Generalized lymphangiomatosis and chylothorax in the pediatric age group

Insufficient hepatic uptake in pediatric patients on lymphoscintigraphy

BACKGROUND

To demonstrate the association between pediatric outcomes and tracer hepatic uptake as a marker of systemic circulation in lymphoscintigraphy.

METHODS

We included 31 initial lymphoscintigraphic studies. We compared the presence or absence of hepatic uptake between deceased and survived patients in both early and delayed images using Fisher's exact test. Kaplan-Meier survival analysis was performed based on imaging results, and these curves were compared using the log-rank test. The primary endpoint was death and the survival period was defined from the day of examination to the day of the last visit or death.

RESULTS

Of 31 patients, six died. Hepatic uptake was significantly different in both early and delayed images (early images, died [with/without visualization] vs. survived [with/without visualization], 0/6 vs. 13/12, P = 0.028; delayed images, died [with/without visualization] vs. survived [with/without visualization], 2/4 vs. 22/3, P = 0.014) between deceased and survived patients. Survival periods were significantly different between the two groups with and without hepatic uptake in early and delayed images (with/without visualization in early imags = 1,177.1 ± 773.8 days/426.7 ± 419.8 days, P = 0.008 and with/without visualization in delayed images = 821.3 ± 738.0 days/467.4 ± 452.4 days, P = 0.003).

CONCLUSIONS

Visualization of hepatic uptake in both early and delayed lymphoscintigraphy is associated with patient outcomes. Hepatic uptake could represent tracer inflow into the systemic circulation, indicating preservation of the connection between the lymphatic system and the systemic circulation. Physicians should evaluate these findings carefully on lymphoscintigraphy.

[Interstitial processes of the lungs in childhood]

Interstitial processes in the lungs of children can be due to several underlying diseases. Knowledge of the child's age is important as genetic aberrations play a major role in diseases in the first 2 years, whereas immunological diseases are more common starting in kindergarden age. In general lung diseases are rare in children, which makes the diagnostics difficult and results in a delayed diagnosis. In addition, pediatric pulmonologists are often very reluctant to perform lung biopsies due to a lack of a specialized pathologist. In order to make a contribution to the diagnostics of pediatric pulmonary diseases, pathologists should be specialized in pulmonary pathology, have a good knowledge of genetic methods and fetal lung development, which includes the genetic factors involved in lung growth and differentiation. A close cooperation with the pediatric pulmonologist is necessary and each patient should be discussed jointly on an interstitial lung disease board to promote the quality of diagnostics. The pathologist should be aware that the developing lungs of children are not just a smaller form of adult lungs and often react very differently. In this article, we mainly focus on diffuse infiltration patterns, such as ground glass and reticulonodular infiltrations as described in high-resolution computed tomography (HRCT). Localized interstitial processes, which can sometimes be tumor-like and malformations are not dealt with; however, vascular malformations are included as these often manifest as diffuse interstitial infiltrations and must therefore be taken into consideration for the differential diagnostics.

Lymphangiomatosis of the systemic skin in an old dog

A 13-year-old, neutered male miniature dachshund was presented with a one-month history of bilateral symmetrical swelling in the pinnae and carpal, cubital and tarsal joints, and swelling in the tail. The lesions were histopathologically characterized by multiple dilated lymphatic vessels lined by a single attenuated layer of endothelial cells. The subcutis was predominantly involved. A number of spindle-shaped cells lining the irregular vessels were observed. Morphological atypia was not evident in these cells. Immunohistochemical analyses revealed that the proliferating endothelial cells were positive for factor VIII-related antigen and CD31. Based on the clinical presentation and histopathological features, the dog was diagnosed with lymphangiomatosis. Treatment with anti-inflammatory prednisolone improved the symptoms.

Progressive lymphangiomatosis and Gorham's disease: case report and clinical implications

Lymphangiomatosis is a rare proliferative disorder of the lymphatic system. The etiology is unknown, rendering it difficult to manage. This case report of lymphangiomatosis with features of Gorham's disease reveals the progressive and unexpected nature of the condition. It highlights the need for further research into the pathophysiology and management of lymphangiomatosis as current treatment options are limited.

Therapeutic strategies for idiopathic chylothorax

STUDY OBJECTIVES

The objectives of the study were to present our institutional experience of idiopathic chylothorax in children and to propose therapeutic strategies.

DESIGN

This was a retrospective, single-center study.

PATIENTS

Patients were 6 children (4 boys, 2 girls) presenting with an idiopathic chylothorax diagnosed from the presence of a chylous pleural effusion with triglycerides greater than 1.2 mmol/L and a cellularity greater than 1000 cells/mL with a predominance of lymphocytes.

RESULTS

Median age of onset was 7 years (range, 2-14 years). Initial symptoms included cough (n = 4), tachypnea (n = 4), asthenia (n = 5), abdominal pain (n = 2), and bronchitis (n = 1). Chest radiography showed 2 left, 2 right, and 2 bilateral pleural effusions. Serum biology assessment was normal in all children. Respiratory function assessment at diagnosis revealed a decrease in functional residual capacity in 3 children and a decrease in lung diffusing capacity in 2 children. Initially, all patients received a medium-chain triglyceride diet for 29 months (range, 10-50 months). Total parenteral nutrition was required for 4 patients (for 1-4 months), and somatostatin was tried in one child. Two children required pleuroperitoneal shunting, bilateral in one case. During the follow-up (median duration, 6 years; range, 2-16 years), chylothorax stabilized in all patients and 5 patients were able to return to a normal diet.

CONCLUSION

A medium-chain triglyceride diet associated in some cases with total parenteral nutrition may stabilize idiopathic chylothorax in children. In cases where conservative treatment has failed, pleuroperitoneal shunting may be useful.

Unique diagnostic features and successful management of a patient with disseminated lymphangiomatosis and chylothorax

Disseminated lymphangiomatosis is a rare vascular tumor characterized by a proliferation of abnormal lymphatic channels that often involves multiple organ systems. One particularly morbid manifestation of this disorder is the presence of bony lytic lesions with associated chylothorax. Because of its unusual nature, this condition is often a diagnostic and therapeutic challenge. In this report, we present the diagnostic features, including a unique radiologic finding, and successful management of a 7-year-old girl with this condition using a combination of aggressive surgery and medical treatment with interferon and pamidronate.

Generalized lymphangiomatosis: radiologic findings in three pediatric patients

Generalized lymphangiomatosis is a rare disease that is characterized by widespread bony and soft tissue involvement of lymphangioma. Radiological evaluation is crucial because the site and extent of the lymphangioma are important prognostic factors. We reported here on three cases of generalized lymphangiomatosis and all three cases showed similar radiologic findings, but a different clinical course. The CT, US and MR images showed sharply defined, non-enhanced cystic lesions involving the mediastinum, bones, spleen, lung and lower neck. The whole body MR imaging with the short tau inversion recovery (STIR) sequence showed good capability for evaluating the extent of disease.

Generalized Lymphangiomatosis Presenting as Cardiomegaly

Lymphangioma refers to the local proliferation of well-differentiated lymphatic tissue. Generalized lymphangiomatosis is rare. We report a previously healthy 8-month-old infant who suffered from tachypnea with mild fever for 2 weeks. Imaging studies revealed a well-defined, large mass occupying the mediastinum, which presented as cardiomegaly. The disseminated mass extended to the thymus, lung, and spleen. Lymphangiomatosis was diagnosed by biopsy. Drainage of the pericardial fluid and total parenteral nutrition did not result in improvement of chylopericardium. Secondary hypogammaglobulinemia and septic shock developed sequentially. Surgical removal of the mediastinal mass and spleen were performed. Daily subcutaneous injection of interferon (IFN) alpha-2b was then given for 3 months. No recurrence was noted during 2 years of follow-up. IFN alpha-2b may be considered as an alternative for the treatment of generalized lymphangiomatosis.

Successful management of lymphangiomatosis and chylothorax in a 7-month-old infant

A 7-month old infant presented with an effusion and multiple lesions in his spleen. A diagnosis of lymphangiomatosis was made based on chylous effusion and an MRI demonstrating numerous enhancing lesions within the spleen on T2-weighed images. Conservative measures, including the withdrawal of feeds and octreotide, did not significantly reduce the rate of chyle production and increasing requirement for respiratory support. Resection of the patient's spleen and partial pleurectomy were associated with a dramatic improvement in his condition. At 27 months the patient was well with no evidence of further lymphangiomas or a recurrence of his chylothoraces.

Systemic diseases and the lung

Systemic diseases affecting the lung are fortunately relatively rare in paediatric practice. A number of conditions do, however, cause significant respiratory complications, which can result in serious morbidity and mortality in this age group. These include connective tissue disorders such as systemic lupus erythematosus, dermatomyositis and scleroderma, inherited connective tissue disorders such as Ehlers-Danlos and Marfan's syndrome, lysosomal storage disorders such as mucopolysaccharidoses, familial dysautonomia, Langerhans cell histocytosis, pulmonary lymphangiomatosis, sarcoidosis and sickle cell disease. The investigations of these conditions are often complex but form part of the overall multisystem review of each individual patient. Treatment is individualised but often requires the extended use of corticosteroids and other immunosuppressants. The outcome is variable and depends on the ability to control the underlying condition. Long-term chronic lung damage is not unusual and these diseases, when they affect the lung, carry a small but significant mortality.

Bone lymphangiomatosis: treatment with percutaneous cementoplasty

STUDY DESIGN

Case report, minimally invasive technique.

OBJECTIVES

Disseminated lymphangiomatosis is a rare disorder that can produce clinical manifestation secondary to soft tissue, visceral and bone involvement. The overall prognosis of this disorder is usually poor, and the current treatment options for its sequelae are limited and only palliative. In this report, we present the use of cementoplasty in the percutaneous treatment of a sacral lymphangiomatous bone lesion producing severe pain.

SUMMARY OF BACKGROUND DATA

Disseminated lymphangiomatosis is a rare disorder that can produce clinical manifestation secondary to soft tissue, visceral, and bone involvement. Major morbidity related to skeletal involvement requiring surgical intervention is less common than that related to visceral involvement, but it has been reported in a few case reports to palliate neurologic sequelae secondary to vertebral involvement. We present case of osteoplasty used to treat a painful osteolytic sacral lesion in a patient with diffuse lymphangiomatosis. Computed tomography guided osteoplasty injecting acrylic bone cement into the lesion resulted in almost immediate reduction in pain.

METHODS

The technique and results of minimally invasive percutaneous computed tomography-guided cementoplasty of a painful osteolytic sacral lesion resulting from chylous reflux in a patient with lymphangiomatosis is presented.

RESULTS

Computed tomography was used to accurately position a 13-gauge needle into a dominant sacral osteolytic lesion. The injection of bone cement into the sacral lesion was then monitored by intermittent CT imaging. The patient reported substantial pain relief within several hours of the procedure.

CONCLUSION

The case presented demonstrates the feasibility and efficacy of computed tomography-guided cementoplasty used to palliate unusual causes of benign osteolytic bone lesions. These procedures can be performed as outpatients with minimal recovery.

Thoracic lymphatic disorders

Thoracic complications of lymphatic disorders can culminate in respiratory failure and death and should be considered in any patient with a lymphatic disease and clinical or radiographic evidence of chest disease. Congenital lymphatic disorders are being increasingly recognized in the adult population. The spectrum of thoracic manifestations of lymphatic disorders ranges from incidental radiographic findings to diffuse lymphatic disease with respiratory failure. This article serves to review some recent advances that allow improved diagnosis and management of thoracic lymphatic disorders. Herein, we describe their anatomical and physiologic effects, the time course of their progression, and the therapies that are currently available. The management of malignant (cancerous) lymphatic disorders of the thorax is beyond the scope of this paper.

Treatment of interstitial lung disease in children

The treatment of interstitial lung disease in children depends on the nature of the underlying pathology. In approximately 50% of cases a specific aetiology can be found such as: chronic viral infection, an auto-immune process, sarcoidosis or alveolar proteinosis. In the remainder, the process is idiopathic and the pathological findings are based on the descriptive morphological features seen in the diagnostic lung biopsy. If a specific cause is found then targeted treatment with antivirals, steroids or other immunosuppressive agents is available. Alveolar proteinosis can be treated by bronchial lavage and GM-CSF. Idiopathic cases are treated primarily with intravenous pulsed methylprednisolone or oral prednisolone backed up hydroxychloroquine. Other immunosuppressive agents such as azathioprine, methotrexate or ciclosporin have been used successfully in individual patients. The prognosis is very variable and includes no response to any therapy, partial response with chronic long term morbidity, to virtually complete recovery. The overall mortality rate is 15%. There are no controlled therapeutic trials available because of the rarity of these conditions in childhood. Unlike in adult practice, no correlation has as yet been demonstrated between the initial pattern of chest x-ray change or the degree of pathological change on the lung biopsy and the clinical outcome. The recurrence rate within families is 1 in 8.

Thoracic lymphangiomatosis in a child

An 8-year-old boy who presented with a mediastinal mass, pulmonary infiltrates, and disseminated intravascular coagulation was diagnosed with lymphangiomatosis. Despite medical management, he developed multiple organ failure and died. The authors discuss the diagnostic findings, medical management, and pathology and review 52 additional cases of thoracic lymphangiomatosis from the literature. Patients presented with chylothorax (49%), a mass (47%), pulmonary infiltrates (45%), bone lesions (39%), splenic lesions (19%), cervical involvement (15%), disseminated intravascular coagulation (9%), and skin involvement (7%). Children (<16 years) had a worse prognosis than older patients (39% vs. 0% mortality). All patients who died had either parenchymal lung involvement or pleural effusion. Thoracic lymphangiomatosis should be included in the differential diagnosis of a mediastinal mass with pulmonary findings.

Improvement of disseminated lymphangiomatosis with recombinant interferon therapy

Disseminated lymphangiomatosis is a rare disorder with a poor prognosis. We present a case involving a 3-year-old boy who presented with pulmonary infiltrates, multiple lytic lesions of the ribcage, and small cystic lesions in the spleen. Open-lung and bone biopsies revealed disseminated lymphangiomatosis. Significant clinical and radiologic improvement were observed and persisted after 28 months of treatment with recombinant interferon alpha-2b (IFN alpha-2b). No significant toxicity has been observed.

The lung in multi-system disease

Lung involvement in multi-system disease is rare in children. When it does occur it is associated with significant morbidity and mortality. Auto-immune diseases such as systemic lupus erythematosis, scleroderma and acute rheumatic disease can cause major lung pathology. Chronic illness such as sickle cell disease, mucopolysaccharidosis or familial dysautonomia can result in long-term recurrent respiratory problems. Rare conditions such as sarcoidosis, pulmonary lymphangiomatosis or Langerhan's histiocytosis occasionally result in major lung disease in this age group. The prognosis for all of these conditions is very variable depending on the severity of the disease itself and its response to treatment which often involves the use of oral corticosteroids or other powerful immuno-suppressants.

Bronchial casts in children with cardiopathies: the role of pulmonary lymphatic abnormalities

Expectoration of bronchial casts, a condition also called plastic bronchitis, is very rare in children. Bronchial casts may be associated with bronchopulmonary diseases associated with mucus hypersecretion, bronchopulmonary bacterial infections, congenital and acquired cardiopathies, or pulmonary lymphatic abnormalities. A classification based on anatomy and pathology has been proposed which identifies an "acellular" group associated with congenital cardiopathies and palliative surgery. We report on 3 cases with bronchial casts associated with cardiopathy. Observations suggest that the formation of bronchial casts may result from lymphatic leakage into the bronchi. The 3 cases on which we report were immunodeficient and had pulmonary lymphatic abnormalities. The bronchial casts contained lymphocytes and lipids, as determined by histologic examination. In the absence of congenital pulmonary or diffuse lymphatic dysplasia associated with cardiopathy, the principal factors resulting in the formation of bronchial casts appear to be surgical trauma to the lymphatic channels surrounding the bronchi, pleural adhesions, and high systemic venous blood pressure. The prognosis for these patients is poor, and possibilities for treatment are limited.

Lymphangiomatosis of the pelvic limb in a Maltese dog

A case of lymphangiomatosis is described affecting the right pelvic limb of an 18-month-old, female Maltese dog. A progressive swelling around the stifle had developed subsequent to a routine tibial crest transposition. The swollen area eventually progressed to involve the entire limb circumferentially, to end abruptly in the mid-metatarsal region. The skin of the affected area was deep red in colour, devoid of hair, and had numerous large, thin-walled vesicles that were easily ruptured and from which a serosanguineous fluid exuded. The swelling pitted on digital pressure and showed fluctuant mobility. The microscopic appearance of biopsied and post mortem material mimicked that of lymphangioma. However, the signalment, clinical presentation and histological features are consistent with a diagnosis of the recently reported variant of human lymphangiomatosis, lymphangiomatosis of the limb.