1
|
Dulmovits BM, Taha DK. Neonatal perspective on central lymphatic disorders. Semin Pediatr Surg 2024; 33:151424. [PMID: 38830311 DOI: 10.1016/j.sempedsurg.2024.151424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
Lymphatic disorders presenting in the first year of life are difficult to identify and manage given the broad range of underlying etiologies. Neonatal lymphatic disease arising from congenital or acquired conditions results in the abnormal accumulation of lymph fluid in the pleura (chylothorax), peritoneum (chylous ascites) and skin (edema/anasarca). There is also increasing recognition of lymphatic losses through the intestine resulting in protein-losing enteropathy (PLE). While the incidence of lymphatic disorders in neonates is unclear, advances in genetic testing and lymphatic imaging are improving our understanding of the underlying pathophysiology. Despite these advancements, medical management of neonatal lymphatic disorders remains challenging and variable among clinicians.
Collapse
Affiliation(s)
- Brian M Dulmovits
- Department of Pediatrics, Division of Neonatology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Dalal K Taha
- Department of Pediatrics, Division of Neonatology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| |
Collapse
|
3
|
Ramirez-Suarez KI, Tierradentro-García LO, Biko DM, Otero HJ, White AM, Dori Y, Smith CL, Vatsky S, Rapp JB. Lymphatic anomalies in congenital heart disease. Pediatr Radiol 2022; 52:1862-1876. [PMID: 35840695 DOI: 10.1007/s00247-022-05449-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 05/16/2022] [Accepted: 06/30/2022] [Indexed: 10/17/2022]
Abstract
Congenital heart disease can lead to various lymphatic complications including traumatic leaks, lymphatic overproduction, conduction abnormalities or lymphedema. Advancements in the imaging of central lymphatics and guided interventions have improved outcomes in these children. Dynamic contrast-enhanced magnetic resonance (MR) lymphangiography allows for the assessment of abnormal lymphatic drainage. This technique is preferred for evaluating lymphatic conditions such as plastic bronchitis, chylothorax, chyloptysis, chylopericardium, protein-losing enteropathy and chylous ascites, among other lymphatic disorders. In this review, we discuss lymphatic abnormalities encountered on MRI in children with congenital heart disease. We also briefly review treatment options.
Collapse
Affiliation(s)
- Karen I Ramirez-Suarez
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
| | | | - David M Biko
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Hansel J Otero
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ammie M White
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Yoav Dori
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Christopher L Smith
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Seth Vatsky
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jordan B Rapp
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA. .,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| |
Collapse
|
4
|
Barrera CA, Johnson AM, Rychik J, Biko DM, Degenhardt K, Moldenhauer JS, Victoria T. Prognostic value of the nutmeg lung pattern/lymphangiectasia on fetal magnetic resonance imaging. Pediatr Radiol 2021; 51:1809-1817. [PMID: 33856503 DOI: 10.1007/s00247-021-05061-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 02/10/2021] [Accepted: 03/16/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND A nutmeg lung pattern on magnetic resonance imaging (MRI) is an imaging finding associated with pulmonary lymphangiectasia. However, the prognostic value of the nutmeg lung pattern is unknown. OBJECTIVE To evaluate the clinical associations of nutmeg lung indicating lymphangiectasia on fetal lung MRI and its relationship with early mortality in fetuses with primary and secondary lymphangiectasia. MATERIALS AND METHODS We retrospectively identified all pregnant patients with a fetal MRI performed for indication of evaluating for pulmonary lymphangiectasia from 2006 to 2019. Two readers evaluated the fetal MRIs and interobserver agreement was calculated. Multivariable logistic regression models were performed to estimate the association of the echocardiographic findings and the presence of nutmeg lung. Kaplan-Meier and Cox regression analyses were performed to evaluate association with mortality in the first 30 days of life. Survival analysis was defined as mortality or orthotopic heart transplant at 30 days of age. P<0.05 was considered significant. RESULTS Our sample included 53 fetuses. Forty-seven (89%) had congenital heart disease (CHD) and 6 (11%) were diagnosed postnatally with primary lymphangiectasia. Interobserver agreement was 0.83. Pulmonary vein congestion on echocardiography was the strongest predictor of nutmeg lung (odds ratio [OR]=12.0, P=0.002). Ten fetuses reached the outcome of heart transplantation (n=1) or death (n=9) within the first 30 days of life. In fetuses with CHD, survival of those with nutmeg lung was significantly lower than in those without (P<0.001). Nutmeg lung was an independent risk factor for 30-day mortality (hazard ratio [HR]: 6.1, P=0.01). CONCLUSION Nutmeg lung pattern on fetal MRI is an independent risk factor associated with 30-day mortality in fetuses with CHD.
Collapse
Affiliation(s)
- Christian A Barrera
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.
| | - Ann M Johnson
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jack Rychik
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - David M Biko
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Karl Degenhardt
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Julie S Moldenhauer
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Teresa Victoria
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|