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Berman RS, Silvestri DL. Dermatologic Problems in the Intensive Care Unit: Part II. J Intensive Care Med 2016. [DOI: 10.1177/088506668600100207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Skin disorders are present in many patients hospitalized in the intensive care unit. They range in severity from being the reason for admission to being a nuisance during care. These cutaneous problems have been categorized into four groups: (1) serious skin diseases that may incur life-threatening complications; (2) subtle skin problems associated with systemic disorders that may be characterized by critical events; (3) prominent cutaneous manifestations that accompany life-threatening systemic diseases; and (4) skin disorders that develop as complications during intensive care. Diseases in the first category were discussed in Part I of this article [1]. In Part II, we discuss diseases in the second category. The remaining disorders will be covered in Parts III and IV.
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Affiliation(s)
- Rita S. Berman
- University of Massachusetts Medical Center, 55 Lake Avenue North, Worcester, MA
| | - Dianne L. Silvestri
- University of Massachusetts Medical Center, 55 Lake Avenue North, Worcester, MA
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2
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Abstract
Hereditary hemorrhagic telangiectasia (HHT), also known as Osler-Weber-Rendu disease, is an hereditary disorder that results in fibrovascular dysplasia with the development of telangiectasias and arteriovenous malformations. It predominantly involves the skin, mucous membranes, viscera, lungs, and brain. Hereditary hemorrhagic telangiectasia shows great genetic heterogeneity, and its phenotypes have been classified based on the recently identified mutated genes: endoglin (HHT-1) and activin-like kinase receptor-1 (HHT-2). Other families with phenotypic HHT do not bear these mutations; therefore, other genes are probably involved as well. Liver involvement is reported in up to 30% of persons affected by HHT. Large arteriovenous malformations in the liver can lead to significant complications, including high-output congestive heart failure, portal hypertension, hepatic encephalopathy, biliary ischemia, and liver failure. Embolization of large arteriovenous malformations in the liver remains controversial; however, liver transplantation can successfully eradicate these complications.
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Affiliation(s)
- Anne M Larson
- Department of Medicine, University of Washington, Seattle, 98195-6174, USA.
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Gupta P, Mordin C, Curtis J, Hughes JMB, Shovlin CL, Jackson JE. Pulmonary arteriovenous malformations: effect of embolization on right-to-left shunt, hypoxemia, and exercise tolerance in 66 patients. AJR Am J Roentgenol 2002; 179:347-55. [PMID: 12130431 DOI: 10.2214/ajr.179.2.1790347] [Citation(s) in RCA: 93] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE This study assessed the effect and safety of percutaneous transcatheter coil embolization of pulmonary arteriovenous malformations. MATERIALS AND METHODS In 58 (88%) of 66 patients, all malformations with feeding vessels greater than or equal to 3 mm in diameter were embolized with steel coils. Arterial oxygen saturation at rest and exercise, intrapulmonary right-to-left anatomic shunt fraction ((99m)Tc-macroaggregate injection), maximum exercise capacity (incremental work rate test), and pulmonary function were measured before and after embolization. Complications were analyzed. RESULTS Three categories of patients were identified. Patients in group 1 (27%) had complete occlusion of all angiographically visible pulmonary arteriovenous malformations; patients in group 2 (61%) had complete occlusion of all malformations with feeding vessels greater than or equal to 3 mm in diameter, but with smaller lesions persisting; and patients in group 3 (12%) had incomplete embolization, with feeding vessels greater than or equal to 3 mm in diameter remaining. The mean right-to-left shunt after embolization was least in group 1 (7%), intermediate in group 2 (10%), and greatest in group 3 (19%). Arterial oxygen saturation and right-to-left shunt fraction returned to normal levels (>96% and <3.5%, respectively) in 33% of patients. A significant improvement occurred after embolization in carbon monoxide diffusing capacity per unit of alveolar volume and in exercise capacity in 16 and 10 patients, respectively. In 93 procedures, 12 complications (13%) occurred. CONCLUSION Coil embolization of pulmonary arteriovenous malformations is effective in reducing right-to-left anatomic shunt fraction and in improving arterial oxygenation. Coil embolization of pulmonary arteriovenous malformations is well tolerated and has a low complication rate.
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Affiliation(s)
- P Gupta
- Department of Imaging, Imperial College Faculty of Medicine, Hammersmith Hospital, Du Cane Rd., London W12 0NN, England
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Shovlin CL, Letarte M. Hereditary haemorrhagic telangiectasia and pulmonary arteriovenous malformations: issues in clinical management and review of pathogenic mechanisms. Thorax 1999; 54:714-29. [PMID: 10413726 PMCID: PMC1745557 DOI: 10.1136/thx.54.8.714] [Citation(s) in RCA: 280] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- C L Shovlin
- Respiratory Medicine, Imperial College School of Medicine, National Heart and Lung Institute, Hammersmith Hospital, Du Cane Road, London W12 0NN, UK
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Bernard G, Mion F, Henry L, Plauchu H, Paliard P. Hepatic involvement in hereditary hemorrhagic telangiectasia: clinical, radiological, and hemodynamic studies of 11 cases. Gastroenterology 1993; 105:482-7. [PMID: 8335203 DOI: 10.1016/0016-5085(93)90723-p] [Citation(s) in RCA: 104] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Hepatic involvement in hereditary hemorrhagic telangiectasia (HHT) is infrequent and poorly studied. The aim of this study was to describe the clinical, radiological, and hemodynamic patterns of this involvement. METHODS Eleven consecutive patients with HHT and hepatic involvement observed within 12 years were retrospectively studied. They were 8 females and 3 males, mean age, 47. RESULTS The patients presented with heart failure (4 cases), hepatomegaly and murmur of the right hypochondrium (7 cases), and digestive hemorrhage (6 cases). Eight patients had anicteric cholestasis. Celiac angiography showed a dilated hepatic artery in 8 cases, disseminated intrahepatic telangiectasias in 10, and early opacification of the hepatic veins in 7. Liver dynamic computed tomography (CT) scan performed in 7 patients allowed the diagnosis of liver involvement in each case. Hemodynamic studies were performed in 5 patients. A left-to-right intrahepatic shunt was proven in the 5 patients. Shunt output was estimated between 25% and 58% of cardiac output. Mild pulmonary hypertension was observed in the 5 cases. CONCLUSIONS Diagnosis of liver involvement in HHT can be made by dynamic CT scan or celiac angiography. The main feature of this involvement is high output heart failure due to left-to-right intrahepatic shunt. Thus, right-heart catheterization is necessary in these patients to confirm and evaluate the shunt.
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Affiliation(s)
- G Bernard
- Departement des spécialités digestives, Hopital Edouard Herriot, Lyon, France
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Guillén B, Guízar J, de la Cruz J, Salamanca F. Hereditary hemorrhagic telangiectasia: report of 15 affected cases in a Mexican family. Clin Genet 1991; 39:214-8. [PMID: 2036743 DOI: 10.1111/j.1399-0004.1991.tb03014.x] [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: 12/29/2022]
Abstract
We report a Mexican family with 15 members affected with hereditary hemorrhagic telangiectasia (HHT), all of them suffering from severe hemorrhagic episodes treated with multiple blood transfusions; one patient had a cerebral arteriovenous fistula that required surgical treatment and two others had severe cirrhosis of the liver. Clinical findings in this family illustrate the variable expressivity in HHT, which should be taken into account for the purpose of genetic counselling and monitoring for early detection of systemic complications.
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Affiliation(s)
- B Guillén
- Unit of Investigation in Human Genetics, Subjefatura de Investigación and Pediatric Hospital, National Medical Center, I.M.S.S. La Raza, Mexico
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Kato S, Ichihara K. Hereditary hemorrhagic telangiectasia with malignant lymphoma. An autopsy case. ACTA PATHOLOGICA JAPONICA 1988; 38:383-91. [PMID: 3394524 DOI: 10.1111/j.1440-1827.1988.tb02310.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
A 60-year-old Japanese woman was diagnosed at autopsy as having had hereditary hemorrhagic telangiectasia (HHT) associated with systemic hemangiomas. In her reproduction period, premenstrual epistaxis frequently occurred. At the age of 60, the patient died of malignant lymphoma. At autopsy, multiple telangiectatic spots were noted on the face, limbs and trunk. The paraaortic lymph nodes, which were enlarged and irregularly conglomerated, were histologically diagnosed as malignant lymphoma of the diffuse large cell type. Submucosal telangiectatic lesions were found in the gastrointestinal system from the oral cavity to the rectum. Cavernous hemangiomas were present in various visceral organs including the liver, spleen, small and large intestines, rectum, appendix, uterus, and jejunal and colonic mesenteries. There was an arteriovenous fistula in the left lung. Examination of her family pedigree showed that the patient had an autosomal dominant trait of inheritance. The pathogenesis of the systemic visceral hemangiomas observed in this patient was considered to be similar to that of harmartoma.
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Affiliation(s)
- S Kato
- Second Department of Pathology, Tottori University School of Medicine, Yonago, Japan
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Abstract
Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu disease) is an autosomal dominant, systemic fibrovascular dysplasia in which telangiectases, arteriovenous malformations, and aneurysms may be widely distributed throughout the body vasculature. Major clinical manifestations include: recurrent bleeding from mucosal telangiectases and arteriovenous malformations; hypoxemia, cerebral embolism, and brain abscess due to pulmonary arteriovenous fistulas; high-output congestive heart failure and portosystemic encephalopathy from hepatic arteriovenous malformations; and a variety of neurologic symptoms due to central nervous system angiodysplasia. Therapy is primarily supportive, consisting of iron supplementation and blood transfusion. Septal dermoplasty and oral estrogens may allow prolonged remission of epistaxis, but permanent surgical cure of gastrointestinal bleeding is rarely feasible because of diffuse angiodysplasia of the alimentary tract. Ligation, resection, or embolization may be indicated for pulmonary arteriovenous fistulas. The prognosis and survival of patients with hereditary hemorrhagic telangiectasia are favorable, providing treatable complications are accurately diagnosed.
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Montejo Baranda M, Perez M, De Andres J, De la Hoz C, Merino J, Aguirre C. High out-put congestive heart failure as first manifestation of Osler-Weber-Rendu disease. Angiology 1984; 35:568-76. [PMID: 6486518 DOI: 10.1177/000331978403500904] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
We present two cases of hemorrhagic hereditary telangiectasia (HHT) or Osler-Weber-Rendu disease which started as heart failure. Both had multiple arteriovenous fistulas, one of them in a rare localization in this disease, a lower extremity. We conclude stressing the importance of thinking of HHT in the presence of obscure heart failure or arteriovenous fistulas and of looking for internal fistulas when faced by a HHT.
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Bartolucci EG, Swan RH, Hurt WC. Oral manifestations of hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu disease). Review and case reports. J Periodontol 1982; 53:163-7. [PMID: 6951030 DOI: 10.1902/jop.1982.53.3.163] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
A review of hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu Disease) is presented. Special emphasis is placed on the oral manifestations which include hemorrhagic vesicles, nodules, papules and ulcers that involve the gingiva and other areas of the mucosa. Two cases are included which were seen in a periodontic clinic prior to the medical diagnosis. The nature of the practice of periodontics necessitates a broad understanding of the systemic diseases reflected in the oral cavity. Hereditary hemorrhagic telangiectasia is one such disease.
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Román G, Fisher M, Perl DP, Poser CM. Neurological manifestations of hereditary hemorrhagic telangiectasia (Rendu-Osler-Weber disease): report of 2 cases and review of the literature. Ann Neurol 1978; 4:130-44. [PMID: 707984 DOI: 10.1002/ana.410040207] [Citation(s) in RCA: 145] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Two cases of hereditary hemorrhagic telangiectasia (HHT) with neurological involvement are presented. One patient had multiple vascular malformations including telangiectasias of the brain, medulla, and spinal cord and a berry aneurysm of the internal carotid artery; she also had a large cerebellar abscess, presumably reflecting the presence of a pulmonary arteriovenous fistula. The second patient had an idiopathic subarachnoid hemorrhage. In more than 200 reported patients with HHT involving the nervous system, 61% had lesions seondary to a pulmonary arteriovenous fistula (cerebral hypoxemia, paradoxical and septic emboli, and brain abscess). The findings emphasize the need for early surgical correction of such fistulas. In 36% of the patients with neurological involvement and HHT, vascular malformations of the brain and spinal cord were documented, and in 3%, portal-systemic encephalopathy was noted. Multiple lesions were frequent. HHT should be considered a generalized vascular dysplasia (universal or systemic angiomatosis), and not simply a benign mucocutaneous disease.
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Radtke WE, Smith HC, Fulton RE, Adson MA. Misdiagnosis of atrial septal defect in patients with hereditary telangiectasia (Osler-Weber-Rendu disease) and hepatic arteriovenous fistulas. Am Heart J 1978; 95:235-42. [PMID: 622957 DOI: 10.1016/0002-8703(78)90468-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Two patients with hereditary telangiectasia (Osler-Weber-Rendu disease) and high-output congestive heart failure secondary to large hepatic arteriovenous malformations had preoperative heart catheterization and exploratory cardiotomy to correct presumed intracardiac left-to-right shunts at the atrial level. At operation, both patients had oxygen-enriched blood returning from the inferior vena cava. Subsequent hepatic angiography demonstrated large hepatic arteriovenous fistulas, and both patients underwent hepatic artery banding and ligation, with reduction of left-to-right shunting.
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Lande A, Bedford A, Schechter LS. The spectrum of arteriographic findings in Osler-Weber-Rendu disease. Angiology 1976; 27:223-40. [PMID: 1053528 DOI: 10.1177/000331977602700404] [Citation(s) in RCA: 28] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
In Osler-Weber-Rendu syndrome, visceral organs are frequently involved in addition to cutaneous and mucous membranous lesions. Detailed arteriographic investigation of 5 patients with this abnormality disclosed characteristic angiodysplastic lesions involving the lungs, liver, spleen, pancreas, gastrointestinal tract and mesentery. Arterial and aortic aneurysms appear to be an integral part of this abnormality. Common to angiodysplastic lesions is a variable degree of arteriovenous shunting. The arteriographic characteristics and the hemodynamic significance of major visceral arteriovenous shunts in hereditary hemorrhagic telangiectasia are discussed.
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MESH Headings
- Adolescent
- Adult
- Angiocardiography
- Arteriovenous Fistula/complications
- Arteriovenous Malformations/complications
- Blood Pressure
- Cardiac Catheterization
- Child
- Child, Preschool
- Ductus Arteriosus, Patent/complications
- Female
- Heart Defects, Congenital/complications
- Heart Defects, Congenital/physiopathology
- Heart Septal Defects, Atrial/complications
- Heart Septal Defects, Ventricular/complications
- Humans
- Hypertension, Pulmonary/diagnosis
- Hypertension, Pulmonary/etiology
- Hypertension, Pulmonary/physiopathology
- Infant
- Infant, Newborn
- Lung/abnormalities
- Male
- Middle Aged
- Prognosis
- Pulmonary Artery/abnormalities
- Pulmonary Veins/abnormalities
- Sex Factors
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Trell E, Johansson BW, Linell F, Ripa J. Familial pulmonary hypertension and multiple abnormalities of large systemic arteries in Osler's disease. Am J Med 1972; 53:50-63. [PMID: 5037289 DOI: 10.1016/0002-9343(72)90115-5] [Citation(s) in RCA: 57] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Razi B, Beller RM, Ghidoni J, Linhart JW, Talley RC, Urban E. Hyperdynamic circulatory state due to intrahepatic fistula in Osler-Weber-Rendu disease. Am J Med 1971; 50:809-15. [PMID: 5089855 DOI: 10.1016/0002-9343(71)90189-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Lundvall O, Iwarsson S. Experiences with two simple aspiration liver biopsy techniques. ACTA MEDICA SCANDINAVICA 1970; 187:225-8. [PMID: 5444979 DOI: 10.1111/j.0954-6820.1970.tb02935.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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