement or the T-cell repertoire, whereas NK-cell monoclonality is difficult to prove due to its lacking such rearranged receptors. We investigated a set of killer immunoglobulin-like receptors (KIRs) and also CD94-NKG2 heterodimers on NK cells, namely the NK-cell repertoire. Skewed repertoires were seen in all patients with EBV-infected NK-cell LPD, but not in any patients with EBV-infected T-cell LPD and were restored only after successful treatment. The normal KIR repertoire is variable for each individual and it seems difficult to detect minimal residual EBV-infected lymphocytes. However, the NK-cell repertoire is feasible for identifying EBV-infected NK-cell LPD and evaluating the treatment effect.

Although flow cytometric (FCM) analysis is one of the most widely used approaches to screen the presence of leucocyte antibodies, it has several drawbacks. First, neutrophils and, especially, monocytes exhibit high background reactivity. Second, to determine antibody specificity, it is often necessary to examine not only neutrophils and monocytes but also other lineage cells including T cells, B cells and platelets. Therefore, we attempted to establish an FCM analysis system in which four lineages of leucocytes and platelets are simultaneously tested with low background. FCM analysis was performed using ethylene diamine tetraacetic acid-anticoagulated whole blood as cell sample without any cell preparation. Discrimination of five cell lineages was carried out based on the differences in forward vs. side scatter distribution and in the expression of CD4, CD20 and CD14. When anti-HNA (human neutrophil antigen) 1b antiserum was applied to HNA 1b-positive blood samples, only neutrophils were unambiguously positive. When anti-Nak(a) (anti-CD36) antiserum was applied, only platelets and monocytes were positive. The background reactivity of neutrophils and monocytes was low enough. When anti-human leucocyte antigen (HLA) class II antiserum was tested, only B-lymphocytes and monocytes were positive. When anti-HLA class I antiserum was tested, all the five-lineage cells were positive.

Eight children underwent reduced-intensity stem cell transplantation (RIST) from an HLA-matched sibling. They received a fludarabine-melphalan based preparative regimen. Stem cell source was bone marrow, and GVHD prophylaxis consisted of cyclosporine A alone. Acute GVHD grade II-IV and grade III-IV were observed in four (50%) and three (37.5%), respectively, out of these eight patients. This incidence was significantly higher than that after conventional bone marrow transplantation, without severe tissue damage, in the same setting of stem cell source and GVHD prophylaxis. Although the number of patients is small, our results suggest that incidence of acute GVHD after RIST for children is significant. It should be remembered that RIST for children does not seem to be an easy transplant procedure from the viewpoint of acute GVHD, although RIST is less toxic.

症例報告

The authors describe a 1-year-old boy who was diagnosed with neuroblastoma by mass screening at age 6 months. The tumor originated from the left retroperitoneum and extended over the midline, involving major vessels and invading the spine with compression of the spinal cord. Although seven courses of chemotherapy consisting of vincristine sulfate, cyclophosphamide, pirarubicin hydrochloride, and cisplatin were administered, there was no reduction in tumor size or decrease in tumor markers. The patient received irinotecan 180 mg/m(2) per day for 3 days. Approximately 3 weeks later the tumor had regressed remarkably, and tumor markers normalized after the second course of irinotecan. This therapy was given a total of four courses every 4 weeks, with the tumor shrinking successively in each session. Four years after treatment there is no sign of recurrence and the patient is doing well. This case may be the first report showing the dramatic efficacy of irinotecan in the treatment of chemoresistant neuroblastoma without the use of other antitumor agents. Irinotecan might be a promising drug in the management of patients with high-risk neuroblastoma.

大量化学療法に術中開創放射線照射を併用し機能を温存できた骨盤内進展横紋筋肉腫の2例を経験した.症例1は右大腿部腫瘤で発見され骨盤腔内に転移を認めた8ヶ月男児.症例2は腹部膨満を主訴に骨盤底に巨大腫瘍を発見された9ヶ月男児.ともに腫瘍組織生検後大量化学療法を先行させ,残存する骨盤内病巣の摘出術の際に術中開創放射線照射を施行した.症例1は治療開始後5年を経過した現在,下肢長の左右差を少し認めるものの歩行障害は無い.症例2は術後約半年,一時的な膀胱機能低下を認めたが現在は改善した.ともに無病生存中である.

In all, 100 unrelated donor bone marrow transplantations (UD-BMT) were performed in our institute between October 1993 and January 2003. Of 93 evaluable patients, 73 patients had hematological malignancy, 13 had nonmalignancy and seven had lymphoproliferative disease. The estimated 9-year event-free survival (EFS) rate was 57.1 +/- 5.5% in all patients. In the following analyses of the patients with hematological malignancy, the standard group had significantly better EFS than the high-risk group (61.5 +/- 7.0 vs 35.6 +/- 9.7%, P = 0.02), and the EFS rate of the tacrolimus (FK-506)+methotrexate (MTX) +/- methylprednisolone prophylactic group for graft-versus-host disease was superior to that of the FK506 without MTX group (75.7 +/- 8.0 vs 55.8 +/- 7.6%, P = 0.02). When we compared the EFS rates of the FK506+MTX+methylprednisolone (mPSL) group and the HLA-matched related donor BMT group in our institute, these were almost similar (75.7 +/- 8.1 vs 68.4 +/- 9.3%). Therefore, UD-BMT using FK-506+MTX +/- mPSL is a safe and useful method for children with hematological malignancy who require allogeneic BMT.

Mediation of Epstein-Barr virus (EBV)-specific cytotoxicity in T lymphocyte via the perforin/granzyme pathway has been demonstrated therefore, a study involving cytolytic molecules was essential for the clarification of hemophagocytic lymphohistiocytosis (HLH) pathogenesis. This investigation, which analysed the frequency of three allelic mutations of granzyme-B (55Q/R, 95P/A and 247Y/H) in patients with EBV-HLH and infectious mononucleosis, identified the high prevalence of the QPY haplotype in EBV-HLH patients in comparison with healthy controls. A > G polymorphism was also detected in intron 5 furthermore, nearly complete linkage disequilibrium was observed among these polymorphisms. The recessive role of the QPY haplotype of granzyme-B might be responsible for the pathogenesis of EBV-HLH. Cytotoxicity and DNA fragmentation of cytotoxic T lymphocytes did not differ among patients characterized by the QPY/QPY, RAH/RAH and QPY/RAH genotypes. This finding suggested that DNA fragmentation in target cells is mediated not only by granzyme-B but also by other molecules, including other granzymes or Fas.

Familial hemophagocytic lymphohistiocytosis (FHL) is a rare and lethal disease which is characterized by high fever, hepatosplenomegaly, neurological symptoms and pancytopenia, and most reported cases result from autosomal recessive inheritance. Allogeneic stem cell transplantation appears to be the only way to cure this disease, and therefore, myeloablative stem cell transplantation had been performed with success. Recently, however, some groups demonstrated that reduced intensity preconditioning regimens could establish engraftment with minimal toxicity in elderly patients. Since FHL is not a malignant neoplasm, we decided to employ this strategy to treat a case of refractory FHL, resulting in a promising outcome. Thus, reduced intensity stem cell transplantation (RIST) seems to be a feasible and useful method for the treatment of FHL.

横紋筋肉腫は小児悪性軟部組織肉腫の代表的な疾患である.当科での11例の治療経験より大量化学療法の意義について検討した.初期の症例において,大量化学療法のみでは局所再発が認められた.しかし,double megatherapy(DM)を導入した集学的治療により,良好な成績が得られている(6/7例寛解).この治療戦略は,生命予後のみならず局所治療による機能障害の軽減にも貢献している.

自家骨髄移植1回法では治癒を期待できないような難治性神経芽腫に対して移植2回法を行ってきた.自家移植2回法の10例中4例,同種移植を含む2回法の12例中6例が寛解を維持している.HLA一致ドナーが得られずHLA不一致移植を施行した7例のうち4例,計画的に父親から移植した4例中3例が寛解であることから,HLAハプロ不一致移植を組み込んだ移植2回法が自家移植2回法を凌駕する可能性が示唆された.

We retrospectively analyzed the clinical results of 81 patients with congenital genetic diseases who were treated with bone marrow transplantation (BMT) from unrelated donors identified through the Japan Marrow Donor Program. The patients were aged between 1 and 38 years (median, 4 years). Thirty-five patients underwent transplantation for metabolic disease (MD), ie, mucopolysaccharidosis (n = 25), adrenoleukodystrophy (n = 7), and others (n = 3). The remaining 46 patients had Wiskott-Aldrich syndrome (n = 16), hemophagocytic syndrome including the inherited type (n = 9), severe combined immunodeficiency (n = 6), hyper-IgM syndrome (n = 4), Chediak-Higashi syndrome (n = 3), Kostmann syndrome (n = 3), and others (n = 5). Fifty-two donor-patient pairs were fully matched at HLA-A, HLA-B, and HLA-DRB1 alleles. The remaining 24 patients received allele-mismatched grafts (20 matched at 5 of 6 loci and 4 matched at 4 of 6 loci). Engraftment occurred in 82.4% of the MD group and 90.7% of the other genetic disease (OGD) group; however, 14 patients (18.2%) experienced either early or late graft failure. The cumulative incidence of grade II to IV acute graft-versus-host disease (GVHD) was 35.5% _ 9.8% in the MD group and 47.3% _(_) 9.5% in the OGD group, and the rate of chronic GVHD was 20% in both groups. Forty-nine patients have survived for 3 to 96 months (median, 20 months). The probabilities of 5-year overall survival and event-free survival were 72.6% _ 11.5% and 65.3% _ 8.6%, respectively, for MD (n = 35) and 72.5% _ 7.3% and 63.6% _ 7.3% for OGD (n = 46). Although patient status before BMT and the occurrence of grade III to IV acute GVHD significantly affected outcome, unrelated BMT is a curative therapeutic option for children with congenital genetic diseases who have no HLA-matched family donors. (C) 2004 The Japanese Society of Hematology.

A 31-year-old woman had been suffering from fever and a sore throat since January 1999, and had a left neck lymphadenopathy in December 1999. Pathological findings of the biopsied lymphnode suggested malignant lymphoma. She was finally diagnosed as having a chronic active Epstein-Barr virus (EBV) infection because of abnormal antibody titers against EBV antigens and an increased EBV load in her peripheral blood. After receiving chemotherapy consisting of CHOP and high dose cytarabine, the amount of the EBV genome decreased below the detection limit before BMT. Therefore, instead of a conventional myeloablative transplant, we performed BMT using reduced-intensity conditioning regimens consisting of fludarabine and melphalan from an HLA-identical sibling donor. After 14 months, the patient remained in complete remission. Menstruation occurred on day 83 following BMT, and the serum level of LH and FSH on day 316 were within normal range. Under these circumstances, RIST seems to be one of the curative treatments for the patients with CAEBV with minimal late side effects.

Many studies have assessed the clinical significance of the detection of minimal residual disease (MRD) in acute leukemia. Thus far, many studies have suggested that MRD detection to evaluate the response to chemotherapy is useful for predicting the prognosis of childhood acute lymphoblastic leukemia (ALL). However, few studies have reported on the significance of MRD in childhood acute myeloid leukemia (AML), because of small numbers of patients and limited availability of MRD markers. Therefore, we monitored MRD using currently available markers at several points during the treatment for childhood AML and tried to intensify the treatment based on the results of MRD. Thirty-one patients (26 de novo cases and 5 other cases) were examined for MRD between February 1999 and May 2002. After the first consolidation therapy (consolidation 1), the expression of Wilms tumor gene (WT1) and/or leukemia-specific fusion genes such as AML1/MTG8, PML/RARalpha, and MYH11/CBFbeta were analyzed. Patients with positive MRD but in hematological remission at that point were recommended to undergo stem cell transplantation (SCT). Positive WT1 expression (more than 10(3) copies/mug RNA) was detected in 18 of 31 patients (58.1%) at onset. After consolidation I therapy, the WT1 expression became negative in 14 of 18 patients. The AML1/MTG8 fusion gene was expressed in 8 patients, PML/RARa was expressed in 3 patients, and MYH11/CBFbeta was expressed in I patient. Four of the 8 patients with AML1/MTG8 expression and all 3 with PML/RARalpha expression also demonstrated positive WT1 expression at onset. Eight (5 de novo cases and 3 other cases) of the 31 patients had no available MRD markers. Four patients who showed persistently high expression of WT1 after consolidation I therapy underwent SCT, and only 1 patient remained in complete remission (CR). Among 14 patients who became negative for WT1 expression, 6 patients received SCT for various reasons. Among 8 patients with the AML/MTG8 fusion gene, 2 became MRD negative and 6 continued to be positive. Four of these 6 patients underwent SCT, and all but one who underwent syngeneic SCT became MRD negative. On the other hand, I of the 2 patients who continued on chemotherapy continued to be MRD positive, suggesting a graft-versus-leukemia effect in allogeneic SCT. All patients with the PML/RARalpha and MYH11/CBFbeta fusion gene continued to be in CR. The 3-year event-free survival in de novo AML was 69.4% +/- 9.8% (n = 26), a result that is encouraging and superior to other reported outcomes. Thus, an MRD-based treatment strategy together with conventional risk factors appears to be required for further improving the outcomes of AML. (C) 2004 The Japanese Society of Hematology.

We performed autologous CD34(+) stem cell transplantation in 3 patients with juvenile rheumatoid arthritis (JRA) refractory to conventional treatment. All patients had systemic type JRA. In case 1 (a 3-year-old boy), purified CD34(+) cells from bone marrow were transplanted after a preconditioning regimen consisting of cyclophosphamide (200 mg/kg) and antithymocyte globulin (ATG) (40 mg/kg). However, the disease flared soon after transplantation. In case 2 (a 13-year-old girl) and case 3 (a 21-year-old woman), a preconditioning regimen consisting of etoposide (VP16) (2 g/m(2)), thiotepa (300 mg/m(2)), and ATG (40 mg/kg) was followed by transplantation of purified CD34(+) stem cells harvested from peripheral blood mononuclear cells. The patients in cases 2 and 3 attained complete remission without any medication. Thus for patients with refractory JRA, autologous CD34(+) cell transplantation appears to be a safe and feasible choice of treatment in terms of good quality of life. However, a greater number of patients and a longer observation period are needed before definitive conclusions can be drawn. Int J Hematol. 2003;78:453-456. (C) 2003 The Japanese Society of Hematology.

A 5-year-old boy received CD34-positive HLA haplo-identical bone marrow transplantation from his father as treatment for refractory advanced neuroblastoma. He had residual disease in the para-aortic lymph nodes and multiple bones after the transplant. However, all of his residual disease had disappeared completely 3 years later. He developed grade I acute graft-versus-host disease (GVHD) but had no symptoms of chronic GVHD or any other complications. This case demonstrates the possibility of a graft-versus-tumor effect against neuroblastoma by HLA-mismatched allogeneic hematopoietic stem cell transplantation.

The aim of this study was to determine whether the gene polymorphisms of Th1/Th2 and immunoregulatory cytokines were associated with aGVHD in Japanese children receiving allogeneic bone marrow transplantation (allo BMT). We investigated polymorphisms of genes encoding interleukin (IL)-4, IL-4 receptor (IL-4 R), IL-10, transforming growth factor (TGF)-β1, TGF-β1 type II receptor (TGF-β1 RII), interferon (IFN)-γ, IFN-γ type 2 receptor (IFN-γ R2), and IFN regulatory factor (IRF)-1. Sixty-seven patients were treated with alloBMT from HLA-identical siblings, and aGVHD was observed in 38. TGF-β1 codon 10 leucine (Leu)/proline (Pro) polymorphism in donors was associated with the development of aGVHD. Patients having donors with the Pro allele had aGVHD more frequently than those without Pro allele (30/45 vs 8/20, odds ratio = 3.00 P = 0.04). TGF-β1 RII 1167 C/T polymorphism in recipients was also associated with the development of aGVHD. The incidence was significantly higher in recipients with T allele than in those without T allele (21/27 vs 16/35, odds ratio = 4.16 P = 0.01). In conclusion, genetic backgrounds of TGF-β1 and TGF-Βb1 RII may be involved in the development of aGVHD in HLA-matched sibling BMT in Japanese children.

We encountered 2 patients with pneumococcal arthritis following bone marrow transplantation (BMT). Both patients received grafts from unrelated human lymphocyte antigen(HLA)-matched donors and had suffered from chronic graft-versus-host disease (GVHD). One, a 10-year-old boy, suffered from Epstein-Barr virus-related lymphoproliferative disease (EB-LPD) and received oral 6-mercaptopurine and methotrexate to manage lymphadenopathy. Twenty-four months after BMT and 7 months after the onset of EB-LPD, pneumococcal arthritis occurred in both knee joints. The other patient, a 10-year-old girl, received multiagent immunosuppressive therapy for her chronic GVHD. At 51 months following BMT, pneumococcal arthritis occurred in her left knee joint. Chronic GVHD of the skin delayed the recovery from the arthritis in both patients. This complication is quite rare but can be very serious, in regard to the patient's performance status following BMT. Although vaccination against pneumococcus or preventive antibiotics should be administered to high-risk patients, early diagnosis and treatment may be the best strategy for pneumococcal arthritis. (C) 2001 The Japanese Society of Hematology.

The plasma levels of a panel of cytokines and cytokine-associated molecules (IL-1 alpha, IL-2, IL-4, IL-6, IL-10, IL12, IL-15, macrophage colony-stimulating factor (M-CSF), interferon-gamma (IFN-gamma), tumor necrosis factor-a (TNF-LU), soluble IL-2 receptor (sIL-2R), soluble tumor necrosis factor receptor I or II (sTNFRI or II)) were assessed in 56 plasma samples of 13 pediatric patients undergoing hematopoietic stem cell transplantation (HSCT, bone marrow: in 12 and cord blood in one) from unrelated donors, Eight patients developed severe (grade III-IV) acute GVHD (aGVHD). The plasma IL-6, IL-10, M-CSF, sTNFRI and II levels were significantly high in the severe aGVHD group compared to the mild (GVHD) group (grade 0-II), The plasma IL-15 level increased transiently in the early period following HSCT and remained high in the severe aGVHD group even after 4 weeks following HSCT, Based on analysis of the: correlations between the kinetics of the plasma cytokine levels after HSCT and the clinical manifestations of aGVHD, IL-15 and/or M-CSF were involved in the development of aGVHD, following elevation of the plasma IL-10 and sTNFRI or II levels. These kinetics suggest that IL-10 and sTNFRs worked as suppressor cytokines and seemed to suppress clinical manifestations of aGVHD. Furthermore, it seemed that the plasma ratio of IL-10/sTNFRII from 5 to 12 weeks following HSCT was linked to the poor outcome in the patients with severe aGVHD, suggesting that IL-10 plays an important role in protecting hosts from transplantation-related complications, including GVHD.

We report two boys with chronic active Epstein-Barr virus infection (CAEBV) refractory to conventional chemotherapy, who received HLA-mismatched allografts of CD34-positive progenitor cells from their fathers. One patient developed veno-occlusive disease (VOD) of the liver on day 18 after transplantation and died on day 26. The other patient received the allograft during partial remission. Although he suffered recurrent infections due to <i>Streptococcus viridans</i>, he is now doing well 23 months after transplantation. CAEBV refractory to chemotherapy is considered to be a fatal EBV-infected T/NK-cell lymphoproliferative disease, and our experiences suggest that CD34-positive progenitor cell transplantation for patients with CAEBV lacking HLA-matched donors may be a feasible and useful treatment. However, the timing of transplantation is considered to be critical, and should be performed when the patient is in good clinical condition.

We investigated the long-term performance status of childhood recipients by means of a questionnaire because the quality of life in the long-term survivors following allogeneic hematopoietic stem cell transplantation remains unclear. Six cases of. secondary malignancy were reported. T-non Hodgkin lymphoma or myelodysplastic syndrome developed in the early period following transplantation and solid tumors such as brain tumors or lingual tumors in the late period. Chronic mucositis caused by the graft-versus-host disease (GVHD) might be involved in the carcinogenesis of the lingual tumor that occurred in a case of Fanconi anemia. Severe GVHD caused by HLA disparity and the administration of antithymocyte globulin were risk factors for the development of EB virus-associated lymphoproliferative disorder (EB-LPD). The deterioration of performance status caused by the development of chronic GVHD was reported in 46 cases. The development of bronchiolitis obliterans, arthropathy because of chronic GVHD of the skin, and encephalopathy related to the immunosuppressants were major sequels that influenced long-term performance status in pediatric survivors. It seems that the Karnofsky score used in this study may not reflect the patient's performance status because there is a discrepancy between the reported scores and symptoms. A new score system must be established to evaluate the quality of life from various aspects in long-term pediatric survivors.

Forty-eight patients who underwent bone marrow transplantation (BMT) from serologically HLA-matched unrelated donors received tacrolimus (FK506) alone or with methotrexate (MTX) and/or methylprednisolone (mPSL) to prevent graft-versus-host disease (GVHD). We analyzed retrospectively the efficacy of FK506 for GVHD propylaxis, and its toxicity, by comparing three groups of patients: those given FK506 alone, those given FK506+mPSL, and those given FK506+MTX+mPSL. Grade III and IV acute GVHD occurred in five of 10 patients given FK506 alone and in 11 of 30 patients given FK506+mPSL. In these groups, severe acute GVHD was commonly seen in the patients who discontinued FK506 administration early after BMT and in those who received bone marrow from genotypically HLA-mismatched donors. Early withdrawal of FK506 was due mainly to severe nephrotoxicity. The incidence of nephrotoxicity was very high in patients who received high-dose FK506 as well as melphalan-containing preconditioning (80% and 50%). None of eight patients who received FK506+mPSL+MTX developed grade III-IV acute GVHD even though five of them received bone marrow from genotypically HLA-mismatched donors. In patients receiving bone marrow from unrelated donors, adjustment of the initial dose of FK506 seems essential in order to avoid severe nephrotoxicity, and combination of MTX and FK506 is useful for preventing severe acute GVHD.

Ligation of CD40 using anti-CD40 or soluble CD40-ligand activates numerous intracellular kinases which transduce signals to the nucleus. The nature whereby these signaling events are coupled to distal functional events in B cells is poorly understood. In this study, using anti-CD40 monoclonal antibodies which recognize different epitopes on CD40, we compare the ability to activate the stress-activated protein kinases (SAPK) such as c-Jun NH2 terminal kinase and p38 in human B cells with CD40 function. Activation of the SAPK pathway correlated with levels of activation of Rel/NF-kappa B transcription factors, but did not appear to be associated with rescue from anti-IgM induced apoptosis by suppressing caspase (CPP32) activity. Somewhat surprisingly, in the presence of IL-4, those antibodies to CD40 which failed to activate SAPK were most active in IgE production. IgE production was augmented in the presence of wortmannin. These studies suggest that rescue from apoptosis and IgE production mediated via CD40 may be independent of SAPK activation, induction of Rel/NF-kappa B, or suppression of CPP32 and that IgE production is, at least in part, regulated by signaling pathways that are dependent on phosphatidylinositol 3-kinase. (C) 2000 Academic Press.

We analyzed 98 pediatric patients who underwent bone marrow transplantation (BMT) from serologically HLA-matched related donors (RD) or unrelated donors (UD) at our institute to clarify the actual status of chronic graft-versus-host disease (cGVHD). There were 36 evaluable cases of RD-BMT and 35 of UD-BMT. cGVHD was observed in 8 RD-BMT cases (22.2%) and in 23 UD-BMT cases (65.7%). In the RD-BMT cases, the limited and extensive types of cGVHD were observed in 4 cases each, whereas in the UD-BMT cases, the limited type was seen in 11 cases and the extensive type in 12. Prior acute GVHD was observed in 6 RD-BMT cases and in 18 UD-BMT cases. Two RD-BMT patients with extensive type cGVHD died of relapse and cytomegalovirus infection, and 4 UD-BMT patients died because of bronchiolitis obliterans, fungal infection, liver failure, and multiple organ failure, respectively The incidence of cGVKD in these pediatric patients was as high as that in adult patients when UD-BMT was performed. Some UD-BMT patients required long-term immunosuppressive therapy after BMT. These findings suggest that cGVHD is a serious problem in pediatric UD-BMT. Therefore, intensive prophylaxis and treatment of GVHD must always be performed after UD-BMT. Int J Hematol. 2000;71:278-282 (C) 2000 The Japanese Society of Hematology.

Background: Antigen receptor ligation induces apoptosis of B lymphocytes, but the molecular mechanisms underlying induction of apoptosis remain unclear, although the growing family of IL-1 beta-converting enzyme cysteine proteases (caspases) are recognized to be major effecters of cellular death. Objective: We sought to delineate and compare the rescue of B-cell apoptosis through CD40 ligand-CD40 interaction and cyclic adenosine monophosphate (cAMP)-dependent protein kinase A in human B cells. Methods: By using tonsillar B cells and the B-lymphoblastoid cell line Ramos, rescue from B-cell apoptosis was compared, as were signaling pathways after activation of cells through CD40 and the adenosine A2 receptor. Results: Both CD40 ligand-CD40 interaction and activation of intracellular cAMP rescue B cells from apoptosis after antigen receptor ligation, Although these pathways do not overlap, they converge by preventing the anti-IgM-induced activation of CPP32 (caspase 3), a member of the IL-1 beta-converting enzyme protease family. Conclusion: These data indicate that the cAMP-protein kinase A-dependent and CD40-signaling pathways regulate B-cell survival and converge at a common point, the inhibition of antigen receptor-induced activation of caspases.

Since patients suffering from infantile leukemia are reported to have a poor prognosis, we have been treating them with intensified chemotherapy and various forms of blood stem cell transplantation (SCT). From December 1992 to October 1998, fifteen patients with infantile leukemia were treated ; 9 ALL (6 had a chromosome 11q23 abnormality or MLL gene rearrangement), 5 AML, and 1 NK cell leukemia. All but two patients with AML received SCT. In the beginning we employed autologous BMT (ABMT) following a preconditioning regimen consisting of busulfan and melphalan for the treatment of 5 consecutive patients (4 ALL and 1 AML). Because of a high relapse rate after ABMT in this setting (4 out of 5 patients), we used allogeneic SCT (allo SCT) with an intensified preconditioning regimen, including TBI for the remaining 8 patients and the 4 relapsed patients. At this writing (April 2000), 6 of 13 patients receiving SCT continue in remission (20-88 months after diagnosis), and 5 of 8 ALL patients are still in remission (20-75 months after diagnosis). Thus allo SCT with an intensified preconditioning regimen including TBI seems to be a feasible method for the treatment of infantile ALL.

Cell growth and proliferation as well as cell cycle arrest and apoptosis all play integral roles in the cellular immune response. The signals that lead to cytokine production by antigen- or mitogen-stimulated T cells have been studied in detail. However, it is not fully understood how these signals promote cell cycle entry and progression to DNA synthesis in T lymphocytes, especially in primary cells. We used a model distinguishing between competence and progression phases to examine quantitative and qualitative differences in signal transduction that resulted in cell cycle entry and G1 phase arrest or led to DNA synthesis in human T cells. Resting peripheral blood T cells were rendered competent by stimulation with submitogenic concentrations of phytohemagglutinin (PHA) or they were stimulated to proliferate using mitogenic concentrations of PHA. The competent state (that is, the capacity to proliferate in response to exogenous IL-2) was characterized by calcium mobilization, a protein kinase C-dependent internalization of CD3, increased mitogen-activated protein kinase (MAPK) activity, transient translocation of AP-1 transcription factors to the nucleus, expression of immediate early genes, activation of G1-phase cyclin-dependent kinases, and increased CD25 (IL-2R alpha) expression. However, all of these events were of lesser magnitude in T cells rendered competent than in T cells stimulated to proliferate. Furthermore, the mitogenic stimulus induced a different pattern of MAPK activation and sustained translocation of AP-1 to the nucleus with concomitant IL-2 production. The data indicate that quantitative and qualitative differences in early signaling events distinguish the acquisition of the competent state or the induction of cytokine production with a commitment to T-cell proliferation. (C) 1999 Academic Press.

In human B cells, antigen receptor ligation and CD40 ligation are known to activate the extracellular-regulated kinases (ERK) and c-Jun N-terminal kinase (JNK) pathways, which in turn regulate many important B cell functions. We previously reported that antigen receptor ligation activated the ERK pathway whereas CD40 ligation activated the JNK/stress-activated protein kinase (SAPK) pathway. Here, we demonstrate that another SAPK, p38/Hog1, is activated by both antigen receptor ligation or CD40 ligation in a human B-lymphoblastoid cell line and tonsillar B cells. Wortmannin, an inhibitor of phosphatidylinositol 3-kinase, partially inhibited ERK2 and p38 activation triggered through the B cell receptor whereas activation of JNK1 and p38 through CD40 was not affected. PD98059, a specific inhibitor of mitogen-activated extracellular response kinase kinase (MEK), significantly inhibited ERK2 activation and partially inhibited p38 activation triggered by anti-lgM antibody treatment, but did not affect CD40-dependent signaling events. In addition, anti-lgM antibody-induced signaling pathways were shown to be PKC-dependent in contrast to the CD40-induced signaling pathways. Thus, the B cell receptor and CD40 recruit the ERK, JNK and p38 pathways by using different upstream effecters.

We performed an unrelated cord blood stem cell transplantation (CBSCT) for a case with congenital dyserythropoietic anemia. After conditioning with TBI, cyclophosphamide, and cyclosporin A, the CBSCT was done from an HLA 2-locus mismatched male donor. She failed to engraft, but a spontaneous recovery of autologous cells was observed. A second CBSCT from a different HLA 2-locus mismatched donor was carried out 149 days after the first CBSCT. The preparative regimen consisted of ATG, cytarabine, cyclophosphamide, and thiotepa, but engraftment was never observed. It is uncertain why the graft failed in the serial CBSCT because she received intensified preconditioning regimen and enough cord blood cells. It is well known, but our case suggests that one should pay much attention to the higher incidence of graft failure in HLA-mismatched CBSCT.

Stimulation of human peripheral B cells via the CD40 receptor and IL-4R together lead to IgE synthesis and secretion, but the intracellular signaling mechanisms by which these signals lead to IgE production are unclear. Roles for the transcription factor NF-kappa B and IL-6 have been postulated in the induction of IgE synthesis by IL-4/CD40, We found that neither anti-CD40 Ab nor IL-4 alone was able to induce significant proliferation of human B cells. However, the combination of anti-CD40 and IL-4 was a potent inducer of B cell proliferation in addition to IgE production from purified human B cells. Furthermore, IL-4 and anti-CD40 synergized for the production of IL-6, While neither IL-4 alone nor anti-CD40 alone was able to induce significant NF-kappa B DNA binding activity, the combination of IL-4 and anti-CD40 induced a strong activation of NF-kappa B, a transcription factor that regulates IL-6 production. These data indicate that both IL-4 and anti-CD40 are required to induce NF-kappa B activation and IL-6 transcription and production, and implicate these events in a signaling pathway augmenting IgE production in human B lymphocytes.

Hemophagocytic lymphohistiocytosis (HLH) is caused by the hyperactivation of T cells and macrophages. The clinical characteristics associated with this disease result from overproduction of Th1 cytokines including interferon-gamma (IFN-gamma), interleukin-2 (IL-2), and tumor necrosis factor-alpha (TNF-alpha). In this study, we analyzed the production of IL-12 and IL-4, which determine Th1 and Th2 response, respectively, and IL-10, which antagonizes Th1 cytokines, in 11 patients with HLH. IL-12 was detected in plasma in all patients (mean peak value, 30.0 +/- 5.0 pg/mL), while IFN-gamma was massively produced in nine patients (mean peak value, 79.2 +/- 112.0 U/mL). IL-4 was not detected in any of the patients. Plasma IL-10 levels were elevated in ail patients (mean peak value, 2,698.0 +/- 3,535.0 pg/mL). There was a positive correlation between the levels of IFN-gamma and IL-10 (P < .01). The plasma concentrations of these cytokines were initially high, before decreasing after the acute phase. However, the decrease in IL-10 levels was slower than that of IFN-gamma. Although the concentration of IL-12 was high at the acute phase, in some patients, a peak in the level was delayed until the chronic phase. Thus, in HLH, production of cytokines that promote development of Th1 cells appears to be predominant over that for Th2 cell development. Overproduction of IL-10 was also observed indicating that a mechanism suppressing hyperactivation of Th1 cells and monocytes/macrophages functions in patients with this disease. (C) 1997 by The American Society of Hematology.

To assess the clinical significance of monitoring minimal residual disease in t(8;21)(q22;q22) AML, RT-PCR assay was conducted during the clinical course of 12 patients who had undergone BMT or conventional chemotherapy. Two cases relapsed after BMT and chimeric RNA was detected soon after BMT in their bone marrow cells. The other three cases, in whom chimeric RNA was not detected after BMT, are in CR at 21 to 33 months following BMT. Similarly, four out of 7 cases who showed negative chimeric RNA after completion of chemotherapy have been in CR at 11 to 34 monthsfollowing completion of chemotherapy. The present findings appear different from other studies which reported the detection of AML1-ET0 chimeric RNA in long-term CR patients.

The immunosuppressant rapamycin (RAP) potentiated apoptosis of the murine T lymphoblastoid cell line S49 induced by dexamethasone (DEX), while RAP by itself did not induce apoptosis of the cells. FK506, in contrast, had no effect on DEX-induced apoptosis; moreover, an excess of FK506 reversed the potentiation of apoptosis by RAP, indicating that RAP exerts its effects through binding to FKBP. Both RAP and FK506 enhanced the MMTV promoter activity by dexamethasone, suggesting that the potentiation of apoptosis is not likely explained by the selective enhancement of transcriptional activity of the glucocorticoid receptor. Of interest, the basal activity of c-Jun kinase (JNK), whose activation has been recently suggested to be involved in cell survival signals in lymphocytes, was reduced by RAP in S49 cells. The reduction of JNK activity by RAP was reversed by the addition of an excess of FK506. In summary, we demonstrate for the first time that RAP has the ability to inhibit JNK activity in lymphocytes where the drug enhances apoptosis. (C) 1997 Academic Press

Although intensive therapy with autologous bone marrow transplantation (ABMT) has improved the outcome of advanced neuroblastoma, nearly half the patients with this disease still relapse after a single ABMT. In our previous study, 10 of 22 patients relapsed within 16 months post-transplantation. Predictive risk-factors for relapse were the presence of bone lesions at diagnosis, and a minor response or progressive disease at transplantation. In order to improve the outcome of these high-risk patients, we tested the feasibility of double autografts. To date, eight patients have been treated, and no treatment-related deaths were observed. Six remain in CR or with stable disease for 6 to 29 months. Although more cases and longer observation are needed to draw conclusions, these results are encouraging.

Aggregation of the high-affinity Fc receptors for immunoglobulin E (IgE) (Fc epsilon RI) on the surface of mast cells initiates intracellular signal transduction pathways including the tyrosine phosphorylation of cellular proteins, phosphoinositide hydrolysis, an increase in intracellular calcium, and protein kinase C activation. These signals are believed to be involved in the exocytic release of inflammatory mediators such as vasoactive amines, cytokines, and lipid metabolites. However, the downstream consequences of these early activation events are not well defined. One exception is the activation of the extracellular signal-regulated kinases/mitogen-activated protein kinases. One member of the mitogen-activated protein kinase superfamily, designated c-Jun amino-terminal kinase (JNK), has been recently identified. JNK is activated following dual phosphorylation at a Thr-Pro-Tyr motif in response to diverse stimuli including tumor necrosis factor-alpha, heat shock, or ultraviolet irradiation. We found that JNK was strongly activated by antigen cross-linking in a mouse mast cell line passively sensitized with ovalbumin-specific IgE. Anti-mouse IgE antibody also activated JNK. MEK kinase 1 (MEKK1) which activates the JNK activator, JNK kinase (JNKK), was similarly activated by antigen stimulation. JNK but not p42(erk2) activation induced by antigen was significantly inhibited in the presence of wortmannin, a known inhibitor of phosphatidylinositol 3-kinase. These results indicate that in response to the aggregation of Fc epsilon RI on mast cells, phosphatidylinositol 3-kinase activation is involved in the stimulation of the MEKK1, JNKK, JNK pathway.

The B cell surface antigen receptor, surface IgM (sIgM), is involved in B cell activation and proliferation, CD40 is involved in regulating IgE production and B cell survival. Cross linking of B cell sIgM activates the Ras/ Raf/p42(erk2) pathway. In contrast, ligation of CD40 by antibody or soluble gp39 (CD40 ligand) leads to activation of the c-Jun kinase (JNK)/stress-activated protein kinase pathway. JNK/stress activated protein kinase activation correlated with the stimulation of MEK kinase activity. CD40 does not activate the p42(erk2) pathway, and sIgM fails to regulate the JNK/stress-activated protein kinase pathway in B cells. Thus, two important cell surface receptors involved in controlling specific B cell response differentially regulate sequential protein kinase pathways involving different members of the mitogen-activated protein kinase family. Anti-CD40 also rescued B cell apoptosis induced by anti-IgM. CD40 ligation did not affect the sIgM stimulation of p42(erk2) activity. Conversely, sIgM ligation did not influence CD40 stimulation of JNK/stress-activated protein kinase. These results suggest that independent, parallel protein kinase response pathways are involved in the integration of sIgM and CD40 control of B cell phenotype and function.

The age-related changes in proportion of various subsets within lymphocytes were investigated in cord blood and peripheral blood from healthy children and adults. The percentages of T and B cells did not show age-related changes, whereas natural killer (NK) cells increased significantly with age. Within lymphocytes or the CD3(+) T cell population the proportion of CD45RA(bright+) lymphocytes decreased and that of CD45RO(+) cells increased, while that of CD45RA(dim+) cells showed no age-related change. Within lymphocytes, the percentage of CD45RA(bright+) CD4(+) cells decreased, together with a decline of that of CD4(+) cells. The proportions of CD45RA(bright+) CD8(+) cells and S6F1(bright+) CD8(+) cells increased with age, and the age-dependent increase of the proportion of CD8(+) cells seems to be mainly attributable to the increases in these subsets. The CD45RA(dim+) CD4(+) and CD45RA(dim+) CD8(+) cells co-expressing CD45RO at a low level nevertheless showed no age-related changes. In gamma delta T cells, both delta TCS1(+) and delta TCS1(-) T cells increased with age, but the delta TCS1(-) gamma delta T cells increased more than the delta TCS1(+) subset. Among lymphocytes, the percentages of CD20(+), CD21(+) and CD22(+) cells remained similar, with no age-related changes, but the proportion of CD5(+) cells within lymphocytes or B cells decreased. The proportions of CD16(+) NK cells among lymphocytes increased with age, and this change was attributable to the increase of CD56(+) cells.

Diffuse alveolar hemorrhage (DAH) is one of the life-threatening complications after bone marrow transplantation (BMT). A 4-year-old boy with acute lymphocytic leukemia received BMT from an unrelated bone marrow donor. The preconditioning regimen consisted of total body irradiation, melphalan and thiotepa. After BMT, severe mucositis was seen. Recovery of white blood cells was seen on day 12 after BMT. On day 22, he developed severe graft-versus-host disease (GVHD) with rash on general skin, bloody diarrhea and fever accompaning cytomegalovirus enteritis. By treatment with steroids, FK506 and ganciclovir, these symptoms seemed to improve. On day 33, however, he showed severe dyspnea. On the basis of bloody sputum and diffuse consolidation of the chest X-ray, diagnosis of DAH was made. Therapies such as steroid pulse and surfactant were ineffective, and he died at day 42. Intensive prophylaxis of GVHD and reduction of mucosal toxicity of conditioning regimen may be needed to prevent DAH in allogeneic BMT.

IFN-&alpha; has antiviral, immunomodulatory and antitumor activity, and thus can be effectively used for treating viral hepatitis and hematological malignancies. We describe here an 8-year-old boy with symptoms suggestive of chronic active EBV infection treated with IFN-&alpha;. He had been suffering from recurrent fever, hepatosplenomegaly and pancytopenia for 3 years and a novel herpesvirus, human herpesvirus-7, was isolated from peripheral blood lymphocytes during the clinical symptoms, but subsequently became ineffective. Recombinant interferon-&alpha; (IFN-&alpha;) was thus administered in consideration of antiviral activity starting from September 1993. However, unusual and life-threatening side effects of this drug, interstitial pneumonitis and renal disturbance, developed with hypercytokinemia after 2 months. These side effects were eliminated through surfactant replacement and plasma exchange.

Two cases of hemolytic uremic syndrome (HUS) following allogeneic bone marrow transplantation (BMT) are presented. Case 1 is a 14-year-old boy with acute leukemia who underwent allogeneic BMT from an HLA-matched sibling. His conditioning regimen was total body irradiation, L-PAM and thiotepa, and graft versus host disease (GVHD) prophylaxis consisted of short-term methotrexate (MTX) and cyclosporin A (CyA).At 7 months after BMT, he was admitted with edema on the lower extremities, hypertension, proteinuria, microhematuria and hemolytic anemia. He was diagnosed as having HUS. By stopping CyA administration, symptoms disappeared within 4 weeks. Case 2 is a 13-year-old girl with severe aplastic anemia who underwent allogeneic BMT from an HLA-matched unrelated donor. Her conditioning regimen was thoracoabdominal irradiation, cyclophosphamide and busulfan. GVHD prophylaxis consisted of short-term MTX and CyA. At 7 months after BMT, she showed pancytopenia, hemolytic anemia, proteinuria, microhematuria and hypertension.Similar to Case 1, administration of CyA was discontinued and anticoagulant therapy was employed with rapid improvement of clinical and laboratory findings. Although various factors such as chemotherapy, irradiation and infections are considered to be causal agents, the pathogenesis of HUS following BMT is still unknown. In the present cases, irradiation and viral infections might be involved in the pathogenesis of HUS.

Allogeneic bone marrow transplantation (BMT) was performed in an infant with chronic myelomonocytic leukemia (CMMoL). The conditioning regimen included busulfan, cyclophosphamide, etoposide, and cytosine arabinoside. On day 53 post BMT, rejection of the graft and auto-hematopoiesis were confirmed by using the RFLP study of the HPRT gene on the X-chromosome. After BMT his spleen became bigger and severe anemia and thrombocytopenia were accelerated. Splenectomy was performed 13 months after BMT. Although the number of erythrocytes and platelets increased and he got well after splenctomy, he suddenly died 19 months after BMT, probably due to sepsis caused by deterioration of leukemia. It is possible that hypersplenism was a cause of graft failure. Splenectomy or irradiation to spleen followed by conditioning regimen employing TBI may be needed to reduce the incidence of graft failure in CMMoL.

Human herpesvirus-7 (HHV-7), which is a newly identified human herpesvirus with an unknown pathologic role, was isolated from a 5-year-old boy suffering from fever, hepatosplenomegaly and pancytopenia. Although the clinical course was similar to that of chronic active Epstein-Barr virus infection, no viruses other than HHV-7 were isolated. This finding raises the possibility that HHV-7 played a pathogenic role in the present patient.

The efficacy of high-dose cytosine arabinoside (HDCA) and phenotypic difference in the prognosis were investigated in T-lineage malignancies (ALL and NHL) in children. Twenty-nine patients from July 1984 to December 1991 were included in this study. Ten patients were treated with the regimen without HDCA (Group A), 9 received single HDCA intensification (Group B) and 10 were treated with cyclic HDCA intensifications (Group C). Disease-free survival (DFS) rates at 48 months were 48%, 38.1% and 71%, respectively. Although these values were not significantly different, cyclic HDCA intensifications seem to be effective for T-ALL and NHL in children, because only 2 patients of Group C relapsed. The phenotype of the samples from Group B and C was divided into 3 groups, i.e., CD3 + group; CD3-, CD4+ and/or CD8+group; and CD3-, CD4-and CD8-group. The patients whose leukemic cells expressed CD3 had a favorable prognosis, and the patients with CD3-, CD4-and CD8-had the worst. Further study is needed to clarify whether the phenotype remains a prognostic factor in patients treated with very intensive therapies or not.

Blasts from eight cases with acute megakaryoblastic leukaemia (AMKL) and seven with transient abnormal myelopoiesis in Down's syndrome (TAM) were investigated to clarify their phenotypic characteristics. CD41 and CD7 were the most frequently expressed in both disorders. CD41 was positive in six TAM and five AMKL cases, and CD7 was positive in five TAM and five AMKL cases, respectively. CD33 was detected in four TAM and five AMKL cases. Other myeloid-lineage associated antigens such as CD13 and CD11b could not be found in TAM but were expressed in five AMKL cases. Interestingly, CD56, a neural adhesion molecule, was expressed in three of four TAM and one of five AMKL cases. Cytoplasmic CD3 antigen was also noted in three of five examined cases. A short-term culture study was conducted on blasts from two TAM cases and five AMKL cases. In two cases in which CD41 was not expressed before culture, the expression of CD41 was enhanced after culture with or without 12-0-tetradecanoyl-phorbol-13-acetate (TPA). The expression of CD7 remarkably was depressed, while that of CD13 was enhanced after culture with TPA. These findings suggest that blasts of TAM and AMKL originate from very immature cells and represent a mixed phenotype. In the present study, distinction of phenotypical differences between blast in TAM and AMKL was not possible.

Variable number of tandem repeats (VNTR) loci are highly polymorphic due to variation in the number of tandemly repeated sequences in different alleles. We analyzed the genotypic typing of VNTR loci (YNZ22 and MCT 118) using polymerase chain reaction after allogeneic bone marrow transplantation (allo-BMT). PCR analysis of VNTR loci was found to be useful for monitoring successful engraftment or hematological chimerism. Compared with conventional methods such as cytogenetic analysis and erythrocyte antigens, PCR analysis showed engraftment or graft rejection during early hypoplastic stages after allo-BMT with no influence from blood transfusion. Interesting cases are presented in the following. In one case, chimerism in PCR analysis preceded the patient's leukemia relapse ; we discuss whether this analysis is capable of the early detection of post allo-BMT relapse. Another case had acute GVHD-like syndrome with no donor-specific fragment in PCR analysis. Thus, PCR analysis of VNTR loci is one of the most useful tools to clarify the engraftment kinetics after allo-BMT.

Five children with B cell lymphoma were treated with the short-term intensive therapy and two of them are still in continuous complete remission for more than two years. Our protocol was based on the strategy of the European and American protocol of B cell lymphoma, that is (1) intensification of early phase of the treatment, (2) intensified central nervous system (CNS) treatment, and (3) shortening of the duration of chemotherapy. Complications were well tolerated, but intensification of CNS treatment introduced the problem of leukoencephalopathy. Because the survival of children with CNS involvement was still poor, bone marrow transplantation needs to be devised for such patients.

Bone marrow transplantation (BMT) was done three times for a 6-year-old girl with myelodysplastic syndrome (MDS). She showed progressive bicytopenia and constitutional abnormalities including short stature and skin pigmentation. We initially diagnosed the patient as having Fanconi's anemia, although the chromosome fragility was not demonstrated by the mitomycin C stress test. The patient received conditioning regimens which consisted of 3 Gy of total body irradiation followed by decreased dose of cyclophosphamide (CY, 10 mg/kg for 4 days) and anti-lymphocyte globulin (ALG, 30 mg/kg for 5 days) and marrow cells from HLA-identical 8-year-old brother were given. However, the graft was rejected. Reviewing the previous bone marrow smears disclosed the abnormalities in the three major cell lines : erythroblasts, granulocytes, megakaryocytes. Therefore, we considered her to have MDS. The second BMT was done with busulfan (4 mg/kg for 4 days) followed by CY (60 mg/kg for 2 days); however, no evidence of engraftment occurred until day 25. Therefore, she received CY (50 mg/kg for 4 days), ALG (40 mg/kg for 4 days) and the third BMT with successful engraftment which was confirmed by the chromosomal karyotype on day 19. She showed remarkable hematological recovery and bone marrow examination on day 54 showed complete disappearance of morphological abnormalities of all cell lineages seen prior to BMT. She is well, with full performance state.

小児の治療指針の分担執筆

細胞株を用いたin vitroの実験結果．

【背景】思春期・若年成人 (Adolescents and Young Adults：AYA)世代のがんの診療には、小児科医が関わっていない場合が多く、その治療実態は明らかではない。また、この世代に特有の心理的および社会的な問題があり、治療成績に影響している可能性もある。【目的】当院で診療したAYA 世代のがん6症例の治療経験より、この世代の診療上の問題点について検討した。【対象】2008年1月から2013年6月までに当院で治療した、もしくは治療中の6例。初発時年齢は15～24歳で、ALL 1例、CML 1例、T-NHL 1例、骨肉腫2例、横紋筋肉腫1例。CML例はネフローゼ症候群にて幼少よりフォローされていたが、他の5例は内科、整形外科、口腔外科より紹介された。病名告知、治療内容、転帰とともに、就学および就業の問題、費用の問題、心理的な問題などを検討した。【結果】治療はそれぞれの疾患に対する小児プロトコールを用いたが、薬剤投与量の減量を必要とした症例もあった。告知は全例に施行した。2例は治

症例報告

【症例】20歳男性【現病歴】生後3カ月時にBruton型無γグロブリン血症と診断され、免疫グロブリン製剤の定期補充を行っている。2年ほど前より腎機能障害が認められ、その後BUN 30㎎/dl、Cr 1.5㎎/dlまで上昇し、尿中β2-MGが32550μg/lを示したため、精査加療目的にて入院となった。発熱や浮腫、高血圧、および多飲・多尿などの症状は認められなかった。尿蛋白(1+)、尿潜血(‐)、尿中decoy cellは陰性。IgG 685㎎/dl、IgG4 5.5㎎/dl、ACE 14.7U/l、ANA陰性、シスタチンｃ 1.96㎎/ｌ、電解質異常は認めていない。腹部超音波、ＣＴでは尿路奇形は認められず、両腎の腫大が認められた。Gaシンチでは両側の腎にのみ集積を認めた。腎生検では、糸球体数は11個認め、うち6個は線維性硬化、1個は半月体形成が認められた。2個の糸球体に代償性腫大を認めた。間質にはリンパ球を主体とした著明な細胞浸潤と尿細管萎縮が認められ、尿細管細胞内に封入体は認められなかった。蛍光染色ではIgG、IgG4は陰性

症例報告

AMLでUBMT後の移植関連合併症のTMAと腸管GVHDを合併した症例における治療経過の報告．

【緒言】小児における移植後晩期合併症（内分泌障害、不妊、二次がん等）は長期フォローをしていく上で重要な問題となっている。今回、当科でSCTを行った小児がん経験者の晩期障害について検討した。【対象】2004年4月から2011年12月までに当院で27例に対して30回のSCTを施行した。腫瘍死4例、治療関連死3例を除く20例が生存し、フォローが可能であった18例を対象とした。【結果】移植時年齢中央値は8歳(1-20歳)、性別は男９例、女9例。疾患内訳は、血液腫瘍9例、造血障害5例、固形腫瘍4例であった。1例が生着不全、1例が計画的に2回移植した。18例20回SCTの移植ソースは、骨髄10(血縁2、非血縁8)、末梢血8(血縁4、自家4)、臍帯血2で、全身放射線照射は8例に施行した。腫瘍性疾患に対して骨髄非破壊的前処置(RIST)を7例に施行した。全例無病生存中であるが、CMLの1例が移植後2年9か月後に細胞遺伝学的再発を認め、DLI+TKIにてCMRを得た。晩期合併症では低身長の傾向であったが、RIST症例では-2

【目的】小児造血器腫瘍に対する治療の向上により、小児造血器腫瘍経験者が増加し、長期生存に伴い晩期障害が問題となってきている。中でも肥満や脂質代謝異常は心血管系疾患のリスク因子であり、生活の質に関連する。今回、われわれは小児造血器腫瘍経験者を対象にBMIおよび脂質代謝について検討した。【対象・方法】2004年4月から2009年1月までに当科で治療した18歳以下の造血器腫瘍症例で、治療終了後2年以上経過し、現在も無治療にて経過観察している小児造血器腫瘍経験者25例を対象とした。維持療法を含む治療群(n=12)と維持療法を含まない治療群(n=13、HSCTを含む)の2群にわけ、治療期間、フォローアップ期間、初診時BMI、治療BMI、TC、Trigなどを後方視的に検討した。【結果】初診時年齢は1～14歳、最終確認年齢は4～21歳、性別は男16例、女9例。内訳は、ALL9例、NHL7例、AML6例、CML1例、JMML1例、MDS1例であった。性別、年齢、フォローアップ期間に有意差を認めなかったが、治療期

移植前処置にATGを用いた同種移植の合併症について検討し，ATGの種類や投与量について考察を行った発表．

【背景】悪性末梢神経鞘腫（MPNST）は従来の治療に抵抗性の難治腫瘍であり，PDGFRを発現していることからイマチニブ（STI）を用いた新規治療の可能性が示唆される．【目的】MPNST細胞株3種を用いてSTIのin vitroにおける作用について検討する．【方法】MPNST細胞株3種（YST-1, PSS, Sch-2）を用いた．STI処理後，cell viabilityをMTT法で検討した．Autophagyの検出は，電顕，ウェスタンブロット法による LC3B-Iから-IIへのシフトおよびacidic vesicular organelles (AVO)の発現により検討した．また，autophagy系路をsiRNAや薬剤により阻害し，その影響を検討した．【結果】細胞株3種はPDGFRを発現し，YST-1株はSTIへの感受性が高かったが，Sch-2株は耐性だった．YST-1株では，STI処理でapoptosisが誘導されたが，zVAD-fmkの存在下でその抑制効果は阻害されず，非apoptosis細胞障害機序の関与が示唆された．STI処理によりMPNST3株にautophagyが誘導された．Autophagy誘導の初期に影響する3-methyladenineやsiRNAによるbeclin-1発現抑制により，STIに

Idiopathic thrombocytopenic purpura (ITP) is thought to be caused by the destruction of platelets (plt) by anti-plt antibodies, but it remains unresolved whether megakaryocytopoiesis is impaired. Recently, we encountered a girl who appeared to have ITP, and presented with transient megakaryocytopenia and pancytopenia. In ITP, the number of megakaryocytes is believed to be normal or elevated, with increased plt production, but it is decreased in some severe cases, presenting a problem in the differential diagnosis from amegakaryocytic thrombocytopenia (AMT). Unlike in ITP, the PA-IgG level is not believed to be elevated in AMT. The mechanism of suppression of megakaryocytopoiesis by ITP antibody has been postulated, but not conclusively proven. This case suggests the pathogenesis of ITP.

慢性骨髄性白血病の治療としての骨髄移植により、完全寛解した頻回再発型ネフローゼ症候群の１例を経験した。特発性ネフローゼ症候群の病因として、造血幹細胞の異常による可能性が示唆されたことを報告した。

【はじめに】輸血の非溶血性副作用に、輸血関連急性肺障害(transfusion related acute lung injury：TRALI)があり、輸血後数時間以内に肺障害をきたす疾患である。今回我々は、臍帯血移植後に血小板輸血でTRALIと考える急性肺障害を呈した2例を経験したので報告する。【症例1】MLL陽性ALLの11か月の男児。JPLSG MLL03プロトコールにて治療を開始した。プロトコールに従い、Bu+VP-16+CYを前処置に臍帯血移植を施行した。Day32よりCMV肺炎で人工呼吸管理、ホスカビルとm-PSLパルス療法を必要としたが、Day39に抜管できた。しかし、Day51に血小板輸血3時間後に急激な低酸素血症と胸部Ｘ線上浸潤影が出現し、再度、人工呼吸管理を行ったが、呼吸症状が進行し、Day70に死亡した。輸血検体より抗好中球・抗単球抗体が検出され、TRALIと診断した。【症例2】AML(M2)の5歳の女児。JPLSG AML05プロトコールに従い寛解導入療法を開始したが不応であり、強化療法後にTBI+CA+CYを前処置に臍帯血移植を施行した。Day19に血小板輸

【緒言】Rosai-Dorfman 病 (RDD) は、発熱と無痛性のリンパ節腫大をきたし、病理学的にリンパ洞内に CD1a(-)、CD68(+)、S-100(+) の組織球浸潤を特徴的とする良性の疾患である。主病変はリンパ節であるが、約 40％ は皮膚、唾液腺、鼻腔、眼窩、骨、軟部組織、中枢神経、泌尿・生殖器などの節外病変を伴う。今回、我々は、頻回再発 RDD の治療経過中に蛋白尿と血尿を認め、腎生検にて MPGN と診断した 1 男児例を経験したので報告する。【症例】7 歳、男児。9 か月時 発熱と左頸部リンパ節腫脹が出現し、生検にてリンパ洞内に著明な CD1a(-)、CD68(+)、S-100(+) の組織球浸潤と貪食像を認め、RDD と診断した。プレドニゾロン (PSL) を開始し、症状の改善を認め、以後、漸減中止した。4 歳 3 か月時に再発を認め、PSL を開始したが、減量に伴い尿蛋白と血尿が出現した。6 歳 0 か月時に耳下腺内のリンパ節腫脹を認め、再発と判断し、PSL を開始したところ、症状の改善とともに尿蛋白と尿潜血も消失した。

ナットクラッカー症候群（LRVES）の新たな症状としての、種々な程度の起立性調節障害（OD）症状が存在することを明らかにした。原因不明の全身倦怠感、不登校に至る高度なOD症状を訴える場合には、LRVESを念頭に置くことが大切である。

【緒言】AYA 世代のがんは、内科で診療される場合が多いが、標準治療や治療成績は明らかにされておらず、問題点も多い。今回我々は、早期再発した T-LBL の治療を通して様々な問題点に遭遇した症例を経験した。【症例】18歳、女性(初発時16歳)。2008.7 前院で胸腺腫の疑いで全摘出されたが、その後の病理診断に難渋し、T-LBLと診断に至った。当科紹介時、すでに 2 か月以上経過し、全身（骨髄･腎臓･脾臓）に浸潤を認めたが、JPLSG ALB-NHL03 プロトコールを開始し寛解を得た。小児病棟のため面会者(友人)が制限され、加えて、高校を 1 年留年したが、翌年 2 学期より復学し、無事進級することができた。2010.10.28 にプロトコールを完遂したが、2 週間後、腹部腫瘤に気付き、造影 CT で卵巣腫瘍(浸潤)と骨髄検査で初診時と同様の芽球を認め、再発と判断した。早期再発は予後不良であることを家族に説明したところ、患者に予後の説明をしないでほしいと希望された。ネララビンを含むサル

【緒言】小児のAML-M6は稀な疾患であり、HSCTにて長期寛解を維持している症例が報告されている。今回、我々はreduced-intensity stem cell transplantation(RIST)で寛解を維持しているAML-M6の女児例を経験したので報告する。【症例】1歳の女児。顔色不良で紹介された。WBC 6300 /μl（Blast 3.0%）、Hb 4.6 g/dl、Plt 1.4 万/μl。骨髄所見は赤芽球59.1%、赤芽球を除いた芽球は47.7%で、3血球系統すべてに異型性を認めた。AML-M6と考え、JPLSG AML05プロトコールの寛解導入療法1を施行した。Day56で好中球数500/μlに到達しなかったが、BMA-2はCRであった．しかし，異型性を伴う血球が残存したため，寛解導入療法2を施行した。BMA-3の中央診断は，芽球6.5%を認め寛解導入不良と判断した。強化療法2コース追加後にFlu+L-PAM+VP-16による前処置で、UCBSCTを行ったが、Day28のVNTRでホストタイプを確認し生着不全と診断した。自己造血が回復し骨髄検査で寛解を維持するも、基礎疾患は造血幹細胞レベルに近い異常が示唆されるので、骨髄

初診時に縦隔腫瘤合併した急性骨髄性白血病例は頻度が少なく，予後不良と言われている．また，5番長腕欠失を含む複雑型染色体異常を伴い，寛解導入療法後に寛解に達したにもかかわらず，強化療法中にその異常染色体をもつクローンから再発した症例の治療経過の報告．

2005年から2010年までに経験した小児骨髄系造血器腫瘍15例の治療経過のまとめ

特発性血小板減少性紫斑病 (ITP)では、抗血小板抗体による血小板の流血中での破壊、あるいは細網内皮系での捕捉が血小板減少の原因とされるが、巨核球造血が障害されているか否かは未解決とされる。 今回我々は、一過性の巨核球、および汎血球減少を呈した血小板減少症があり、無巨核球性血小板減少症 (amegakaryocytic thrombocytopenia: AMT)との鑑別や治療方針に苦慮したITPと思われる1例を経験した。 ITPでは骨髄巨核球数は増加あるいは正常とされ、巨核球での血小板産生は亢進しているとされるが、極期では減少する例も指摘されており、減少するAMTとの異同が問題となりうる。また、ITPと異なり、AMTではPAIgGは増加しないとされる。 ITPでの、巨核球への抗体による抑制メカニズムは想定されてはいるものの未確定であり、その病態を示唆するものであるとも考えられた。

2004年4月から2010年7月までに当科で加療した7例の造血障害に対する治療成績について検討した。当科における造血障害の治療成績ではISTの奏効率は低かったが、全例BMTにて生存している。

ALL（14歳女子）の治療経過でPRESによる神経症状とHD-MTX後の薬剤排泄遅延と腎障害を認め，透析と血漿交換を必要とした症例の報告．

今回、我々は、当初化膿性リンパ節炎として治療経過中に悪性リンパ腫と診断に至った 1 男児例を経験したので報告した。頸部腫瘤で化膿性リンパ節炎を併発した場合、生検で頸部腫瘤を適切に採取できなかった場合、炎症所見のみをとらえて、診断を誤る可能性があるため、注意を要する。

症例は、14歳の男児。AMLと診断後、初期治療に不応のため、非寛解のままHLA 完全一致血液型不一致の兄 (ドナー:A 型、レシピエント:O型) よりPBSCTを施行した。赤血球系のみ生着が得られず、抗A血球凝集素価は1024倍と高値であり、血液不一致に伴うPRCAと考えられた。Day 530よりCsAを再投与したところ、赤血球数の増加を認め、抗A血球凝集素価も4倍まで低下した。しかし、Day 595の骨髄検査で再発を確認した。非寛解でHLA ハプロ一致血液型不一致の父 (A型) よりBMTを施行した。移植後PRCAは、レシピエント由来の残存形質細胞が原因と考えられているが、本例ではDLI、PBSC再輸注やrituximabに不応で、CsAの再投与で軽快したことから異なる機序の可能性も考えられた。また、PRCA軽快後に再発したことから、その機序とGVL効果の関連も示唆された。

イマチニブによる処理で悪性末梢神経鞘腫細胞株3種にオートファジーが誘導されることを示した．そのオートファジーをバフィロマイシンA1によりブロックすると，イマチニブによる増殖抑制効果が単独の場合と比較して有意に増強させた．以上よりイマチニブにより誘導されるオートファジーは傍行反応であることが示唆された．

今回、我々は眼球突出を契機に診断された 2 例を経験したので、臨床経過を報告した。 2 例の視機能は正常であるが、眼窩腫瘍では、眼球偏位や視神経浸潤に伴う視力障害を引き起こすこともあり、可及的速やかに診断し治療を開始する必要があると考える。

2例の再発B細胞性造血器腫瘍に対するサルベージ療法でリツキシマブを併用した治療経過を報告．

神経芽腫への同種造血幹細胞移植の有効性とその症例報告

造血幹細胞移植後にABO血液型ミスマッチに起因する赤芽球癆が持続し，ドナーリンパ球輸注やリツキサン等の治療に対して反応せずに長期にわたり輸血依存となった．移植後530日目にシクロスポリンを再投与したところ赤芽球癆が軽快した症例の臨床経過報告．

今回、我々はうっ血乳頭で発見された慢性骨髄性白血病 (CML) の1女児に対して、イマチニブにより細胞遺伝学的寛解を得た後に同種末梢血幹細胞移植を施行した。経過を報告し、現時点での小児 CML の治療について考察した。小児 CML においても、イマチニブが第一選択と考えられる。しかし、イマチニブの長期投与で骨代謝への影響が報告され、発育途上の小児例においてもその影響が危惧される。イマチニブ反応良好群であれば、診断後1年程度の細胞遺伝学的寛解の時点で骨髄非破壊的前処置法にて同種移植を施行するのが、現時点での最適な根治療法ではないかと考えられる。

今回、我々は小児では稀なろ胞性リンパ腫の再発例に対して、リツキサン併用化学療法後の第 2 寛解期に、臍帯血による骨髄非破壊的前処置法を施行したのでその経過を報告した。小児 NHL の再発後の標準治療は確立していないが，リツキサンを併用したR-ICE 療法は安全で有効な治療であると考えられた。本例では、bcl-2 を発現しており、Lorsbach らの予後不良例に相当するため、GVL 効果が期待できる同種移植を選択した。

今回、我々は小児では稀なろ胞性リンパ腫の再発例に対して、リツキサン併用化学療法後の第 2 寛解期に、臍帯血による骨髄非破壊的前処置法を施行しましたのでその経過を報告させていただきます。小児 FL の病理組織像ではろ胞性とび慢性の双方の増殖様式を示すものが多く、鑑別に苦慮する例が多く、本例も初発時は DLBCL と診断されましたが，再発時の病理組織像を含めた再検討で、初発からも FL であったと診断されました。現在，移植後12か月を経過し，軽い限局型慢性 GVHD （皮膚）を認めますが，寛解を維持しています。

Major ABO 不適合同種移植後の pure red cell aplasia (PRCA) は、移植後 60 日目を経過して網赤血球低値 (RET 10 ‰ 未満) で赤血球輸血依存の状態と定義されている。頻度は約 20% 程度であり、移植後の合併症として注意が必要な疾患である。今回、われわれは、非寛解時期に兄をドナーに ABO 不適合同種移植を施行し、DLI、エリスロポエチン、リツキサン等の治療を行なったにもかかわらず、1年以上 PRCA が持続し、治療に難渋している症例を経験しているので報告する

小児の慢性骨髄性白血病（CML）の治療方針は、成人と同様にイマチニブが第一選択と考えられる。しかし、その長期投与による安全性は不明である。今回、我々はイマチニブにより細胞遺伝学的寛解を得た後に reduced-intensity stem cell transplantation (RIST) を施行したので報告する。イマチニブの長期投与で骨代謝への影響が報告され、発達途上の小児例においてもその影響が危惧される。イマチニブ反応良好群であれば、診断後1年程度の臨床経過でRIST で同種移植するのが、小児 CML の現在におけるベストの治療法ではないかと考えられる。

悪性末梢神経鞘腫におけるPDGFRの発現とそのシグナル伝達系路を阻害するイマチニブの臨床効果，および細胞株を用いた今後の新規治療に関する検討したもの．イマチニブにJNK阻害剤（SP600125)の細胞株増殖抑制の増強を報告．

小児科クリニカル・クラークシップにポートフォリオを取り入れた内容について報告した。また、アンケート調査をもとに、ポートフォリオの良かった点および問題点について述べた。

眼球突出を主訴とした進行性神経芽腫の一例を経験し、治療法として手術、化学療法の後に2回移植法を施行した。それについての症例報告を行った。

表題について発表した。

眼症状を契機に発見された福山型筋ジストロフィーの1女児例についての症例報告

症例報告

白血球抗体を検出する方法として, フローサイトメトリー (FCM) 法が一般的に用いられているが, 同方法にはいくつかの欠点がある. その一つは, 好中球や単球抗のバックグラウンド蛍光が高い事, また, 抗体の特異性の同定には好中球, 単球のみならずT-リンパ球, B-リンパ球, 血小板といった他の血液細胞との反応性も同時に検討する必要がある事である. その為, 我々は低バックグラウンドで, かつ, 4系統の白血球と血小板を同時に測定する方法の樹立を試みたので報告する. FCM解析にはエチレンジアミン4酢酸 (EDTA) 採血した全血を試料として用い, 5系統細胞の識別はFSC/SSC分布とCD4, CD20, CD14の発現の有無を基に行なった. その結果, 抗HNA (human neutrophil antigen) 1b血清をHNA 1b陽性細胞と反応させた場合には, 好中球のみが陽性となり, 抗Nak^a (抗CD36) 血清と反応させた場合には, 血小板と単球が陽性となった. 好中球と単球のバックグラウンドは十分に低くなった. また, HLA Class IIの抗血清を用いたところ, Bリンパ球と単球が陽性となり, HLA Class Iの抗血清では5系統の細胞が陽性であった.

今回我々は、骨髄所見でM6と類似したJMML症例を経験したので報告する。症例は、2歳、男児。主訴は、白血球増多、発熱と肝脾腫。平成17年12月より、下腹部に広範囲の皮疹を認めた。入院時、肝脾腫、発熱、リンパ節腫脹、貧血と皮疹（色素沈着）を認めた。血液検査にて、WBC 53200 /μl、Hb 8.5 g/dl (HbF 63.3 %)、Plt 4.3万 /μl、Ret 70 ‰、LDH 2578 IU/l、赤血球と白血球に著しい形態異常を認めた。骨髄検査では、有核細胞数 80.3×104 /μl、巨核球数 0 /μl、芽球 29 %で単球系（75 %）と骨髄球系（25 %）の形質を示した。赤芽球系は、有核細胞数の64.2 %を占めており、異形成を認めた。染色体検査では、20細胞すべてにmonosomy 7を認めたが、遺伝子検査（マルチプレックス）では、bcr-abl遺伝子を含めて異常はなかった。また、in vitroでのspontaneous colony formationとhypersensitibity to GM-CSFは陽性であった。臨床症状とコロニー検査所見よりJMMLと診断し、芽球の増多を認めていたため、AML99プロトコールの寛解導入療法を

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症例報告

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