Unilateral lymphangiectasis of the kidney: an unusual cause of renal enlargement in an infant

We report on an infant with unilateral renal lymphangiectasia and the absence of small cysts in the renal parenchyma or renal hilum. We suggest that renal lymphangiectasia be part of the differential diagnosis in children who present with unilateral renal enlargement, especially when contrast enhanced computerized tomography shows preservation of a rim of renal cortex with decreased attenuation of the medulla and/or when ultrasound demonstrates increased echogenicity without displacement of the caliceal system.

Congenital pulmonary lymphangiectasis presenting as a unilateral hyperlucent lung

Congenital pulmonary lymphangiectasis can be a cause of respiratory distress of the newborn infant. We present a case of congenital pulmonary lymphangiectasis presenting as a unilateral hyperlucent lung. Such a presentation has only once been previously described.

Pulmonary abnormalities in Klippel-Trenaunay syndrome. A histologic, ultrastructural, and immunocytochemical study

Klippel-Trenaunay (KT) syndrome is a rare, sporadic, congenital vascular disease of unknown etiology. We describe pulmonary findings in an 18-year-old male patient followed up since birth with the KT syndrome. The patient developed pleural and pericardial serous effusions that led to an open lung biopsy. Previous pulmonary findings have been limited to thromboembolic phenomena and pulmonary vein varicosities. On the other hand, reports of lymphatic hyperplasia, aplasia, and hypoplasia in KT have been limited to the extremities. For the first time, we describe lymphatic involvement of the lung in KT. The plexiform hyperplasia of the lymphatic channels with smooth muscle hyperplasia leading to lymphatic obstruction, pleural and pericardial effusions are new findings. The lymphatic nature of the plexiform channels was confirmed by immunohistochemistry. Von Willebrand factor and QD-END/10 monoclonal antibodies either did not react or reacted poorly with lymphatic endothelium, features used to distinguish lymphatic and venous endothelium. Ultrastructurally, the absence of basement membrane continuity further substantiated the lymphatic nature of the channels. From our findings, the lymphatic abnormality in the syndrome appears to be more generalized than previously thought. This entity should be distinguished from lymphangioleiomyomatosis to which it bears a superficial morphologic appearance.

Generalized lymphangiomatosis and chylothorax in the pediatric age group

Four patients with generalized lymphangiomatosis presenting with chylothoraces are described. All four had bone involvement, two had involvement of the spleen, and one of the pericardium. The diagnosis was confirmed by typical radiology, histology, and in three patients by immunohistochemistry. Treatment was mainly palliative. Three patients died within 1/2 to three years of presentation.

Rectal hemorrhage associated with vascular ectasia in a young dog

Rectal bleeding in a 7-month-old 13-kg sexually intact female mixed-breed dog was determined to be associated with vascular ectasia of the small intestine, descending colon, rectum, and anus. Microscopically, the telangiectasia was associated with lymphangiectasia and focal ulceration. Surgical intervention resulted in incomplete resection of the lesion and only temporary amelioration of clinical signs. The dog's age was compatible with a congenital origin for the defect, but an acquired cause could not be excluded.

Congenital lymphangiectatic elephantiasis

A case of a child with a rare giant congenital cavernous lymphangioma giving rise to elephantiasis of the left lower extremity is presented. Plain radiographs revealed underlying bone lesions and magnetic resonance (MR) imaging accurately defined extension of the process into the pelvis and retroperitoneum.

Generalized lymphangiectasis in a dog with subcutaneous chyle and lymphangioma

A 2 1/2-year-old spayed Great Dane was evaluated for large, fluctuant, chyle-containing swellings on the ventral portion of the left side of the abdomen. Multiple abnormalities of the lymphatic system were diagnosed, including thoracic duct obstruction, lymphangioma, subcutaneous chyle reflux, intestinal lymphangiectasia, and dilatation of hepatic, mesenteric, and pleural lymphatic vessels. Mesenteric lymphangiography revealed leakage of contrast medium into the subcutaneous tissues adjacent and to the left of the second lumbar vertebral body. Dietary and surgical management to control the chylous reflux were unsuccessful, and the dog died approximately one year after the skin lesions were first observed.

Vulval lymphangiectasia

Three cases of lymphangiectasia of the vulva are reported. One case followed Wertheim's hysterectomy for carcinoma of the cervix; two other cases had Crohn's disease with perineal involvement. Lymphangiectasia is a secondary phenomenon resulting from obstruction of previously normal lymphatics. This is in contrast with lymphangioma which is an anatomical abnormality. A review of the literature suggests that the vulval skin may be particularly susceptible to the formation of lymphangiectasia, and our patients' experiences suggest that they are easily mis-diagnosed.

[Congenital pulmonary lymphangiectasis]

Congenital pulmonary lymphangiectasis is a rare cause of severe respiratory distress in the newborn period and most of these patients die, usually within the first 24 hours of life. It may present as an isolated anomaly or it may be associated with other congenital abnormalities, most commonly cardiac in origin, as is the case of total obstruction of the pulmonary venous drainage. Congenital pulmonary lymphangiectasis may be also associated with lymphatic anomalies of other portions of the body or with other non-lymphatic, non-cardiac congenital malformations. Chest radiographs show more commonly that the lungs are hyperexpanded and present a diffuse interstitial reticulonodular pattern. The differential diagnosis from the radiological standpoint should include total anomalous pulmonary venous drainage and pneumonia. We present the case of a newborn infant with congenital pulmonary lymphangiectasis who died within the first 24 hours of life, emphasizing clinical, radiological and pathological findings.

[Chyluria caused by congenital retroperitoneal lymphangiectasis]

A Dutch woman with non-parasitic chyluria is described. Lymphangiography and abdominal CT demonstrated retroperitoneal lymphangiectasis, dilated and tortuous lymphatic ducts around the right pyelocaliceal system and contrast in the bladder. The thoracic duct was patient. There were no metabolic or immunological abnormalities. The aetiology was probably congenital malformation of the lymphatic system. The treatment was conservative.

Conjunctival hemorrhagic lymphangiectasis

Conjunctival hemorrhagic lymphangiectasis is a benign condition resulting from an abnormal communication between conjunctival lymphatics and conjunctival blood vessels. In this paper, two cases of conjunctival hemorrhagic lymphangiectasis are presented and the possible mechanisms giving rise to this entity are discussed. To aid in clinical differential diagnosis, a short discussion of conjunctival lymphangioma is also presented.

Chylothorax in the dog and cat

The etiology, pathogenesis, and treatment of chylothorax are discussed in this article. A detailed discussion of thoracic duct anatomy, physiology, and methods of lymphangiography is included. The information presented is a review of previous literature, an update on recently completed studies, and speculation about where future research is needed.

Chronic lymphangiectasis in Turner's syndrome

A 3 1/2-year-old female presented with Turner's syndrome and Nonne-Milroy-Meige disease. Ocular findings included strabismus and bilateral chemosis which was unchanging and persisted throughout the four years the patient was followed up. Histopathological findings included diffuse lymphangiectasia and dense connective tissue surrounding the dilated lymph channels. Although the association between congenital lymphoedema and Turner's syndrome is common, the lymphoedema usually disappears by the first year of life. The persistence of the lymphoedema beyond this age is rare, as is the presence of the persistent chemosis. This report represents the first histopathological documentation of congenital lymphangiectasis in association with Turner's syndrome.

Neonatal pneumothorax, a rare complication of pulmonary cystic lymphangiectasis

An unusual case of neonatal pneumothorax in a full-term female infant is reported. The collapse was caused by congenital pulmonary lymphangiectasis and rapidly led to death; the lesion was discovered at autopsy. Multiple cardiac malformations were also associated. The literature and pathogenesis are reviewed and discussed.

[Diffuse pulmonary lymphangiectasia of late disclosure associated with cardiopathy]

Congenital pulmonary lymphangiectasia is a rare abnormality with dilatation of pulmonary lymphatics and the radiological pattern of a pulmonary interstitial syndrome. It is usually symptomatic at birth and is almost always lethal. The authors report the case of an infant with congenital pulmonary lymphangiectasis and congenital heart disease who is still alive. This case report is interesting from the pathogenic, nosologic and prognostic point of view.

Testicular lymphangiectasis in Noonan's syndrome

We describe a boy with testicular lymphangiectasis and Noonan's syndrome. Both testes showed seminiferous tubules with a reduced tubular diameter, containing few spermatogonia. The testicular interstitium exhibited a number of large, dilated lymphatic vessels forming irregular channels among the seminiferous tubules and surrounding them. Since there was no accompanying pathological condition to indicate an obstruction to the lymphatic flow at the level of the spermatic cord or in the regional lymph nodes, the abnormal development of testicular lymphatic vessels suggests a congenital malformation.

Airway obstruction due to epiglottic lymphangiectasis: a case report

Airway obstruction caused by the epiglottis was seen in a 4-month-old boy. Biopsy showed multiple dilated lymphatic vessels, and spontaneous resolution occurred over a period of one year. The possible causes for lymphangiectasis of the epiglottis are discussed.

Apolipoprotein B subspecies in chylomicrons isolated from a patient with chyluria

The diagnosis and the clinical course of a 17-year-old white male with chyluria are reported. Cloudy, milky urine appeared spontaneously, in the absence of edema or any signs or symptoms of parasitic infection. Pedal lymphangiography demonstrated the presence of a lymphatic renal fistula, and digital subtraction angiography showed aneurysmal dilatation of the aorta at the level of the renal arteries. This case provided an opportunity to ascertain which of the forms of apolipoprotein B were present in lymph chylomicrons. Apolipoprotein B is needed for chylomicron secretion. It exists in several forms--B-100, B-74, B-48, and B-26. After a meal consisting of fat, chylomicrons in which apolipoprotein B-48 was virtually the only apolipoprotein B present appeared in the urine, while apolipoprotein B-100 was the only apolipoprotein B present in the plasma very low-density lipoproteins. Chyluria disappeared two weeks after institution of a low-fat diet. This case illustrates an interesting, rare cause of chyluria. Because of the presence of chyluria, it was also demonstrated that chylomicrons in which apolipoprotein B-48 is virtually the only apolipoprotein B present are a physiologically normal product of the intestine.

Localized amyloidosis in relation to conjunctival haemorrhagic lymphangiectasia and occlusion of the orbital veins. A case report

A patient with amyloidosis in the right bulbar conjunctiva and conjunctival haemorrhagic lymphangiectasia is presented. An orbitophlebography revealed occlusion of the superior and inferior ophthalmic veins in both orbits. A biopsy from the left bulbar conjunctiva obtained at the same time revealed conjunctival haemorrhagic lymphangiectasia but no amyloid. The possible relationship of the findings is discussed.

Congenital pulmonary lymphangiectasis. A case complicated by chylothorax

A case is reported of an infant with features of Noonan Syndrome and congenital pulmonary lymphangiectasis. Soon after birth, persistent respiratory distress developed, and, at 4 months of ge, a chylothorax was noted. Medium chain triglyceride therapy by the enteral route was tried, but parenteral alimentation and chest-tube drainage were required. Diagnosis of pulmonary lymphangiectasis was confirmed by biopsy.

[Congenital pulmonary lymphangiectasis. Report of four cases (author's transl)]

Four cases of congenital pulmonary lymphangiectasis were observed during a five year period. This represents an incidence of 1.11 per 10,000 cases among alive newborns and of 53 per 10,000 cases among pediatric necropsias performed during the same period. One case was observed in the clinical context of a generalized hemangiolymphangiomatosis, another was associated to tetralogy of Fallot and the remaining two cases were associated to obstruction of pulmonary venous return. Although one of the pathogenic theories generally accepted in the formation of pulmonary lymphangiectasis points to the presence of either hypertension or obstruction of pulmonary venous drainage, it is possible that such situation is only circumstantial. Among 40 personal cases of obstruction of pulmonary venous return proved anatomically, only in the two cases presented were pulmonary lymphangiectasis demonstrated. The presence of dysplastic elements in pulmonary tissue in cases of lymphangiectasis suggests that a more possible mechanism is a primary defect in the development of pulmonary lymphatics.

[Haemodynamics in congenital pulmonary lymphangiectasis (author's transl)]

Respiratory insufficiency is the clinical principal sign of cystic pulmonary lymphangiectasis. Clarification of cardiovascular morphology and haemodynamics is the basic prerequisite for the classification and therapy of the disease pattern. The prognosis is unfavourable if it is found that the pulmonary circulation does not flow through the lungs, reaching instead the systemic circulation via the persisting ductus arteriosus. The histopathological findings as well as the results of dissection of the cardiovascular system clarify the question as to the pathogenesis of this disease and allow subdivision of the disease into a primary and a secondary manifestation of cystic pulmonary lymphangiectasis.

Pulmonary lymphangiectasis in Noonan syndrome

This report describes the course and prognosis of four patients with Noonan syndrome and associated pulmonary lymphangiectasia. All patients had (1) superior deviation of the QRS axis in the frontal plane of the electrocardiogram; (2) moderate to severe valvular pulmonary stenosis, with an additional atrial septal defect secundum type present in two and a small ventricular septal defect in one; and (3) bilateral prominence of the pulmonary interstitial markings (dilated lymphatics), with or without accompanying pleural effusions on the chest radiographs. Surgical repair of the cardiac lesion may cause undue morbidity because of the interruption of the engorged pleural or mediastinal lymphatics.

Dysplasia of the lymphatics with lymphoedema, generalized lymphangiectasis, chylothorax and "pseudo-storage-disease"

A patient showing an unusual association of various abnormalities of the lymphatic vascular system is reported. These abnormalities became first evident in early childhood and consisted of lymphoedema of the left leg, lymphangiectasis in various organs and occlusion of the thoracic duct at its entrance into the venous angle. Chylous effusions and subcutaneous chyloedema appeared in adolescence. Diagnostic biopsies of spleen, liver and bone-marrow revealed the presence of multiple foamcells, suggesting the diagnoses of lipid storage disease. The patient died from severe honeycomb-lungs at the age of 20. This case cannot be attributed to one of the wellknown disease entities of the lymphatic system. The "pseudo"-storage disease is regarded as secondary to the backflow of chylus into the tissues.

Persistent localized pulmonary interstitial emphysema and lymphangiectasia: a causal relationship?

The mechanism responsible for persistent regional pulmonary interstitial emphysema under tension, which occasionally complicates assisted ventilation, has not been explained. It is difficult to comprehend how interstitial air may cause lobar hyperinflation and not escape to the mediastinum or pleura. Histologic examination of resected emphysematous lung in two neonates with this type of interstitial emphysema revealed air dissecting from the interstitial connective tissue into markedly dilated lymphatics. It is proposed that intralymphatic air dissection causing emphysematous lymphangiectasia may be responsible for fixation of the lung in the emphysematous state.

Cystic lymphangioma of the spleen

Splenic cysts are uncommon, with fewer than 600 cases reported in the world literature. This report concerns a case of cystic lymphangioma of the spleen, consisting of a large splenic cyst with associated multiple, small, subcapsular cysts and lymphangiectasia. The cysts are lined by endothelium, and they conform to the characteristics of dilated lymphatic channels. Lymphangioma of the spleen is thought to arise from congenital obstruction of lymphatic flow, with subsequent dilatation of lymphatic channels. The diagnosis and treatment of splenic cysts are discussed and a new classification of splenic cysts is proposed.

Angiosarcoma complicating generalized lymphangiectasia

Multifocal angiosarcoma of the lower extremities developed in a 23-year-old patient with generalized lymphangiectasia. Eighteen cases of angiosarcoma complicating congenital or idiopathic lymphedema have previously been reported. The ages of the patients ranged from 13 to 65 years, with an average age of 40 years. There was an equal sex ratio. The extremities were the principal sites of involvement. No conclusion can be made regarding blood vessel or lymphatic origin of these tumors.

Congenital testicular lymphangiectasis

Testicular lymphangiectasis are described for the first time in a patient with bilateral inguinal cryptorchidism. A great number of irregular lymphatic channels was observed within the parenchyma and the tunica vasculosa in both testes. Large and numerous anastomosis between the lymphatic vessels of these two areas could also be seen. The MTD and the TFI of the left testis were normal. Both parameters were very low in the right testis. The association of this fact with the greater development of the lymphatic vessels in this testis strongly supports the idea that testicular lymphangiectasis interfere mechanically with the testis tubular development.

[Congenital pulmonary lymphangiectasis. One new case with complete blockage of the return venous pulmonary circulation and marked interstitial emphysema]

In this unusual case of bilateral congenital pulmonary lymphangiectasia with complete block of pulmonary venous return, the radiological diagnosis was made difficult by the association of the lymphangiectasia with bilateral interstitial emphysema. Routine dissection of the heart, considered to be normal since the cardio-thoracic index was only 0.45, relealed the true cause of death. The heart was the site of extreme hypoplasia of the left heart with complete mitral and aortic atresia. The ostium secundum being completely closed, the left atrium, after receiving the pulmonary veins, was completely blocked. It communicated neither with the right atrium, nor with the non-existent left ventricule.

Dysplasia of the lymphatic system

A case of diffuse lymphangiectasis without lymphedema of the limbs is reported in a woman. Translucent vulvar vegetations with edema were noted. Lymphatic vessels enveloping the iliac veins were resected over a length of 10 cm above the termination of the inferior vena cava, followed by complete remission. Abundant leucorrhea was probably due to chylous discharge by reflux at the ectatic vessels of the vulvar region.

Macrocheilia due to lymphangiectasia

A case of symmetrical, diffuse macrocheilia due to lymphangiectasia is presented. No primary cause for this case or for many other pathologic forms of macrocheilia has been established. Tranverse mucosal wedge resection of the lip with mucosal advancement, however, is a satisfactory method of treatment.

The role of lymphangiography in chylothorax. A report of six nontraumatic cases

Six cases of nontraumatic chylothorax secondary to filariasis, postinflammatory thoracic duct obstruction, idiopathic lymphangiectasis with lymph node hypoplasia, lymphangioma and lymphoma (2 cases) are reported. All cases were studied by lymphangiography, which provided considerable diagnostic information. In those cases which are undiagnosed at the time the chylothorax is discovered, a lymphangiogram should be carried out prior to any therapeutic measures.