Eur J Pediatr (1999) 158 [Suppl 3]: S211 ± S220 Ó Springer-Verlag 1999

Long term prophylaxis in patients with haemophilia A and B C. Escuriola Ettingshausen á H. Schmidt á C. Weimer á M. Funk I. Martinez Saguer á W. Kreuz C. Escuriola Ettingshausen á C. Weimer á M. Funk I. Martinez Saguer á W. Kreuz Johann Wolfgang Goethe University Hospital, Department of Paediatrics, Frankfurt/Main, Germany H. Schmidt Johann Wolfgang Goethe University Hospital, Department of Radiology, Frankfurt/Main, Germany Objective: Evaluation of optimal onset of prophylactic treatment in order to prevent haemophilic arthropathy in severe and moderate haemophilia A and B patients. Therefore 51 out of 61 recruited severe and moderate haemophiliacs were prospectively followed up by investigating their ellbow, knee and ankle joints using standardized radiological and orthopaedic scores at 3±4 yearly intervals. In addition age at onset of prophylaxis, the total number of joint bleedings before and after start of prophylaxis as well as F VIII and IX exposures were recorded. All patients received virusinactivated F VIII or F IX concentrates at dosages of 30±40 IU/kg body weight i.v. three times per week (haemophilia A) and twice weekly (haemophilia B). Three patient groups were evaluated according to the age at onset of prophylaxis. In group I (n = 25, start of prophylaxis <2 years of life after the ®rst joint bleed at the latest) 23 out of 25 patients had una€ected joints with constant radiological and orthopaedic scores of zero or 1 after a median of 7.7 years of prophylactic treatment. Patients of group II (n = 11, onset of prophylaxis 2nd-5th year of life after 6 joint bleeds in median) showed neither radiological nor orthopaedic alterations at study entry. Worsening joint scores were detected despite ongoing prophylaxis after the 3-yearly interval (median orthopaedic score 2, median radiological score 5). Late-onset or secondary prophylactic treatment was started at the age of 5 years and above in group III (n = 19) after more than 10 joint bleeds (median). They already showed considerable joint damage at study entry with a median radiological score of 11 and a median orthopaedic score of 4. Despite prophylactic treatment, both, orthopaedic (median 9) and radiological scores (median 17) deteriorated after 3 years. Comparing the radiological outcome, a signi®cant di€erence was evaluated between the three groups (P < 0.01; Wilcoxon rank sum test) revealing patient group I to have the best and patient group III the worst outcome. As one of the most critical predictors for development of haemophilic arthropathy, the absolute number of joint bleeds was correlated with the recent radiological scores which proved to be signi®cant (r = 0.921; P < 0.01). According to our experience even a small number of joint bleedings (>6) cause irreversible osteoarthropathic alterations leading to haemophilic arthropathy. Once apparent, further progression of joint damage could not be arrested despite of prophylactic treatment. Therefore e€ective prophylaxis should be started before or at latest after the ®rst joint bleed in severe haemophilia A and B.

Gene therapy for haemophilia: current status C. Schmitt C. Schmitt Institute for Exp. Haematology and Transfusion Medicine, University of Bonn, Germany Therapy of haemophilia today is based on the i.v. injection of factor VIII (FVIII)- and factor IX (FIX)-concentrates. This

ABSTRACTS

substitution therapy allows the patients to lead a life with almost normal quality and life-expectancy. But due to the physiological and psychological stress on the patients and the high costs of F VIII concentrates, there is demand for alternative therapeutic strategies. For this, gene therapy-approaches for haemophilia are under strong investigation. Many e€orts on gene transfer and protein expression of F VIII and F IX in animals have been made during the last years. There, mainly viral systems have been used successfully as well in ex vivo as in in vivo attempts. For F IX, high level and long term expression of the protein in mice has been reached using retroviral, adenoviral and adeno-associated viral vectors. F VIII transfer raises more problems, mainly because of the big size of the F VIII coding sequence (cDNA). In this ®eld, most successes have been made using adenoviral vectors and Bdomain-deleted F VIII cDNAs. These vectors were able to produce therapeutical levels of F VIII in mice for several months. For both, F VIII and F IX, expression of therapeutic levels of the respective protein in haemophilia A or B dogs and correction of the phenotype was achieved by using adenoviral vectors for the transfer of the F VIII or F IX cDNA. Problems concerning the immune response against the viral capsid and viral proteins, cytotoxic e€ects and the e€ectivity of infection and expression have to be solved in further investigations. Although there is a continuously progress in this ®eld, the application of hemophilia gene therapy to humans will need some time. In conclusion gene therapy for haemophilia will only be acceptable, when it is safe and e€ective enough to facilitate patients life in comparision to the existing substitution therapy.

Additional evaluation of von Willebrand factor multimers by densitometry faciliates diagnosis of von Willebrand disease variants J.-D. Studt á U. Budde á R. Schneppenheim M. v. Depka Prondzinski á A. Ganser á M. Barthels J.-D. Studt á M. v. Depka Prondzinski A. Ganser á M. Barthels Medical School Hannover, Div. of Haematology and Oncology, Germany U. Budde Laboratory Association Keeser, Arndt and Partner, Hamburg, Germany R. Schneppenheim University of Hamburg, Children's Hospital, Div. of Paediatric Haematology, Germany Von Willebrand disease (VWD) is diagnosed by clinical ®ndings and laboratory evaluation of parameters as von Willebrand factor antigen (VWF:Ag) concentration, ristocetin cofactor activity, collagen binding activity and FVIII coagulant activity. For the essential subclassi®cation, analysis of the von Willebrand factor (VWF) multimer patterns is the present standard. Qualitative interpretation of VWF multimers visualized is mainly limited to experts. We applied densitometry for evaluation of VWF multimer patterns. The aim was to obtain additional qualitative and quantitative information to make results of VWF multimer analysis better comparable and more transparent for physicians not specialized in subtyping of VWD. A normal control group and patients with VWD type 1, with VWD type 2A, and with VWD type 2M were investigated. VWF multimers were separated by discontinuous SDS-gel-electrophoresis (intermediate resolution system) and detected by luminography. Films then were exposed to the luminescence and were scanned with a Sharp JX330 transmission scanner with ®lm scanning unit JX3F6. Densitometric

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calculation was made with the 1-D Advanced program (AAB, Fullerton, CA).VWF multimer bands were represented as peaks of characteristic areas, form and distribution. Evaluation of the same reference pool on 60 ®lms as well as of the normal group showed reproducible and characteristic patterns with only slight variation. VWD type 1 displays a picture similar to the normal group but diminished in absolute peak areas according to the lower VWF:Ag concentration. No qualitative alterations were observed. In type 2A VWD, characteristic patterns of several subtypes could be identi®ed. In type 2M (type I Vicenza), supranormal multimers can be made visible more easy than by inspection. The point of applying densitometry is that abnormal multimeric patterns are better visible and comparable for the physician outside the laboratory who is ®nally responsible for making the diagnosis of VWD.

Evaluation of standardized bleeding history in preoperative screening C. Wendt á W. Eberl C. Wendt á W. Eberl Department Pediatrics, Klinikum Braunschweig Objective: To determine predictive value of di€erent preoperative investigations compared with standardized bleeding history. Methods: Preoperative screening tests (PTZ, APTT and thrombocyte count) were done in 475 children undergoing routine operative interventions (tonsillectomy, adenectomy, tympanoplasty etc.). Determination of bleeding time was added, if the history of the patient and/or the parents ruled out positive answers in a standardized questionnaire. Further diagnostic evaluation resulted from positive bleeding time or postoperative complications. Results: Bleeding complications were observed in 21 children (28% major, 72% minor bleedings), no life threatening complication occurred. Preoperative laboratory investigations predicted one of these bleedings, APTT was prolonged with normal factor analyses and normal bleeding time. Bleeding history was positive in four other cases, extended diagnostic evaluation revealed no factor de®ciency, abnormal bleeding time or positive willebrand tests. Preoperative diagnostic evaluation identi®ed 7 children with bleeding disorders (willebrand disease 4, F XII de®ciency 2, F V de®ciency 1). False positive results for APTT were obtained in 23 children, including 6 patients with presumed antiphospholipid inhibitor and 17 preanalytical problems. 1 child with willebrand disease was treated with anti®brinolytic agents and DDAVP, no bleeding complication occurred. 3 other patients were removed and therapied conservative. 3/4 patients with willebrand disease were identi®ed by history and consecutive bleeding time, 1/4 by prolonged APTT. Positive predictive value of PTZ/APTT recognizing willebrand disease was lower than standardized history. Conclusion: Routine laboratory tests are not very sensitive tools to predict postoperative bleeding complications. Patients with elevated risk, e.g. with Willebrand disease may be better identi®ed by means of standardized bleeding history and limited, but directed bleeding time investigation.

Heparin-induced thrombocytopenia type II (HIT type II) in three children with deep vein thrombosis (DVT) B. ZoÈhrer á W. Zenz á H. M. Grubbauer á H. Kroll á S. Gallistl W. Muntean B. ZoÈhrer á W. Zenz á H. M. Grubbauer S. Gallistl á W. Muntean Department of Pediatrics, University of Graz, Austria W. Zenz á S. Gallistl á W. Muntean Ludwig Boltzmann Res. Inst. for Pediatric Hemostasis and Thrombosis, University of Graz, Austria

H. Kroll Institute for Clinical Immunology and Transfusion Medicine, University of Giessen, Germany We report three children with DVT of the lower extremities who developed HIT type II eight to 14 days after starting intravenous heparin therapy. The ®rst patient was a 4-year-old girl with antiphospholipid antibodies (APA) and thrombosis of the left femoral vein. Eight days after starting i.v. heparin therapy progression of DVT to the right femoral and iliac vein and development of thrombosis of the right axillary vein were observed. Oral anticoagulation was complicated by coumarin-induced skin necroses three days after starting acenocoumarol. The second patient, a 12-year-old boy with hereditary protein S de®ciency, developed DVT. Despite thrombolytic therapy and systemic heparin administration, the thrombosis showed progression up to a temporary inserted caval vein ®lter 14 days after starting heparin. Anticoagulation therapy was changed from heparin to danaparoidsodium (Orgaran) and no further disease progression was observed. The third patient, a 9-year-old girl showed DVT of the left femoral vein and APA. After detection of HIT type II Orgaran was started and no further disease progression was noticed as well. Our observations suggest that HIT type II is a life-threatening complication of heparin treatment in children and that the use of Orgaran might be bene®cial in this age group.

Antiphospholipid antibodies (APA) in childhood ± diagnostic approach to a dilemma F. Bergmann á U. Budde F. Bergmann á U. Budde Labassociation Keeser & Arndt, Coagulation Laboratory, Hamburg Preoperative determination of PT and aPTT is still requested ± especially in children before any ENT-surgery and in many cases the coagulation pro®le is abnormal, mostly the aPTT is prolonged. The prolongation is mainly due to APA, which interfere with phospholipids used in the test system for determination of aPTT and intrinsic factors. This phenomenon is transient and in asymptomatic children clinically irrelevant. However, in children with thromboembolic complication the presence of APA has major impact on diagnosis, prognosis and therapy. Our test panel, depending on the available amount of plasma, consists of PT, aPTT (medium sensitive to APA) and mixing studies with normal plasma. If this test is negative, determination of intrinsic factors follows. If the test is positive, inhibitors against speci®c coagulation factors have to be excluded. The test panel for lupus anticoagulants consists of one prothrombin time based assay (TIT), one aPTTbased test (StaclotÒ LA-testsystem) and one diluted test of Factor Xa-activation (dRVV-testsystem). In asymptomatic patients the work up may be terminated after exclusion of a factor de®ciency and exclusion of inhibitors to coagulation factors. However, in children with thromboembolic disease all tests previously described, together with testing for cardiolipin antibodies, should be applied to detect APA and diagnose the antiphospholipid antibody syndrome with all its consequences.

Primary and secondary antiphospholipid syndrome G. Horne€ G. Horne€ Klinik und Poliklinik fuÈr Kinder- und Jugendmedizin, Martin-Luther-UniversitaÈt Halle-Wittenberg, e-mail: gerd.horne€@medizin.uni-halle.de Antiphospholipid antibodies (APA) are a heterogeneous group of autoantibodies directed to phospholipid-bound plasma proteins

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including prothrombin and b2-glycoprotein (apolipoprotein H). In children, APA can frequently be detected in response to infections, are transient and did not lead to complications. Clinical manifestations including arterial and venous thrombosis, thrombocytopenia, hemolytic anemia, frequent fetal loss, neuropsychatric and skin disorders in association with APA will de®ne the antiphospholipid syndrome (APS, Hughes-syndrome). Secondary APS will be diagnosed in the presence of autoimmune diseases (SLE, MCTD, scleroderma, dermatomyositis, rheumatoid arthritis, juvenile rheumatoid arthritis, primary Raynaud syndrome), hematologic diseases, malignancies or chronic infections. Primary APS will describe patients who do not have sign of either SLE or other associated disorders. To make this di€erence will be of prognostic and therapeutic relevance, but is not always easy. Management of APS will be quite di€erent between the two types. In secondary APS, treatment of the underlying disorder may be of importance. Recurrent thrombosis will indicate life long oral anticoagulation which has to be weighed against the risks, especially in childhood. The presence of APA only will not indicate any medical therapy.

Antithrombin III substitution in the neonate Alex Veldman á JoÈrg Brand á Doris Fischer á Gudrun JaÈger Antje Allendorf á Rolf SchloÈsser á Wolfhart Kreuz A. Veldman á J. Brand á D. Fischer á G. JaÈger á A. Allendorf R. SchloÈsser á W. Kreuz Johann Wolfgang Goethe University Hospital, Department of Paediatrics, Theodor Stern Kai 7, 60596 Frankfurt/Main, Germany During the neonatal period the coagulation system of both, term and preterm infants is in a process of maturation. Apart from iatrogenic manipulations such as vascular catheters, the neonate runs grave risk to develop spontaneous thrombotic complications. Many investigations have shown a physiologic low level of inhibitors of the coagulation system as antithrombin III (AT III), Protein C and Protein S in the well neonate. When the coagulation cascade is activated by additional risk factors like infection, severe RDS, necrotizing enterocolitis or asphyxia, a substitution of AT III is thought to have the potential to prevent the neonate from hypercoagulability. To determine whether a rationale for AT III substitution can be based on low AT III levels in speci®c diseases of the neonate, AT III plasma activity of 86 consecutive admitted neonates with a gestation age between 24 and 33 weeks on the NICU in the Frankfurt University Children's Hospital have been analysed. Within the ®rst 24 h and again between day 4 and seven of life, routine coagulation tests including TPZ, PTT, Fibrinogen and AT III were performed. Clinical data, especially adverse events as intracerebral bleedings, RDS, thrombotic events or haemorrhages were documented. In the initial testing (within the ®rst 24 h of life), no signi®cant decrease in plasma AT III activity was found in the following subgroups, compared with the overall (n = 86) median plasma AT III activity of 36% (range 9±97%): RDS (III° + IV°), IVH (III° + IV°), infection, asphyxia (umbilical artery ph < 7.10), and very low birth weight (BW <1000 g). In those 22 children who have been substituted with AT III concentrate afterwards, no unfavourable outcome or side e€ects were observed. We therefore feel that AT III replacement therapy in the neonate can be recommended if the child is presenting clinical and laboratory signs of hypercoagulability. A rationale for standard substitution in speci®c diseases can not be derived form our data.

Growth factors and hemostasis: Differential effects of GM-CSF and G-CSF on coagulation activation ± laboratory and clinical evidence H. BoÈnig á S. Burdach á U. GoÈbel á W. NuÈrnberger

H. BoÈnig á U. GoÈbel á W. NuÈrnberger Department of Pediatric Hematology and Oncology, Center of Child Health, Heinrich-Heine-University Medical Center, DuÈsseldorf, Germany S. Burdach Department of Pediatrics and BioCenter, Martin-Luther University Medical Center, Halle, Germany Granulocyte-macrophage (GM-CSF) and Granulocyte colonystimulating factors (G-CSF) are two equally e€ective hematopoietic growth factors in terms of their potential to shorten the period of neutropenia following high-dose chemotherapy or to mobilize hematopoietic stem cells for transplantation. Thus the choice between the two preparations must be based on a careful comparison of adverse e€ects. Both GM-CSF and G-CSF have been implicated in disturbances of the hemostatic system, resulting in hemorrhagic as well as thrombotic complications. We therefore compared the e€ects of GM-CSF therapy on hemostasis both exvivo and clinically. In this study, 36 patients who were treated with myeloablative regimen according to the Hyper-ME ‹ C protocal received post-transplant hematopoietic support with GM-CSF (n = 17) or G-CSF (n = 19). These patients were closely monitored for alterations of humoral coagulation parameters and clinical evidence of hemorrhagic or thrombotic events. GM-CSF, but not G-CSF, induced a signi®cant, albeit usually mild activation of the coagulation cascade. Clinically, we observed an increased frequency of veno-occlusive disease in the GM-CSF group, while other thrombotic events were rare. At the same time, Hemorrhage was both more common and more severe in GM-CSF treated patients compared with those on G-CSF. We conclude that, in comparison to G-CSF, GM-CSF induces an activation of the coagulation system and is associated with an increased risk of hemostasis associated treatment complications.

Continuous infusion of a pasteurized C1-Inhibitor concentrate in patients with severe Hereditary Angioedema (HAE) I. Martinez-Saguer á C. Heller á W. Kreuz I. Martinez-Saguer á C. Heller á W. Kreuz Center of Paediatric Haematology/Oncology, University Clinics, Frankfurt/Main, Germany Hereditary Angioedema (HAE) is an autosomal-dominant disorder caused by a de®ciency of functional C1-Esterase Inhibitor (C1INH, type I) or reduction in C1-INH functional activity and normal C1 inhibitor antigen (type II). C1-INH is an important regulator of the complement, kinin and ®brinolysis system. The clinical symptoms are characterized by recurrent episodic swelling of subcutaneous and submucosal tissues mainly of the extremities, face, pharynx, larynx, and gastrointestinal tract. These attacks generally last between 12 and 72 h. Laryngeal edema may cause asphyxia with a high risk of mortality, up to 30%. However, according to our clinical experience, a strong association between the occurence of attacks and the psychological instability is likely. 30±40% of HAE attacks are precipitated by psychological stress. Presently, many patients receive attenuated androgens or antifribrinolytics as prophylactic treatment. But this therapy shows many disadvantages, like severe drug-related side e€ects (mental illness, anenorrhoea, hirsutism, clitorism and/or hepatocellular adenoma), non-e€ectiveness during acute attacks and it is not recommended in childhood and reproductive women. Because of severe and life-threatening manifestations, severe side e€ects of attenuated androgens, and high frequency of clinical symptoms, some of our patients receive prophylactic C1-inhibitor concentrate (Berinertä) twice or three times weekly. We report on the use of continuous infusion (CI) of Berinert HS in three women aged 22±47 years with severe HAE during three surgical procedures. Initially,

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all patients received 1000 IU Berinert as an intravenous bolus injection followed by 0.5±1 IU Berinert/kg bw/h. C1-IHN activity levels were assessed before and after bolus injection as well as during CI. Levels were maintained within normal ranges. Neither attacks of HAE nor side e€ects of Berinertä occurred during surgery and/or postoperatively. Clinical ecacy, constant maintenance levels, and a reduced requirement of concentrate in comparison to pulsatile administration modus was shown in all patients. In regard to virus safety, neither seroconversion of hepatitis A-, B-, C-, G- nor HI viruses was observed.

Ef®cacy and safety of substitution therapy with C1-Esterase Inhibitor (C1-INH) in VLBW infants A. Sandvoss á W. Eberl A. Sandvoss á W. Eberl Children's Hospital, Braunschweig Introduction: In VLBW infants with severe IRDS or sepsis a relative C1-INH de®ciency with subsequent anaphylatoxin C5a formation occurs during the ®rst 24 h of life leading to a capillary leak syndrome (CLS) with volume refractory hypotension. Aim of the study: In order to evaluate possible bene®cial e€ects of C1-INH substitution therapy we treated critical ill VLBW at high risk of a CLS in an uncontrolled trial with commercial C1-INH (BerinertR) preparation. The aim of this study was to particularly address questions concerning dose, timing and duration of this intervention. Patients: 36 VLBW infants divided into three groups of patients were treated with C1-INH at a dose of 150±200 IE/kg every 8 h: 1) 15 infants with severe IRDS/sepsis, treatment within the ®rst 6 hours of life (early treatment group); 2) 11 infants with severe IRDS/sepsis, treatment at the end of the ®rst 24 h (late treatment group); 3) 10 preterm infants with a median age of 4 weeks with severe sepsis or necrotising enterokolitis (NEC), treatment when capillary leakage was evident (sepsis group). Results: Almost all patients responded to C1-INH substitution therapy with improved diuresis, less positive ¯uid balance and increased cardiovascular stability with less volume or vasopressor support. This response was more pronounced in those infants treated early during the course of the disease with a more rapid weight loss, less catecholamine need during the ®rst 72 h and a slightly better surfactant response. Despite a more immature population with higher CRIB scores in the early treatment group there was a better outcome with respect to severe IVH/PVL. We did not observe any thrombotic event despite the use of central venous or arterial lines for better hemodynamic monitoring. In addition treatment was safe in sepsis/NEC patients with coagulation activation and DIC. Nevertheless some infants died as a consequence of severe CLS with multi system organ failure (MSOF). Depending on clinical criteria there were some treatment failures particularly in those infants with C1-INH activity being lower than 150% after substitution. Antigen concentration was signi®cantly higher than activity supporting functional inactivation of C1-INH. Conclusion: Treatment with C1-INH was safe, concerns about inhibition of ®brinolysis with subsequent enhanced risk of thrombosis did not seem to be justi®ed. In order to avoid substitution failure a value above 150% activity should be achieved using an initial bolus of 200±300 IE/kg. An early treatment at the onset of capillary leakage or even a prophylactic approach in high risk situations should be considered. Based on the current knowledge controlled randomized trials with C1-INH as an antiin¯ammatory approach are warranted.

Is the application of C1-INH in CLS associated with thrombosis? S. Lyding á W. NuÈrnberger á U. GoÈbel

S. Lyding á W. NuÈrnberger á U. GoÈbel Department of Pediatric Hematology and Oncology, HHU Medical Center, Duesseldorf, Germany Introduction: Although no prospective study for dose ranges and indications has been published so far, C1-INH is an increasingly administered drug in intensive care medicine. C1-INH prevents uncontrolled and ongoing activation of complement and contact system, which, as in capillary leak syndrome (CLS), contributes to an in¯ammatory response with edema, oliguria and catecholamine refractory hypotension. Whereas in solid organ transplantation, edema and hypotension may be localized (e.g. lung transplantation), generalized CLS represents a shock like condition with poor prognosis if uncontrolled. In contrast to hereditary angioedema (HAE), where the application of C1-INH has been validated, serum levels of C1-INH are not decreased in patients with CLS. High doses of C1-INH have been reported to contribute e€ectively to resolution of CLS, but case reports of thrombosis as potential side e€ect of therapy also emerged [1]. Study: In preparation of a prospective study, medical centers using C1-INH in therapy other than for HAE, in Germany, Austria and the Netherlands were asked for number of treated patients, with short enumeration of indications, doses, and potentially therapy induced side e€ects. 24 centers (Germany: 22, Netherlands: 1, Austria: 1) took part in this survey. Results: We received data of a total of 302 patients. In analysis of the administered doses, there seemed to be a clear cut between two groups of regimens: either clearly under 800 IE/kg cumulative dose (lower dose range, median dose 171 IE/kg) or clearly above 800 IE/kg (higher dose range, median dose 1300 IE/ kg). In the lower range of doses, 205 patients had been administered C1-INH for generalized CLS (patients after BMT, after severe thermal injury, in multiorgan failure or sepsis), or organ reperfusion after solid organ transplantation. In seven patients, transiently augmented ¯uid resorption and left heart stress during therapy were reported. A total of 97 patients had been treated with higher doses of C1-INH, the majority of them after cardiac surgery with aorto-pulmonary bypass (n = 69). In this group, six cases (6/ 69) of potentially therapy induced thromboses were seen, all patients in this group had a central line during therapy. Conclusion: The present data underlines the urgent need for a clinical study to elucidate the exact dosage and indications for C1-INH therapy. Dose related complications due to the therapy with C1INH, especially in regard to the patient's underlying condition have to be analyzed. 1. Stieh J, Biomed Progr 1996; 9:13±16.

Meningococcal sepsis and Waterhouse-Friderichsen-Syndrome in childhood. A retrospective study C. Albertz á U. Lieser á U. Sitka á S. Burdach C. Albertz á U. Lieser á U. Sitka á S. Burdach Martin-Luther-UniversitaÈt Halle-Wittenberg, Kinderklinik, 06097 Halle, e-mail: [email protected] Meningococcal sepsis (McS) and Waterhouse-Friderichsen-Syndrome (WSF) are associated with a mortality up to 95%. The accumulation of 4 cases within 3 month (Jan.±March 1999) was the reason for a retrospective study of all cases treated in our hospital between 1990±1999. Method: 19 patients with McS or WFS have been treated on our intensive care unit between 1990±1999. Results: the mean age was 5.3 years (2 month±17 years). Out of 19 patients, 3 died of the disease. In 8 cases Neisseria miningitidis was cultured from cerebrospinal ¯uid (CSF) and/or blood samples. In one case ± hemolysing streptococcus could be isolated in the CSF. At time of admission all children had cutaneous hemorrhages, and 5 of them even had extended Livores. 3 out of these 5 patients died. In total 9 patients showed severe signs of shock with low blood pressure and

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severe disturbance in hemostasis (PTT > 180 s, Fibrinogen <1 g). Conclusion: Although having new therapeutic approaches like therapy with AT III, Protein C and rtPA there is still a high rate of patients with fatal outcome. Stabilising blood pressure and appropriate treatment of hemostatic disorders are the essential basis of successful therapy of McS and WFS.

Replacement therapy of protein C concentrate in infants and adolescents with meningococcal-induced sepsis and purpura fulminans C. Escuriola Ettingshausen á A. Veldman á T. Beeg I. Martinez Saguer á G. JaÈger á W. Schneider á W. Kreuz C. Escuriola Ettingshausen á A. Veldman á T. Beeg I. Martinez Saguer á G. JaÈger á W. Schneider á W. Kreuz Johann Wolfgang Goethe University Hospital, Department of Paediatrics, Frankfurt/Main, Germany Meningococcal-induced septic shock with purpura fulminans (PF) is known to be associated with a high mortality. Microvascular thrombosis is caused by the activation of multiple pathways resulting in multi organ failure due to severely reduced perfusion. In septic shock Protein C (PC) plasma levels are reported to be strongly decreased and to be signi®cantly correlated with both, the poor clinical outcome as well as the extension of skin lesions in PF. This supports PC replacement therapy as a supplementary therapeutic approach to conventional intensive care (IC) treatment. We report on 8 patients aged 0.2±17 years with meningococcal-induced sepsis and PF. All subjects showed strongly reduced PC activity (median 0.11 IU/ml, range 0.02±0.48 IU/ml) at admittance to our intensive care unit (ICU). Glasgow meningococcal septicaemia prognostic score (GMSPS) ranged between 6 and 11 (median 9). Additionally to IC treatment patients received replacement therapy with human, virusinactivated PC concentrate (Baxter/Immuno). After an initial bolus injection of 100 IU/kg bw, the treatment was followed by dosages of 50 IU/kg bw up to 6 times per day. Under this regimen PC plasma levels were maintained within normal ranges (median 0.69 IU/ml, range 0.49±0.78) particularly during the initial phase of treatment. Due to decreased AT III levels (median 0.69 IU/ml, range 0.49±0.78 IU/ml) all patients received AT III concentrate. One patient underwent peritoneal dialysis. 6 out of 8 patients survived, one of those required limb amputation. Both patients who died imposed with a tremendously low PC level at admission to our hospital. Under PC substitution declining signs of PF presenting a restored microcirculation as well as normalizing haemostatic parameters were assessed in all patients, even in those who died. No adverse events were observed with any PC concentrate administration. Protein C concentrate as an antithrombotic and ®brinolytic agent showed a strong bene®t on deranged coagulation status and reduced microcirculation in patients with meningococcal-induced sepsis and PF.

Hemostatic disorder in meningococcal sepsis. A case report C. Albertz á U. Sitka á R. Schobeû C. Albertz á U. Sitka á R. Schobeû Martin-Luther-UniversitaÈt Halle-Wittenberg, Kinderklinik, D-06097 Halle, e-mail: [email protected] Meningococcal sepsis (McS) and Waterhouse-Fridrichsen-Syndrome (WFS) are associated with high risk for fatal outcome. The case report is about a 13 years old boy transferred from another hospital to our intensive care unit with the diagnosis WFS. The patient was already treated with Streptokinase, AT III and Heparin. At the time of admission he had a Neisseria sepsis index

of 6 points (NESI, NuÈrnberger et al.). He showed massive cutaneous hemorrhages all over his body. To treat the the hemostatic disturbance (Quick: 7%, PTT: >180 s, Fibrinogen: <0.6 g/l) we substitute AT III with a maximum dose of 150 IE/kg body weight, additional 2 g Fibrinogen and Factor XIII was given. On the second day of his treatment the patient developed pleural e€usions, ascites and a remarkable lung edema cause by a capillary leak syndrome. The patient had to receive arti®cial respiration. Treatment with C1-Esterase-Inhibitor was necessary. The development of crushkidneys with oligo- and hyposthenuria caused by massive rhabdomyolysis with increased Myoglobin serum levels made a hemodialysis over 10 days unavoidable. Conclusion: Antithrombin III is established in treatment of meningococcal sepsis because of its antiin¯ammatory and anticoagulatory e€ect. Fundamental for decreasing of lethality are the therapy of disturbance in hemostasis and early intensive therapeutic intervention including arti®cial respiration and hemodialysis.

Plasminogen activator inhibitor (PAI)-1 and tissue-type plasminogen activator (t-PA) in infants with thromboembolism following cardiac catheterisation U. Nowak-GoÈttl á R. Junker á H. Vielhaber á E. Hagemeyer D. Kececioglu U. Nowak-GoÈttl á R. Junker á H. Vielhaber á E. Hagemeyer D. Kececioglu Department of Pediatrics, University-Hospitals Freiburg and MuÈnster To evaluate the role of PAI-1 and t-PA in children with an estimated risk of vascular occlusion reported from 7% to 16% we conducted a prospective study in infants and children with underlying cardiac disease. 125 children (neonate±16 years) were investigated. In 10 infants out of 125 children vascular occlusion occurred, closely related to cardiac catheterisation and arterial or venous lines during major cardiac surgery. Seven of the 10 infants with (n = 7) and without (n = 3) prothrombotic risk factors showed evidence of a basically impaired ®brinolytic system. Six of the 10 infants showed increased PAI-1 activity along with elevated t-PA antigen, clearly correlated with the 4G/4G genotype of the PAI-1 gene polymorphism before the ®rst cardiac catheterisation was performed. In conclusion, preliminary data of this study indicate that infants with underlying cardiac disease and basically increased PAI-1 activity caused by the 4G allele in the promoter polymorphism of the PAI-1 gene are at high risk of developing early thrombo-embolism during cardiac catheterisation.

Low incidence of thrombotic events in children with acute lymphoblastic leukemia treated according to COALL-92 and 97 protocol Christine Mauz-KoÈrholz á Ralf Junker á Ulrich GoÈbel Ulrike Nowak-GoÈttl C. Mauz-KoÈrholz á U. GoÈbel Department of Pediatric Hematology and Oncology, Heinrich-Heine University Medical Center, DuÈsseldorf, Germany U. Nowak-GoÈttl Department of Pediatric Hematology and Oncology, WestfaÈlische-Wilhelms-University Medical Center, MuÈnster, Germany R. Junker Department of Clinical Chemistry and Laboratory Medicine/ Institute of Arteriosclerosis Research, WestfaÈlische-WilhelmsUniversity Medical Center, MuÈnster, Germany

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The reported incidence of thromboembolism in children with acute lymphoblastic leukemia (ALL) treated with L-asparaginase, vincristine and prednisone varies from 2.4 to 11.5%. In a retrospective analysis, here the role of prothrombotic risk factors in children with ALL treated according to the COALL study protocol was investigated in 107 patients who have been treated at the Pediatric Oncology Department of the University Medical Center DuÈsseldorf between 1992 and 1998. The prevalence rates of thrombotic risk factors such as factor V (FV) G1691A mutation, the prothrombin (PT) G20210A variant, the TT677 methylenetetrahydrofolate reductase (MTHFR) genotype and de®ciencies of protein C, protein S, antithrombin and increased lipoprotein (Lp) (a) concentration (>30 mg/dl) in this cohort was comparable to previously reported data for other leukemic patients. However, venous thromboembolism occurred in only 3 of the 107 children (2.9%), and none of these children carried a prothrombotic risk factor. While in the past, acquired hypercoagulability during asparaginase treatment was considered an important risk factor for the development of venous thromboses in children with ALL, a most recent study suggested a strong association between hereditary prothrombotic risk factors and the development of thromboembolism. The results of this study, however, demonstrate that the pathogenesis of thromboses in children with ALL appears to be even more complex, suggesting that the role of hereditary and acquired disturbances of coagulation in the development of thromboses might depend on the treatment regimen.

Incidence of lupus anticoagulants and phospholipid antibodies in children without and in adults with and without thrombophilia H. J. Siemens á S. Gutsche á S. BruÈckner á P. Bucsky á K. Kruse H. A. Katus H. J. Siemens á S. BruÈckner á H. A. Katus Department of Internal Medicine II, Medical University of LuÈbeck, LuÈbeck, Germany S. Gutsche á P. Bucsky á K. Kruse Department of Pediatrics, Medical University of LuÈbeck, LuÈbeck, Germany Introduction: Lupus anticoagulants and anti-phospholipid antibodies are considered risk factors in patients with thromboembolic diseases. While the incidence of such acquired coagulation disturbances in adults are well described, only few data exist for children. In a ®rst step to collect new data, we therefore analysed the presence of di€erent lupus anticoagulants in 200 consecutive children. Patients and Methods: The children screened for lupus anticoagulants were exclusively those which did not have any thromboembolic complications in their past medical history. On the other hand, the group of adults comprised 200 patients after DVT (deep vein thrombosis) and 200 patients without thromboembolic events as controls. The following parameters were determined: the lupus screening tests dRVV (diluted Russel viper venom, American diagnostic) and LA-test (Stago, France), a lupus-sensitive APTT (PLL, Platelin LS, Organon, Eppelheim)

children % neg adults % pos adults % neg OR ch) vs. ad+ (95% CI) P-value

and three di€erent anti-phospholipid antibodies against cardiolipin, b2-glycoprotein I and phosphatidylserin (Imtec, Berlin, Germany). All samples were centrifuged at 3000 g, aliquoted and then deep-frozen at )35°C. Results: The table below shows signi®cant di€erences of the determined parameters between the three groups. The children have higher values compared to the adults for lupus anticoagulants, whereas their values for antiphospholipid antibodies are lower on average. This has to be taken into account when evaluating children with thromboembolic diseases.

Leptin is not associated with plasminogen activator inhibitor-1 antigen in obese children and adolescents Karl Sudi á Siegfried Gallistl á Wolfgang Muntean Martin Borkenstein K. Sudi á S. Gallistl á W. Muntean á M. Borkenstein Institute for Sport Sciences, Ludwig-Boltzmann Research Institute for Pediatric Hemostasis and Thrombosis, Division for Diabetes and Endocrinology, Department of Pediatrics, Karl-Franzens University Graz Objective: There is evidence that hyperleptinemia might be associated with parameters of ®brinolytic processes in adults. We studied whether body fatness and leptin interact with plasminogen activator inhibitor-1 antigen (PAI-1-Ag) and tissue-type plasminogen activator antigen (tPA-Ag) in obese children and adolescents. Methods: 23 boys (mean ‹ SD, age: 10.7 ‹ 3.3 years, body mass index, BMI: 28.7 ‹ 5.4) and 19 girls (age: 11.9 ‹ 2.7 years, BMI: 29.4 ‹ 4.8) were investigated. Body fat mass (FM) of children was calculated and blood samples were determined for levels of leptin, PAI-1-Ag and tPA-Ag. Results: When children were grouped into three subgroups according to their maturation, maturity was associated with higher levels of FM and leptin (H = 9.68, P < 0.01). Percentage fat mass, PAI-1-Ag and tPA-Ag were not signi®cantly di€erent between the three subgroups. However, pearson correlation revealed a signi®cant association between stages of maturation and PAI-1-Ag (r = 0.34, P < 0.02). PAI-1-Ag and leptin were correlated to FM (r = 0.63 and r = 0.54, P < 0.001), but leptin was not independently correlated to PAI-1-Ag after adjustment for FM. However, PAI-1-Ag was independently associated with tPA-Ag (r = 0.36, P < 0.02; after adjustment for FM). Multiple regression analysis revealed that FM contributed independently to the variation in leptin (adj. R2 = 0.39) and PAI-1-Ag (adj. R2 = 0.29, all P < 0.001). PAI1-Ag contributed to the variation in tPA-Ag (adj. R2 = 0.15, P = 0.014) but this was not independent from adiposity. Discussion: The results might indicate that fat mass of children contributes to the variation in leptin and PAI-1-Ag. The increase in levels of fatness and PAI-1-Ag is also the consequence of the pubertal development which might suggest that an unfavourable metabolic and ®brinolytic risk pro®le might already emanates from the pubertal stage. Leptin is not independently linked with ®brinolytic processes but the role of leptin to mediate metabolic processes during adolescence obesity remains to be elucidated.

dRVV

LA-t

PLL

Cardio

Glyko

Phospho

21.3 11.5 7.5 2.1 1.2±3.6 <0.01

22.8 9.5 5.7 2.8 1.6±4.9 <0.01

26.2 16.6 5.1 1.8 1.1±2.9 <0.02

12.4 24.1 17.3 0.4 0.6±0.2 <0.01

2.9 14.9 6.7 0.2 0.4±0.0 <0.01

2.4 17.6 6.3 0.1 0.3±0.0 <0.01

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Effect of alpha 2-macroglobulin on the anticoagulant activity of activated protein C Gerhard Cvirn á Siegfried Gallistl á Bettina Leschnik Wolfgang Muntean G. Cvirn á S. Gallistl á B. Leschnik á W. Muntean Ludwig Boltzmann Research Institute for Pediatric Thrombosis and Hemostasis, Department of Pediatrics, University of Graz, Austria Thrombotic events are less frequent in children than in adults, which has been suggested to be partially due to elevated alpha 2macroglobulin (a2M) levels in childhood. On the other hand it has been shown that a2M binds to activated protein C (APC). Therefore, we investigated the e€ect of di€erent a2M concentrations on the anticoagulant e€ect of APC in newborn and adult plasma. To 200 ll plasma containing di€erent amounts of a2M 1.6 lg/ml APC was added and subsequently the plasma was activated via the extrinsic pathway. At timed intervals aliquots were withdrawn from the activated plasma and assessed for free thrombin generation (thrombin potential) and prothrombin activation (prothrombin fragment 1+2). At physiologic concentrations of a2M the e€ects of 1.6 lg/ml APC on the prolongation of the clotting time, diminution of the thrombin potential and of prothrombin activation were negligible in newborn and adult plasma. When levels of a2M were decreased 1.6 lg/ml APC caused signi®cant prolongation of the clotting time and a signi®cant diminution of the thrombin potential and of prothrombin activation. Further reduction of the a2M content resulted in further improvement of the anticoagulant action of APC. In conclusion, the lower the a2M content, the higher was the anticoagulant e€ect of APC in newborn and adult plasma. Since we have previously shown that the anticoagulant e€ect of APC in newborn plasma is comparable to its e€ect in adult plasma our results argue against the assumption that a2M protects children from thrombotic events. We suggest, that increased levels of a2M in vivo might even inhibit the anticoagulant e€ect of APC.

Cardiovascular ®tness is not a predictor of hemostatic and metabolic risk factors for coronary heart disease in obese children and adolescents S. Gallistl á K. M. Sudi á W. Zenz á B. Leschnik M. Borkenstein á W. Muntean S. Gallistl á K. M. Sudi á W. Zenz á B. Leschnik á M. Borkenstein W. Muntean Ludwig Boltzmann Research Institute for Pediatric Hemostasis and Thrombosis, Department of Pediatrics, and Division of Sport Sciences, University of Graz, Austria Beside metabolic disturbances hemostatic risk factors have been demonstrated to be predictive for coronary heart disease in adults. It has been shown that exercise and cardiovascular ®tness (CV ®tness) might have a positive in¯uence on these parameters. Nothing is known about a possible relation between CV ®tness and hemostatic risk factors in obese children. From 35 obese children and adolescents (18 male, 17 female, age 11.4 ‹ 3 years, BMI: 29.2 ‹ 5.2), who were screened for metabolic and hemostatic risk factors for coronary heart disease, 23 were eligible for assessment of CV ®tness using a bicycle ergometer test. When patients were divided in two groups by the median of CV ®tness (watt/kg body weight), children with lower power output (£2.77 watt/kg) showed signi®cantly higher values for BMI, fatmass, factor VIIc, ®brinogen, and tissue type plasminogen activator antigen (tPA-Ag). In addition, patients with lower power output showed signi®cantly higher levels of triglycerides, VLDL, insulin, and C-peptide. Factor

VIIc, tPA, and correlated signi®cantly with fatmass, VLDL, insulin, and C-peptide. However, in multiple linear regression analysis, only fatness explained signi®cant independent proportions of the variance of the hemostatic and metabolic risk factors. Our results demonstrate a close correlation between low cardiovascular ®tness and hemostatic and metabolic risk factors in obese pediatric patients. However, power output was not a signi®cant predictor of hemostatic or metabolic risk factors for CHD when fatness was included in the multiple regression models.

Effect of gestational age on cord-blood computerized thrombelastography (cTEG) B. Trusen á M. Girisch á R. Rauch á C. KaÈndler á J. Klinge M. Ries B. Trusen á M. Girisch á R. Rauch á C. KaÈndler á J. Klinge M. Ries Childrens hospital of the University of Erlangen Background: cTEG is a useful screening instrument to detect abnormalities in the hemostatic and ®brinolytic system. Platelet function, activity of clotting factors and the ®brinolytic system depend on gestational age. We performed cTEG on newborn infants (24±41 weeks gestational age) to evaluate the in¯uence of gestational age (GA) on cTEG and to detect disturbances of the hemostatic and ®brinolytic system. Methods: cTEG was performed on citrated cord-blood samples of 68 newborns of di€erent gestational ages (group A ³ 37 wk n = 38; group B 31±36 wk n = 16; group C £ 30 wk n = 14. Results: Term newborns (group A) had R values of 10.5 ‹ 6.1 mm (median ‹ SD; 10 mm = 5 min), K values of 4.0 ‹ 2.8 mm, maximal amplitude of 58.5 ‹ 8.0 mm and angles of 64.5 ‹ 13.2°. 30 and 60 min lysis was 2.5 ‹ 2.9 and 6.5 ‹ 4.4% respectively. Results in group B were similar to group C: Compared to Group A the R values in B and C were longer (15.0 ‹ 5.8 and 14.8 ‹ 11.6) and there was a tendency towards longer K (4.8 ‹ 2.1 and 4.8 ‹ 3.4), greater MA (62.5 ‹ 7.0 and 67.8 ‹ 10.7), smaller angle (60.8 ‹ 11.4 and 62.5 ‹ 14.5)and less lysis (1.5 ‹ 0.9 and 1.3 ‹ 5.3 at 30 min; 5.0 ‹ 2.0 and 4.0 ‹ 11.9 at 60 min). We found three newborns (one 27 wk of gestation and two mature newborns) in a pronounced hyper®brinolytic state. Conclusions: 1. Gestational age in¯uences cord-blood computerized Thrombelastography. Immature infants seem to have greater R values. 2. cTEG can identify premature infants in a hyper®brinolytic state. 3. Further research is necessary to evaluate the clinical relevance of cTEG ®ndings, especially whether cTEG might identify patients at risk for intracranial hemorrhage.

Severe bleeding complications in a patient suffering from both F VII de®ciency and von Willebrand JuÈrgens disease H.-H. Wolf á W. Voigt á R. Schobess á F. H. Herrmann H.-J. Schmoll H.-H. Wolf á W. Voigt á H.-J. Schmoll University Hospital Halle, Department Haematology and Oncology R. Schobess University Hospital Halle, Department Pediatrics H.-J. Schmoll University of Greifswald, Institute of Human Genetics A 30 year old female patient was admitted to the gynecologic department for diagnostic conization. There was no history of severe bleeding complications neither associated to tonsillectomy

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24 years ago nor to labor 11 years ago, respectively. The patient had been on an estrogen anticonceptive. She underwent second and third conization because of persistent bleeding day 8 and 13 after ®rst surgery, but bleeding persisted. On day 29 abdominal hysterectomy was performed. At the patient's ®rst presentation in our laboratory on day 40 global tests (activated partial thromboplastin time, INR as well as prothrombin time) were within the normal range, but she presented plasma concentrations of F VII 45%, F VIII 44%, vWF antigen 20%, vWF ristocetin cofactor 24%, PFA Col/Epi >300 s, PFA Col/ADP 298 s. Multimeric analysis revealed von Willebrand-JuÈrgens disease IIA. On day 53 and 71, respectively, the patient underwent laparotomy because of severe infection followed by perfusion therapy and secondary healing. Due to substitution therapy by F VII and F VIII/vWF concentrates there were no further severe bleeding complications. Screening of the family revealed von Willebrand-JuÈrgens disease IIA also in the patient's mother. F VII mutation Ala294Val was detected by molecular analysis in the patient and her daughter. The patient's daughter presented compound heterocygotic with a second mutation of F VII gene (deletion of 15 bp in exon 8) not previously characterised.

The Gardner-Diamond-Syndrome A. Nimtz á G. Linss A. Nimtz Kinderklinik im Klinikum Frankfurt (O), D-15234 Frankfurt (Oder), Germany G. Linss Hautklinik im Klinikum Frankfurt (O), D-15234 Frankfurt (Oder), Germany The Gardner-Diamond-Syndrome, also called `autoerythrocytesensitisation-purpura', is a rare and striking disorder. Nearly all a€ected patients are young females, showing unique ecchymoses and painful bruisings on the skin of the extremities and the abdomen. The combination of the clinical symptoms with sometimes even severe haemorrhages and the unexpected normal levels of the plasmatic coagulation parameters requires further extensive examinations to diagnose a Gardner-Diamond-Syndrome. We report of a 16-years-old girl with petechial bleedings and later on with ecchymoses and painful bruising on her forearm. Because of the prolonged bleeding time a haemostatic disturbance was assumed. Step by step we excluded all known disorders of the coagulation system, which may be underlying the haemorrhages, including congenital factor de®ciencies, von Willebrand disease, platelet function disorders and alterations of the ®brinolytic system. Therapeutic interventions with DDAVP, cortisone and antibiotics failed. After consulting a dermatologist an autoerythrocyte sensitisation test according to Gardner and Diamond was carried out and the positive result ®nally con®rmed the diagnosis Gardner-Diamond-Syndrome.

Evans syndrome in 3 patients: diagnostic dilemmas, clinical course and treatment options Roswitha Dickerho€ á A. MuÈller R. Dickerho€ á A. MuÈller Johanniter Kinderklinik, St. Augustin, Kinderabteilung Krankenhaus der BorromaÈerinnen, Trier Immune thrombocytopenia accompanied by autoimmune hemolytic anemia with or without neutropenia was described by Evans 50 years ago and is known today as Evans Syndrome (ES) or Immune Pancytopenia. Precise diagnosis of this complex disease is often missed. We present 3 patients with ES who remained undiagnosed for several months to years. They underwent unnec-

essary diagnostic interventions, received poorly planned therapy and demonstrate the wide spectrum of this disease with its chronic relapsing course. Our patients were 3 boys who presented with immune pancytopenia within the ®rst 5 years of life, hemolytic anemia being the ®rst event in all. Two of them who in addition to immune pancytopenia had massive hepatosplenomegaly and enlarged lymphnodes, had several lymph node biopsies each to rule out malignant disease. One patient had 4 bone marrow aspirates. All had received multiple doses of IVIg and large amounts of corticoids. In addition one of the boys had been treated with androgens, G-CSF, numerous immunosuppressants and splenectomy without success. Diagnosis of ES was established 6 months, 6 years and 12 years into the disease. Since then one patient has developed LE nephritis and is on combined immunosuppressive therapy. The second is on low dose Cyclosporin-A and PRD for severe bleeding tendency and recurrent episodes of hemolysis. Because of poor corticoid tolerance he is being considered for treatment with Mycophenolat-Mofetil. The third patient is presently asymptomatic on no therapy with low normal hematological values. Evans Syndrome is a chronic disease which is not restricted to the hematopoietic system. ITP is only one facet of the disease. Early diagnosis is mandatory to prevent unnecessary diagnostic work-up and unwarranted therapy.

Congenital amegakaryocytic thrombocytopenia (AMT) ± unsuccessful treatment with recombinant human interleukin 11 (Neumega) G. Strauû á M. Ballmaier á S. Wehnert á H. Schulze á K. Welte G. Strauû á M. Ballmaier á S. Wehnert á H. Schulze á K. Welte PaÈdiatrische HaÈmatologie und Onkologie, Medizinische Hochschule, D-30623 Hannover Background: Clinical studies with recombinant interleukin 11 (rhIL-11) demonstrated stimulation of hematopoetic stem cells and increased proportion of megakaryocytes in adults (1). Also, rhIL-11 reduced the need of platelet transfusion after chemotherapy-induced thrombocytopenia in children (2). Patients: We examined the e€ect of rhIL-11 in two children (3 year old girl and 5 year old boy) with congenital amegakaryocytic thrombocytopenia. Both su€ered from a severe thrombocytopenia (2± 3 ´ 109/L platelets) and a recurrent history of epistaxis. They received 100 lg/kg body weight rhIL-11 (Neumega) subcutaneously every day. Results: The therapy was well tolerated. Only dilutional anemia was seen as a side e€ect, due to an increase of plasma volume, which was reversible after discontinuation of rhIL-11 therapy. Both children showed decreasing petechiae and hematomas without changes in platelet count on day 2±5. On day 7 they started both with increasing bleeding symptoms such as recurrent epistaxis and bleeding into conjunctival tissue. We stopped the therapy on day 10. Platelet counts were lower than prior to therapy. After rhIL-11 therapy both children developed increasing bleeding symptoms and needed several units of packed platelets for 4 weeks. Conclusion: We propose that rhIL-11 treatment lead to a transient exhaustion of megakaryocytic progenitor cell pool as an e€ect of faster maturation of megakaryocytes followed by a decreased platelet count for some weeks. Literature: (1) Orazi et al. Exp Hematol 24:1289±1297, 1996. (2) Kirov et al. Blood 90:581a, 1997.

Survey on acute Childhood-Immune-Thrombocytopenia (ITP) in Germany A. H. Sutor á A. Harms á K. Kaufmehl A.H. Sutor á A. Harms á K. Kaufmehl UniversitaÈts-Kinderklinik, Freiburg

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Question: Treatment of childhood ITP is a topic of controversy. Worldwide there are many di€erent opinions. In order to obtain facts about the present policy we performed a prospective survey in Germany. Methods: Questionnaires were sent to all German children hospitals in a monthly interval between October 1, 1996 and September 30, 1997 with the support of ESPED. De®nition of acute ITP: Acute bleeding symptoms in otherwise healthy children with thrombocytopenia (platelet count <30,000/ll). Results: 323 children were reported, the incidence can be estimated as 2.15 per 100,000 children and year. The mean age was 5.7 years, the incidence decreased markedly after year 8. In the age group up to 6 years boys were predominant. At least 60% had a preceeding infection. 97.5% had only mild bleeding symptoms, such as purpura alone or additional mild mucous bleeding, 2.5% had serious bleeding requiring blood transfusion or nose tamponade. There was no CNS-bleeding and no death. The mean platelet count was 8,252/ll. 61% of the patients were treated with immunoglobulins [Ig] (either alone or as ®rst choice), 19% with Glucocorticoids [GC] (either alone or as ®rst choice), 6% with Ig plus GC, whereas 14% did not receive Ig or GC. Conclusion: Despite the fact that almost all children with ITP had only mild bleeding symptoms, 86% received medications to increase the platelet count. From this prospective study no answer can be obtained whether these medications are clinically e€ective or not.

Drop of leucocytes after treatment with immunoglobulins in children with acute immune Thromocytopenia (ITP) A. H. Sutor á E. BergstraÈûer á K. Kaufmehl A. H. Sutor á E. BergstraÈûer á K. Kaufmehl UniversitaÈts-Kinderklinik, Freiburg Objective of the study: Most studies in children with ITP treated with immunoglobulins concentrate on the rise of platelet count. Since primary hemostasis is dependent not only on platelets we also evaluated the alterations in white and red blood cells. Methods: Included were consecutive 13 children with acute ITP. We compared platelets, leukocytes (WBC), and erythrocytes (RBC) before, and within 24 h after a single dose of 0.4 g/kg body weight of immunoglobulins (BergstraÈûer et al. Mschr Kinderheilk 145:526, 1997). Results: There was a signi®cant rise of platelets from a mean of 7.23/ll (Standard error of the mean [SE]: 1.49/ll) to 23.769/ll (SE: 5.116/ll) and a signi®cant drop of WBC from 8.654/ll (SE: 0.616/ll) to 5.654/ll (SE: 0.372/ll). The fall of WBC was observed in all 13 children. The percentage of monocytes did not change signi®cantly (6.4% before, 5.8% after treatment). There was no change of RBC (4.5 ´ 1012/l before and after treatment). Conclusion: After therapy with immunoglobulins the increase of platelets is accompanied by a signi®cant drop of WBC. Whereas the blockage of the phagocytic monocyte-macrophage system is thought to cause the increase of opsonized platelets, this cannot be true for the drop in WBC. Since WBC also contribute to primary hemostasis, further research on the pathomechanism of the decrease of WBC and its in¯uence on clinically relevant hemostasis is warranted.

Inef®cacy of low molecular weight heparin in a young boy with congenital nephrotic syndrome of the Finnish type M. Girisch á M. BoÈswald á R. Rauch á M. Ries á J. Klinge M. Girisch á M. BoÈswald á R. Rauch á M. Ries á J. Klinge Children's hospital of the University Erlangen-NuÈrnberg Background: The congenital nephrotic syndrome (CNS) of the Finnish type is an autosomal recessively inherited disease characterised by intrauterine onset of massive proteinuria. The mean problem in these patients is urinary loss of proteins with secondary

symptoms of hypoproteinemia and loss of antithrombin (AT). Thromboembolic complications occur with a frequency of 3±5% in children with CNS. Case report: The boy was born by sectio caesarea in the 39 gestational week with 1980 g. In the ®rst days of life he presented proteinuria, edema and an increased cholesterine level. On the tenth day he developed a thrombosis of the vena cava inferior which was treated with heparin, AT-concentrates and rtPA. After two days of treatment we saw complete resolution of the thrombus. In the following he was treated with AT and a continuous infusion of heparin. At the age of three months we decided to start low molecular weight heparin (Fragmin) in a dose of 140 IU/kg twice a day in order to discharge him. Despite high doses of LMWH and good anti thrombin levels of 70%, anti-Xalevels (Chromogenix, Immuno), measured two to four hours after injection were always below 0.1 IU/ml. Therefore oral anticoagulation with phenprocoumon was started to prevent further thromboembolic complications. The boy is now three years and ®ve months old and no thromboembolic events occurred. Discussion/Conclusion: LMWH has successfully used before in patients with nephrotic syndrome. de Saint-Martin et al. (1997) reported the successful treatment of a thrombosis of the sinus sagittalis superior in a 3-year old child by LMWH. Rostocker et al. (1995) recommended LWMH for prevention of thrombotic complication in nephrotic syndrome. On the other hand there are reports of reduced heparin ecacy in nephrotic syndrome. Guillot et al. (1979) reported a 7-year old girl with nephrotic syndrome, repeated thrombosis and in vitro inactivity of heparin. And Vermylen et al. (1987) found a signi®cantly reduced heparin sensitivity in children with nephrotic syndrome compared to a group of healthy controls. As we saw no sucient anti Xa levels in our patient we speculate that the glomerula damage resulted in an increased renal loss of LMWH.

Clinical experience with low molecular weight heparins in pediatric patients S. Hofmann á R. Knoȯer á J. Wendisch á G. Siegert á D. MuÈller H. Taut-Sack á J. Dinger á N. Lorenz á B. Tittel á M. Kabus S. Hofmann á R. Knoȯer á J. Wendisch á D. MuÈller H. Taut-Sack á J. Dinger á N. Lorenz á B. Tittel á M. Kabus Department of Pediatrics, University Hospital of Technical University Dresden, Germany G. Siegert Department of Clinical Chemistry, University Hospital of Technical University Dresden, Germany Low molecular weight heparins (LMWHs) have been proven to be ecious and safe for prophylaxis and treatment of venous thrombosis in adults. Because the experiences with LMWHs in pediatric patients are limited we retrospectively analyzed the clinical results obtained from 51 children (age range from 2 weeks to 19 years, mean 11.7 years) treated with LMWHs in our hospital. Patients were treated for prophylaxis during immobilisation after orthopedic surgery (n = 25) and after trauma (n = 12), reocclusion/apposition prophylaxis after thrombolysis (n = 7), treatment of venous and arterial thromboembolism (n = 3), prophylaxis by thrombosis with a suspected thrombus age of more than 2 weeks (n = 2) and in patients with high risk for the development of thrombosis (n = 2). Four di€erent LMWHs (FraxiparinÒ ± n = 41, ClexaneÒ ± n = 7, Fragmin PÒ ± n = 2, MonoembolexÒ ± n = 1) were used for short-term prophylaxis (2 to 3 weeks after surgery or trauma, n = 37) and long-term prophylaxis/treatment (2 to 11 months). In the 37 patients given short-term prophylaxis and in the two high risk patients no thrombotic events occured. In the 4 children with long-term prophylaxis after successful thrombolytic therapy no reocclusion and in the two with failed success no apposition of thrombus was observed. In another patient with unsuccessful

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thrombolytic therapy, a preterm newborn (34th gestational week) with thrombosis of Aorta abdominalis localized near the bifurcation, the dissolution of thrombus was detected during the following treatment with ClexaneÒ. Of the 3 patients receiving LMWHs for initial treatment of thrombosis one had complete and two had no recanalization. Fraxiparin 0.3Ò (3000 anti factor Xa IU) was used for short-term prophylaxis independent on the body weight and without determination of anti factor Xa activity. The reached doses ranged from 36 to 158 anti factor Xa IU/kg. Long-term prophylaxis was given in most of the patients as doses of 45±100 anti factor Xa IU/kg resulting in anti factor Xa activities between 0.16±0.62 IU/ml. For treatment of thrombosis the doses of 120±210 anti factor Xa IU/kg corresponded to 0.47± >1.0 anti factor Xa IU/ml. Side e€ects were observed in two patients ± a slight gastrointestinal bleeding in an infant caused by overdosing and a temporary reversible hair loss in an adolescent. In conclusion, LMWHs proved to be ecious and safe in prophylaxis and treatment of thromboembolic events in children. For the long-term prophylaxis and treatment with LMWHs a monitoring of the anti factor Xa activity is mandatory because the pharmacokinetics di€er from patient to patient and certainly also from drug to drug.

The neonatal renal vein thrombosis ± symptoms, sonographic ®ndings and results of thrombolytic and anticoagulation therapy in three cases S. HoÈhne á U. Sitka á S.-O. HoÈhne á W. Hirsch C. Taege á R. Schobeû S. HoÈhne á U. Sitka á R. Schobeû Departement of Pediatrics, Martin-Luther-University Halle-Wittenberg S.-O. HoÈhne Departement of Pediatric Surgery, Martin-Luther-University Halle-Wittenberg W. Hirsch Departement of Diagnostic Radiology, Martin-Luther-University Halle-Wittenberg C. Taege Institute of Pathology, Martin-Luther-University Halle-Wittenberg The symptoms in newborn abdominal mass, haematuria and thrombocytopenia are suspected for renal vein thrombosis (RVT). Three cases with unilateral RVT and associated suprarenal bleeding are reported. 1. Newborn infant with left-side RVT: Symptoms were left-side renal mass, haematuria and 44 Gpt/l thrombocytes. Because of the risk for brain bleeding and the

contraindication for thrombolysis unfractionated heparin was given two weeks in addition with AT-III-substitution. After a partial recanalisation of the renal vein in further a second occlusion was seen. Following the degeneration of this kidney the nephrectomy was necessary, when the infant was four months old. 2. Preterm infant with perinatal thrombosis on the left side: Renal tumor, erythrocyturia and thrombocytopenia were the clinical signs. It was successfully treated with heparin 500 IU/kg*d. 3. Pre-term infant with acquired right-side thrombosis at the 25-th day of life: At ®rst a thrombolytic therapy with 2 mg/kg*d rt-PA was given three days in addition with heparin and AT III. It was followed by heparin therapy for a time of three months with successful result. Diagnostics and therapeutic management of the renal vein thrombosis in newborn are discussed.

Cerebral haemorrhage by factor XIII-de®ciency as part of ulcerative colitis and thrombosis by homozygotic homocysteinaemia (MTHFR TT 677 Genotype) U. Lieser á R. Schobeû á U. Preiû á W. Hirsch á U. Sitka S. Burdach U. Lieser (&) á R. Schobeû á U. Preiû á W. Hirsch á U. Sitka S. Burdach Martin-Luther-UniversitaÈt Halle-Wittenberg, Kinderklinik, D-06097 Halle, e-mail: [email protected] Ulcerative colitis is known as cause for acquired factor-XIIIde®ciency. We report the case of a ®fteen years old patient su€ering from ulcerative colitis for three years. During an acute episode of ulcerative colitis we noticed headache, unclear language and later loss of consciousness with dilated and irregular pupils without light reaction. Cranial CT showed a 7 ´ 4 ´ 7 centimetres big cerebral haemorrhage and thrombosis of the transverse sinus on the right side. Further analysis showed a remarkable reduced factor XIII of 23%. Additional we found a homozygotic homocysteinaemia (MTHFR TT 677 Genotype). To our opinion the combination of two risk-factors (factor XIII-de®ciency and homocysteinaemia) induced this extensive cerebral haemorrhage. We treated with heparin and started a rehabilitative program. 12 month after the acute haemorrhage our patient presented a left side spastic hemiparesis and only minimal symptoms of cerebral dysfunktion. Conclusion: Regular analysis of factor XIII-levels and sucient substitution by a level under 50%, always depending on the clinical condition, should be part of routine monitoring and treatment of patients with ulcerative colitis. Cerebral haemorrhage in infancy can be an initial clinical manifestation of thrombophilia. Early diagnosis is necessary for an appropriate and successful treatment.