Volume 88 Number 2
3.
4. 5. 6.
Henn, RM, and Collin, DB: Amebic abscess of the liver: Treatment failure with metronidazole, JAMA 224:1394, 1973. Patton, RD: Treatment of amebic abscess, N Engl J Med 289:869, 1973. Wilde, H: Hepatic amebic abscess not responding to metronidazole, N Engl J Med 289:378, 1973. Stillman, AE, Alvarez, V, and Grube, D: Hepatic amebic abscess; unresponsiveness to combination of metronidazole and surgical drainage, JAMA 229:71, 1973.
Renal venous thrombosis--another cause of acute renal failure following cardiac surgery in infancy To the Editor: Chesney and associates, 1 in a report of 20 cases of acute renal failure in infants following cardiac Surgery, did not mention renal venous thrombosis as an etiologic possibility. We recently cared for an infant with pulmonary valvular atresia and intact ventricular septum who developed azotemia five days following a successful Blalock-Taussig procedure. Bilateral renal venous thrombosis was diagnosed on the basis of hernaturia, proteinuria, bilaterally enlarged kidneys, persistent azotemia, and radiographic findings. The patient responded to fluid and potassium restriction. Arneil and associates, 2 in a review of 165 infants with renal venous thrombosis, found that cyanotic heart disease, often with angiography, was the only significant etiologic factor in their series. Although the kidneys were enlarged in our patient, Arneil and assoc!ates~ emphasize that 44% of their patients did not have palpable kidneys. Renal venous thrombosis must be considered with acute renal failure in infants following cardiac surgery even without enlarged kidneys. In addition to the excellent therapeutic and diagnostic recommendations o f Chesney and associates, ' we recommend monitoring platelet counts and peripheral smears in such infants, since disseminated intravascular coagulation may occur with renal venous thrombosis? F. Bruder Stapleton, M.D. Fellow in Pediatric Nephrology Michael A. Linshaw, M.D. Assistant Professor of Pediatrics Chief Section of Pediatric Nephrology Richard Zakheim, M.D Associate Professor of Pediatrics Section of Pediatric Cardiology Department of Pediatrics University of Kansas Medical Center 39th St. at Rainbow Blvd. Kansas City, Kan. 66103 REFERENCES
1. Chesney R, Kaplan B, Freedom R, Haller J, and Drummond K: Acute renal failure: An important complication of cardiac surgery in infants, J PEDIATR 87:381, 1975.
Letters to the Editor
2. 3.
365
Arneil G, MacDonald A, Murphy A, and Sweet E: Renal venous thrombosis, Clin Nephrol 1:119, 1973. Renfield M, and Kraybill E: Consumption coagulopathy with renal vein thrombosis, J PEDIATR 82:1054, 1973.
Prenatal diagnosis of chromosomal mosaicism To the Editor: The prenatal diagnosis o f true mosaicism is difficult and may never be excluded with absolute certainty? " 2 Bloom and associates ~ have made the prenatal diagnosis o f 46, XX/47, XX + D mosaicism in a case subsequently confirmed by analysis of fetal tissues. Kardon and associates' made an initial diagnosis o f 45, X in one case. Subsequent studies of the amniotic fluid obtained at the time of abortion in that case revealed a 46, XY karyotype. In another case, five out of 64 cultured amniotic fluid ceils were observed with 47 chromosomes in each? Subsequent chromosomal analysis of skin, lung, and amnion of the abortus revealed a normal karyotype. A few investigators combined their experience and reported four cases in which the prenatal diagnosis o f chromosomal mosaicism posed serious dilemmas. ~ They found discrepancies in the karyotypes of cells from different culture flasks of a single sample, between cultures from successive amniocenteses, and between amniotic cell cultures and fetal tissues obtained after abortion. 6 Most recently Sutherland and associates~ also documented their experience with six cases of mosaicism in amniotic cell cultures. We, too, have recently encountered a disturbing case of chromosomal mosaicism, among a handful o f experiences -~ in over 1,000 cases studied. A 31-year-old, gravida 2, para 0 patient elected an amniocentesis for prenatal genetic studies because her first pregnancy had ended with the delivery of a stillborn with anencephaly. There was no other pertinen t family history. Amniocentesis was performed at 16 weeks of pregnancy and chromosomal analysis revealed 124 cells with a normal XY karyotype and 11 cells (8.2%) with a 47, XXY karyotype, confirmed with trypsin banding. The parents were duly informed of this result and the option of terminating the pregnancy was raised. Because of known difficulties in making the prenatal diagnosis of chromosomal mosaicism, a second amniocentesis was offered for confirmatory studies. The parents elected this approach, and cytogenetic observations on the second amniotic fluid studied revealed only a normal 46, XY karyotype in 71 metaphases examined. During careful counseling of both parents together, clear indication was given that the dilemma of mosaicism had in fact not been excluded and that it remained entirely possible for the cells from the second sample studied to have simply originated from multiple though normal cell lines (multiple dishes of amniotic cell cultures were studied each time). The option for terminating the pregnancy was again raiSed. The parents elected to continue the pregnancy, and a normal-appearing phenotypic male was duly delivered. Chromosomal analysis of 30 cultured peripheral
3.
4. 5. 6.
Henn, RM, and Collin, DB: Amebic abscess of the liver: Treatment failure with metronidazole, JAMA 224:1394, 1973. Patton, RD: Treatment of amebic abscess, N Engl J Med 289:869, 1973. Wilde, H: Hepatic amebic abscess not responding to metronidazole, N Engl J Med 289:378, 1973. Stillman, AE, Alvarez, V, and Grube, D: Hepatic amebic abscess; unresponsiveness to combination of metronidazole and surgical drainage, JAMA 229:71, 1973.
Renal venous thrombosis--another cause of acute renal failure following cardiac surgery in infancy To the Editor: Chesney and associates, 1 in a report of 20 cases of acute renal failure in infants following cardiac Surgery, did not mention renal venous thrombosis as an etiologic possibility. We recently cared for an infant with pulmonary valvular atresia and intact ventricular septum who developed azotemia five days following a successful Blalock-Taussig procedure. Bilateral renal venous thrombosis was diagnosed on the basis of hernaturia, proteinuria, bilaterally enlarged kidneys, persistent azotemia, and radiographic findings. The patient responded to fluid and potassium restriction. Arneil and associates, 2 in a review of 165 infants with renal venous thrombosis, found that cyanotic heart disease, often with angiography, was the only significant etiologic factor in their series. Although the kidneys were enlarged in our patient, Arneil and assoc!ates~ emphasize that 44% of their patients did not have palpable kidneys. Renal venous thrombosis must be considered with acute renal failure in infants following cardiac surgery even without enlarged kidneys. In addition to the excellent therapeutic and diagnostic recommendations o f Chesney and associates, ' we recommend monitoring platelet counts and peripheral smears in such infants, since disseminated intravascular coagulation may occur with renal venous thrombosis? F. Bruder Stapleton, M.D. Fellow in Pediatric Nephrology Michael A. Linshaw, M.D. Assistant Professor of Pediatrics Chief Section of Pediatric Nephrology Richard Zakheim, M.D Associate Professor of Pediatrics Section of Pediatric Cardiology Department of Pediatrics University of Kansas Medical Center 39th St. at Rainbow Blvd. Kansas City, Kan. 66103 REFERENCES
1. Chesney R, Kaplan B, Freedom R, Haller J, and Drummond K: Acute renal failure: An important complication of cardiac surgery in infants, J PEDIATR 87:381, 1975.
Letters to the Editor
2. 3.
365
Arneil G, MacDonald A, Murphy A, and Sweet E: Renal venous thrombosis, Clin Nephrol 1:119, 1973. Renfield M, and Kraybill E: Consumption coagulopathy with renal vein thrombosis, J PEDIATR 82:1054, 1973.
Prenatal diagnosis of chromosomal mosaicism To the Editor: The prenatal diagnosis o f true mosaicism is difficult and may never be excluded with absolute certainty? " 2 Bloom and associates ~ have made the prenatal diagnosis o f 46, XX/47, XX + D mosaicism in a case subsequently confirmed by analysis of fetal tissues. Kardon and associates' made an initial diagnosis o f 45, X in one case. Subsequent studies of the amniotic fluid obtained at the time of abortion in that case revealed a 46, XY karyotype. In another case, five out of 64 cultured amniotic fluid ceils were observed with 47 chromosomes in each? Subsequent chromosomal analysis of skin, lung, and amnion of the abortus revealed a normal karyotype. A few investigators combined their experience and reported four cases in which the prenatal diagnosis o f chromosomal mosaicism posed serious dilemmas. ~ They found discrepancies in the karyotypes of cells from different culture flasks of a single sample, between cultures from successive amniocenteses, and between amniotic cell cultures and fetal tissues obtained after abortion. 6 Most recently Sutherland and associates~ also documented their experience with six cases of mosaicism in amniotic cell cultures. We, too, have recently encountered a disturbing case of chromosomal mosaicism, among a handful o f experiences -~ in over 1,000 cases studied. A 31-year-old, gravida 2, para 0 patient elected an amniocentesis for prenatal genetic studies because her first pregnancy had ended with the delivery of a stillborn with anencephaly. There was no other pertinen t family history. Amniocentesis was performed at 16 weeks of pregnancy and chromosomal analysis revealed 124 cells with a normal XY karyotype and 11 cells (8.2%) with a 47, XXY karyotype, confirmed with trypsin banding. The parents were duly informed of this result and the option of terminating the pregnancy was raised. Because of known difficulties in making the prenatal diagnosis of chromosomal mosaicism, a second amniocentesis was offered for confirmatory studies. The parents elected this approach, and cytogenetic observations on the second amniotic fluid studied revealed only a normal 46, XY karyotype in 71 metaphases examined. During careful counseling of both parents together, clear indication was given that the dilemma of mosaicism had in fact not been excluded and that it remained entirely possible for the cells from the second sample studied to have simply originated from multiple though normal cell lines (multiple dishes of amniotic cell cultures were studied each time). The option for terminating the pregnancy was again raiSed. The parents elected to continue the pregnancy, and a normal-appearing phenotypic male was duly delivered. Chromosomal analysis of 30 cultured peripheral
