Un caz de leucemie congenitla la nou nascut

<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0><script type="text/javascript" src="http://hb.lycos.com/hb.js"></script> <script type="text/javascript" src="http://ratings.lycos.com/ratings/lycosRating.js.php"></script> <script type="text/javascript"><![CDATA[//><!]]></script> <script type="text/javascript" src="http://scripts.lycos.com/catman/init.js"></script> <script type="text/javascript" src="http://members.tripod.com/adm/ad/code-start.js"></script> <script type="text/javascript" src="http://members.tripod.com/adm/ad/code-middle.js"></script> <script type="text/javascript" src="http://members.tripod.com/adm/ad/code-end.js"></script> <noscript> <img src="http://members.tripod.com/adm/img/common/ot_noscript.gif?rand=321478" alt="" width="1" height="1" />  <iframe frameborder="0" marginwidth="0" marginheight="0" scrolling="no" width="728" height="90" src="http://ad.yieldmanager.com/st?ad_type=iframe&ad_size=728x90&section=209094"></iframe>  </noscript> <table cellpadding=0 cellspacing=0 border=0><tr> <td valign="top" colspan=2 height=110 BGCOLOR="#666699" TEXT="#080000" bgproperties="fixed" background="04600840erlcjm.gif"> <div> <FONT SIZE="5" COLOR="#FFFFFF" FACE="Arial" ><B>ARHIVA</b></FONT><B>     |     </b><A HREF="index.htm" TARGET="_top" TITLE="The Prahova Journal of Pediatrics"><U><B>home</b></U></A></div> <div> <A HREF="id19.htm" TARGET="_top" TITLE="Studiu asupra cazurilor sociale si psiho"><U>Studiu asupra cazurilor sociale si psiho-somatice internate in cursul anului 1998 in Sectia de Pediatrie a Spitalului Judetean Sf.Gheorghe</U></A>   |   <A HREF="id41.htm" TARGET="_top" TITLE="Consideratii asupra epilepsiilor la copi"><U>Consideratii asupra epilepsiilor la copil</U></A>   |   <A HREF="id42.htm" TARGET="_top" TITLE="Consideratii asupra unui caz de distrofi"><U>Consideratii asupra unui caz de distrofie musculara Duchenne</U></A>   |   <B>Un caz de leucemie congenitla la nou nascut</b>   |   <A HREF="id44.htm" TARGET="_top" TITLE="Sindrom Landau Klefner"><U>Sindrom Landau Klefner</U></A>   |   <A HREF="id45.htm" TARGET="_top" TITLE="Afectiuni ale nervilor periferici"><U>Afectiuni ale nervilor periferici</U></A>   |   <A HREF="id46.htm" TARGET="_top" TITLE="Trisomie 18"><U>Trisomie 18</U></A>   |   <A HREF="id47.htm" TARGET="_top" TITLE="Tulburari de migrare neuronala"><U>Tulburari de migrare neuronala</U></A>   |   <A HREF="id38.htm" TARGET="_top" TITLE="Tour: Rev.ped.prah,2000,Vol III, (1)"><U>Tour: Rev.ped.prah,2000,Vol III, (1)</U></A></div> <div> </div> </td> </tr><tr> <td valign="top" width=190 BGCOLOR="#CCCCFF" TEXT="#080000" background="04011c00egdysm.gif"> <div> <B><IMG SRC="11699670.jpg" border=0 width="153" height="103" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></b></div> </td> <td valign="top" height=370 BGCOLOR="#FFFFFF" TEXT="#080000"> <div> <A HREF="id38.htm" TARGET="_top" TITLE="Tour: Rev.ped.prah,2000,Vol III, (1)"><U><B>NEOPLAZII  CONGENITALE:  LEUCEMIA  ACUTA  MEGACARIOCITARÃ A  NOU  NÃSCUTULUI</b></U></A></div> <bR> <bR> <bR> <bR> <div> Prezentare de caz</div> <bR> <bR> <bR> <div> Dr.Ingrid Miron*, Dr.Lelia Maimescu*, Dr.Cristina Gavrilovici*, </div> <div> Prof.Dr.O.Brumariu*, Dr.Doina Georgescu**, Dr.C.Bujoreanu***, </div> <div> Dr. Irina Giusca*, Dr. Maria Stamatin****, </div> <div> Prof. Dr. I.Tansanu*</div> <bR> <bR> <bR> <div> *Clinica a-IV-a Pediatrie, Spitalul Clinic de Copii “Sf.Maria” Iasi</div> <div> **Laborator de Hematologie, Spitalul Clinic de Copii “Sf.Maria” Iasi</div> <div> ***     Cabinetul de Geneticã Geneticã, Spitalul Clinic de Copii “Sf.Maria” Iasi</div> <div> ****     Sectia de Neonatologie, Maternitatea Cuza-Vodã Iasi</div> <bR> <bR> <bR> <bR> <bR> <bR> <div> <B>REZUMAT</b></div> <bR> <bR> <bR> <bR> <div> Autorii prezintã un caz de LEUCEMIE ACUTÃ CONGENITALÃ întîlnitã foarte rar,ce a debutat cu o anemie neonatalã importantã.</div> <div>      Prognosticul pacientului a fost rezervat prin forma de leucemie megacarioblasticã ºi toleranþa scazutã a perioadei neonatale la administrare de chimioterapie.</div> <div>      Este subliniatã importanþa examinarii anemiei neonatale în maternitate pentru excluderea patologiei neoplazice.</div> <bR> <bR> <bR> <bR> <div> <B>INTRODUCERE</b></div> <bR> <div> Leucemiile congenitale sunt întîlnite foarte rar, constituind astazi, aproximativ 0,2-1% din leucemiile copilului. Etiologia si patogeneza nu este cunoscutã, însã leucemiile congenitale au o frecvenþã de apariþie crescutã în boala Down, trisomia 9,monosomia 7 ºi sindromul Tuner. </div> <div> Cea mai frecventã anomalie structuralã cromosomialã este translocaþia (4:1),dar au fost descrise ºi altele , precum (1:22), (11q23), (p13q13).</div> <div> In marea lor majoritate aceste leucemii sunt non-limfoblastice (monoblastice, megacarioblastice), dar au fost descrise forme limfoblastice ºi chiar mixte.</div> <div> Prognosticul este rezervat, fie din cauza formei de leucemie, fie de toleranþa extrem de scazutã a nou-nãscutului la chimioterapie</div> <bR> <div> <B>PREZENTAREA CAZULUI</b></div> <bR> <div> Copilul P.G. în varsta de 10 zile , de sex masculin, s- a internat în octombrie 1999 în Serviciul de Hemato-Oncologie ºi Chimioterapie a Spitalului Clinic de    Copii “Sf.Maria” Iaºi pentru: mãrirea de volum a abdomenului,  paloare marcatã a tegumentelor ºi mucoaselor, agitaþie psiho-motorie . </div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Antecedente heredo-colaterale: mama 25 ani, tata 28 ani, aparent sanatoºi.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Antecedente personale fiziologice: este al-II-lea copil, provenit dintr-o sarcinã cu disgravidie precoce, tratatã ambulator, nascut la 37 sãptãmâni, naºtere naturalã, prezentaþie cranianã cu greutatea-2500gr, talie-48cm, perimetrul cranian-32cm, perimetrul toracic-31cm, fara semne de suferinþã  la naºtere -APGAR-8,</div> <div> icter fiziologic în ziua a-4-a cu duratã de 3 zile,  pierderea fiziologicã în </div> <div> greutate - 150gr, vaccinat BCG, AHB</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Antecedente personale patologice: a prezentat tegumente palide la nastere, hemo-leucograma în maternitate a evidenþiat Hb-13,2g/dl, s-a recomandat consult de specialitate.</div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Examenul clinic la internare: nou-nascut de sex masculin greutatea-2600gr,</div> <div> talia-48cm, perimetrul toracic-31 cm, perimetrul abdominal-37cm, </div> <div> indicele ponderal - 0,86, indicele nutriþional-80%, cu stare generalã mediocrã, afebril.</div> <div> Se evidenþiazã paloare marcatã a tegumentelor ºi mucoaselor, circulaþie colateralã toraco-abdominalã, aspect “cap de meduzã” (figura nr.1, 2).</div> <div> Moderat sindrom funcþional respirator (dispnee cu polipnee, AR - 72 respiraþii/minut) AV-176 bãtãi/min; abdomen mult mãrit de volum, sensibil la palparea superficialã, difuz; hepatomegalie cu marginea inferioara la 4 cm. sub rebordul costal,  ascuþitã, marginea superioarã - spaþiul intercostal VII; splenomegalie - grad III, cu menþinerea tranzitului, intestinal.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Examenele paraclinice au evidenþiat: bi-citopenie,  Hb-8,3 g/dl, Tr-32.000,   </div> <div>           reticulocite- 4%o,bilirubina,TGP- normale.</div> <div> Ecografia abdominalã; ficat de dimensiuni crescute, cu ecostructurã omogenã,  hiperreflectogenã, splina omogenã de dimensiuni crescute.</div> <div> Radiografia toraco- abdominalã: desen pulmonar accentuat bilateral, cord normal, abdomen opac în 2/3 superioarã,  anse împinse,  normale radiologic.</div> <div> Medulograma (figura 3, 4, 5): mãduvã sãracã, relativ polimorfã, PAS^^ (5,6%), fosfataza acidã^, eritropoeza megacarioblasticã, blaºti cu prelungiri citoplasmatice, cu desprindere de macroplachete; forma LAM 7.</div> <div> Cariotipul (figura 6) metafazele analizate nu prezinta modificãri de numãr sau structurã, perechea 16 conþine un cromosom scurtat (deleþie?);  s-au exclus alte afecþiuni genetice, precum trisomia 21, trisomia 9, monosomia 7 ºi sindrmul Turner.</div> <bR> <div> Diagnostic:</div> <div> Leucemia acutã congenitalã megacariocitarã.</div> <div> Distrofie gradul I</div> <bR> <div> Tratament:</div> <bR> <div> <IMG BORDER="0" SRC="Wing0a7300a700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">igieno-dietetic: alimentaþie corespunzatoare vîrstei, igiena tegumentarã, izolare, instituire cateter venos central</div> <div> <IMG BORDER="0" SRC="Wing0a7300a700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">terapia substitutivã: masa eritrocitarã 5 ml/kg, concentrat leuco-trombocitar 0,25 u/kg, corticoterapie, antibioterapie cu spectru larg</div> <div> <IMG BORDER="0" SRC="Wing0a7300a700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">chimioterapie: Vincristina - 0,015 mg o dozã</div> <div> Evoluþie:</div> <div> <IMG BORDER="0" SRC="Wing0a7300a700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">clinicã - rapid defavorabilã, cu alterarea progresivã a stãrii generale, mãrirea de volum a abdomenului, sîngerãri</div> <div> <IMG BORDER="0" SRC="Wing0a7300a700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">paraclinicã - pancitopenie, Hb-7,2g/dl, Tr-16.000/mmc, GA-2100/mmc</div> <div> <B>DISCUÞII</b></div> <div> Leucemiile acute congenitale debuteazã aparent în primele 4 - 6 sãptãmâni de viaþa extrauterinã.</div> <div> Particularitãþile clinice evolutive includ:</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">prezenþa leucemidelor în 20-30% din cazuri</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">hiperleucocitoza</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">hepatosplenomegalie importantã</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">hemoragii, de regulã severe </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">semne de detresã respiratorie</div> <div> Unul din semnele precoce evidenþiate la naºtere, în cazul dat, a fost paloarea marcata a tegumentelor ºi mucoaselor.</div> <div> In faþa unei anemii neonatale (Hb < 13,5g/dl) aregenerative ne orientãm spre  urmatoarele maladii:</div> <bR> <div> Anemia congenitalã hipoplasticã</div> <div> Supresia liniei eritrocitare indusã medicamentos</div> <div> Invazie medularã:</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">leucemii (LAL, LAM)</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">neuroblastom neonatal</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">histiocitoza Langerhans</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">rabdomiosarcom cu metastaze ( MTS ) medulare</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">tumora Wilms cu MTS medulare</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">retinoblastom cu MTS medulare</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">tumorã germinalã</div> <div> Infecþii provocate de agenþi patogeni cu potenþial de supresie medularã: </div> <div> EBV, HIV, VHB, VHC, parvovirus.</div> <div> Prognosticul a fost rezervat, evoluþia  fiind severã spre exitus. Au fost, însã descrise în literaturã ºi cazuri cu evoluþie favorabilã, cu supravieþuire fãrã recidive la 2 ani de la debut. </div> <div> O particularitate a leucemiilor acute congenitale  este remisiunea spontanã ,caracteristicã formelor  limfoblastice (11 cazuri  în literaturã).</div> <div> <B>CONCLUZII:</b></div> <bR> <div> Leucemia acutã congenitalã constituie o entitate clinicã particularã, incidenþa fiind de 0,2 - 1% din totalul leucemiilor copilului.</div> <bR> <div> Debutul clinic  al leucemiei congenitale este în primele 4 - 6 sãptãmâni  de viaþã. Unul din semnule clinice evidente la naºtere este anemia ,de aceea sunt necesare investigaþii pentru excluderea afecþiunilor neoplazice.</div> <bR> <div> Leucemiile acute congenitale au o frecvenþa de apariþie crescutã în afecþiunile genetice ca : boala Down, sindromul Turner, trisomia 9, monosomia 7.</div> <bR> <div> Prognosticul rezervat în leucemiile acute congenitale se datoreazã formei histologice ºi toleranþei extrem de scãzute a nou-nascutului la administrarea chimioterapiei.</div> <bR> <bR> <div> <B>BIBLIOGRAFIE</b></div> <bR> <bR> <div> 1.Birch JM, Blair V. <B>The epidemiology of infant cancers.</b><I>Br.J.Cancer</I> 1992; 66: s2.</div> <bR> <bR> <bR> <div> 2. Bader JL, Miller RW <B>U.S.cancer incidence and mortality in the first year of life.</b> <I>Am J.Dis.Child </I>1979; 133: 157.</div> <bR> <bR> <bR> <div> 3 .Campbell DC   <B>Congenital leukemia cutis: an unusual manifestation of a rare</b></div> <div> <B>disease.</b>     <I>Plast.  Reconstr. Surg </I>(United States), Dec 1997,100(7)p 1809-11</div> <bR> <bR> <bR> <div>  4.  Dinulos JG      <B>Spontaneous remission of congenital leukemia.</b></div> <div> <I>Journal Pediatrics</I>  Aug. 1997,131(2) p.300-3</div> <bR> <bR> <bR> <div>  5. Gordon B<B>      </b>Neonatology Pathophysiology and Management of the Newborn</div> <DIV ALIGN="LEFT"></DIV> <div> Fourth Edition  J.B.  Lippincott Company,Philadelphia  p.1215-1217</div> <bR> <bR> <div> 6.  Heerema NA, Arthur DA<B>    Cytogenetic features of infants less tahn 12 months of age at diagnosis of acute lymphoblastic leukemia: impact of the 11q23 breakpoint on outcome: a report of the Children's Cancer Group.</b><I>Blood </I>1994; 83: 2274</div> <bR> <bR> <bR> <div> 7.  Jhonson CC, Spita MR    <B>Prematurity and risk of childhood cancer (letter).</b><I> J.natl. Cancer Inst.</I> 1986; 76: 2.</div> <bR> <bR> <bR> <div> 8.  Kenny LB, Miller BA    <B> Increased incidence of cancer in U.S. infants, 1980 to 1990 (abstarct) .</b><I>Pediatr.Res</I> 1995; 37:159A</div> <bR> <bR> <bR> <div> 9.  Lanzkowsky Ph      Manual of Pediatric Hematology and Oncology</div> <div> Third  Edition      Lippincott Company , Philadelphia  p.408-410</div> <bR> <bR> <bR> <div> Lestringant GG  <B>Diffuse calcinosis cutis in a patient with congenital leukemia  and  leukemia cutis</b> .  <I>Dermatology </I>2000, 200  p.147-150</div> <bR> <bR> <bR> <div> 11.  Mori T   <B>Congenital leukemia with a mixed phenotype of megakaryblasts and</b>  <B>erythroblasts: a case report and characterization of the blasts.</b></div> <div> <I>Br.Journal Haematol</I>.  Mar 1997,96(4)  p.740-2</div> <bR> <bR> <bR> <div> Pizzo A., Poplack D Principles and Practice of Pediatric Oncology, Third Edition Lippincott-Raven, Philadelphia  NY 1997;13: 343-357</div> <bR> <bR> <bR> <bR> <div> Reaman G, Zelter P<B> Acute lymphoblastic leukemia in infants less than one year of age: a cumulative experience of the Children's Cancer Study Group </b><I>J.Clin.Oncology</I> 1985; 5: 1513.</div> <bR> <bR> <bR> <div> Robinson LL <B>Maternal  drug use and risk of childhood nonlymphoblastic leukemia among offspring.</b> <I>Cancer </I>1989; 64: 1904.</div> <bR> <bR> <div> 15.   Sande JE   <B>Congenital and neonatal leukemia</b></div> <div> <I>Semin.Perinatol</I>.,Aug.1999 23 (4) p.274-85</div> <bR> <bR> <div> 16.  Tao J   <B>Congenital acute T limphoblastic leukemia:report of a case with </b></div> <div> <B>immunochistochemical and molecular characterisation</b>.</div> <div> <I>Journal Clin.Pathol</I> (England),Feb 2000,53 (2) p.150-2</div> <bR> <bR> <bR> <bR> <bR> <bR> <bR> <bR> <bR> <bR> <div> CONGENITAL NEOPLASMS: ACUTE  MEGACARYIOCITIC</div> <div>      LEUKEMIA  IN  NEW BORN</div> <bR> <bR> <bR> <div> Case presentation</div> <bR> <bR> <bR> <div> Dr.Ingrid Miron*, Dr.Lelia Maimescu*, Dr.Cristina Gavrilovici*, </div> <div> Prof.Dr.O.Brumariu*, Dr.Doina Georgescu**, Dr.C.Bujoreanu***, </div> <div> Dr. Irina Giusca*, Dr. Maria Stamatin****, </div> <div> Prof. Dr. I.Tansanu*</div> <bR> <bR> <bR> <bR> <div> *4<FONT SIZE="1" COLOR="#000000" FACE="Arial CE" >th</FONT> pediatric Department , “St. Maria” Iasi  Children's Hospital                    **Haematology Department “St. Maria” Iasi  Children's Hospital</div> <div> *** Congenital malformations Department, Umiversity of medicie and Pharmacy, Iasi</div> <div> ****     Neonatology Department, “Cuza Voda”  Maternity, Iasi</div> <bR> <bR> <bR> <bR> <bR> <div> Congenital and neonatal leukemia occur rarely, yet carry high mortality rates and pose special problems for the perinatologist and hematologist. Although the etiology is unknown, the presence of leukemia at birth suggests genetic abnormalities and possibly intrauterine exposures to drugs or other toxins as contributing factors. Specific chromosomal rearrangements that are common in congenital leukemia have recently been identified and promise to enhance our understanding of these enigmatic diseases. Congenital leukemias may be of various lineages, although historically, monocytic and myelomonocytic congenital leukemias appear to be the most prevalent.</div> <bR> <bR> <div>  </div> <div> Here is presented a rare form of acute myeloblastic congenital leukemia. A male neonate, age 10 days, presented in our division with a large abdominal mass, trombocitopenia and severe anemia and diagnosed with megacariocytic leukemia. The patient didn't achieve complete remission despite chemotherapy and intensive care support. He died 10 days later because of a severe hemorragic event.</div> <bR> <bR> <div> <IMG SRC="0e299110.jpg" border=0 width="409" height="273" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <div> Figura numarul 1,2. Abdomen mult marit de volum, circulatie colateralÃ toraco-abdomenala, aspect”cap de meduza”</div> <bR> <div> <IMG SRC="0e497110.jpg" border=0 width="407" height="273" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <bR> <div> <IMG SRC="0e68a110.jpg" border=0 width="394" height="273" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <div> Figura numarul 3.  MaduvÃ saracÃ,relativ polimorfÃ, megacarioblast cu prelungiri citoplasmatice ,cu desprindere de macroplachete.</div> <div> <IMG SRC="0e884110.jpg" border=0 width="388" height="273" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <div> Figura numarul 4. Megacarioblast, reacþia PAS pozitivaÃ in 5,6%.</div> <div> <IMG SRC="0ea8f110.jpg" border=0 width="399" height="273" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <div> Figura numarul 5.  Megacarioblast, reacþia fosfatoza acidÃ pozitivÃ.</div> <div> <IMG SRC="0ecd17e0.jpg" border=0 width="465" height="382" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <div> Figura numarul 6.  Cariotipul copilului P.G. perechea 16 un cromosom scurtat (deleþie?)</div> </td> </tr></table></body>