Chronic defibrination syndrome due to a giant hemangioma associated with microangiopathic hemolytic anemia

Pulmonary thromboembolism associated with Klippel-Trenaunay syndrome

Klippel-Trenaunay syndrome (KTS) is a rare congenital anomaly characterized by unilateral limb overgrowth, venous varicosities, and capillary malformations (port wine stains) of the affected limb or limbs. Large venous malformations such as those observed in KTS are rare, and many physicians are unfamiliar with the potential complications, which include hypercoagulability, thrombosis, and pulmonary embolism (PE). As a result, patients may suffer from delayed diagnosis of a potentially life-threatening thromboembolic event. We present 2 cases of children with KTS complicated by PE, and we review the English-language literature regarding pathophysiologic features, interventions, and outcomes of PE in the setting of KTS among both pediatric and adult patients, with emphasis on issues relevant to pediatricians.

Postoperative severe microangiopathic hemolytic anemia associated with a giant hepatic cavernous hemangioma

Complications related to liver hemangioma are rare. We herein describe the case of a patient with three giant cavernous hemangiomas of the liver, of which two were resected for symptoms. A significant microangiopathic hemolytic anemia occurred in the early postoperative period, leading to acute renal failure and necessitating blood transfusions. The systematic evaluation of hemolytic processes in the postoperative patient is described. Surgeons should be aware of the potential for hemolytic complications after major surgery when giant hepatic hemangiomas are present.

Disseminated intravascular coagulation current concepts of etiology, pathophysiology, diagnosis, and treatment

The pathophysiologic mechanisms and clinical and laboratory manifestations of DIC are complex, partly because of inter-relationships within the hemostasis system. Only by clearly understanding these extraordinarily complex pathophysiologic inter-relationships can the clinician and laboratory scientist appreciate the divergent and wide spectrum of often-confusing clinical and laboratory findings in patients with DIC. Many therapeutic decisions to be made are controversial and lack validation. Nevertheless, newer antithrombotic agents and agents that can block, blunt, or modify cytokine activity and the activity of vasoactive substances seem to be of value. The complexity and variable degree of clinical expression suggest that therapy should be individualized depending on the nature of DIC, the patient's age, etiology of DIC, site and severity of hemorrhage or thrombosis, and hemodynamics and other appropriate clinical parameters.

Disseminated intravascular coagulation: a review of etiology, pathophysiology, diagnosis, and management: guidelines for care

The pathophysiologic mechanisms, clinical, and laboratory manifestations of DIC are complex in part due to interrelationships within the hemostasis system. Only by clearly understanding these extraordinarily complex pathophysiologic interrelationships can the clinician and laboratory scientist appreciate the divergent and wide spectrum of often confusing clinical and laboratory findings in patients with DIC. Many therapeutic decisions to be made are controversial and lack validation. Nevertheless, newer antithrombotic agents, and agents that can block, blunt, or modify cytokine activity and the activity of vasoactive substances appear to be of value. The complexity and variable degree of clinical expression suggests that therapy should be individualized depending on the nature of DIC, age, etiology of DIC, site and severity of hemorrhage or thrombosis and hemodynamics and other appropriate clinical parameters. At present, treatment of the triggering event, low-dose heparin or antithrombin concentrate and wise choice of components when indicated appear to be the most effective modes of therapy.

Klippel-trenaunay weber syndrome

A 36 yrs old male patient presented with a 4 months history of a mass in neck along with a small swelling on the forearm from past several years. There was neither any bony involvement nor mental abnormality. He was operated upon and followed up for 2 years when ultimately he was cured. The case is reported due to its rarity and unusual presentation.

MRI of intralesional hemolysis in focal nodular hyperplasia of the liver

A case of Kasabach-Merritt syndrome caused by focal nodular hyperplasia of the liver is presented with atypical magnetic resonance findings due to intratumoral hemosiderin deposition. The high sensitivity of magnetic resonance imaging for iron served to identify the site of hemolysis in this patient with Kasabach-Merritt syndrome.

Successful multimodal therapy for kaposiform hemangioendothelioma complicated by Kasabach-Merritt phenomenon: case report and review of the literature

We present the management challenge provided by a patient with kaposiform hemangioendothelioma associated with Kasabach-Merritt phenomenon. A female child presented at 14 months of age with an ecchymotic swelling of her right upper arm and axilla. Subsequently, she developed profound thrombocytopenia and hypofibrinogenemia (Kasabach-Merritt phenomenon). Biopsy of the lesion revealed kaposiform hemangioendothelioma, which has been reported as the predominant pathologic diagnosis associated with Kasabach-Merritt phenomenon. To achieve involution of the lesion and preserve function of the arm, the following interventions were involved: embolization, systemic interferon, cyclophosphamide, epsilon aminocaproic acid, and compression therapy. The clinical management of this patient was formidable until we arrived at the proper combination of therapies. Multimodal intervention may be required to manage fastidious hemangioendotheliomas of childhood, achieve clinical improvement, and prevent further morbidity.

Malignant hemangioendothelioma: a case of sudden unexpected death in infancy

A case is reported in which an unsuspected multifocal malignant hemangioendothelioma indirectly caused the sudden, unexpected death of a 5-month-old girl because of its location. To our knowledge, this is the first reported case of sudden, unexpected death associated with this type of tumor. The findings of this unusual case are presented along with a review of relevant literature.

Prenatal diagnosis of an extensive haemangioma of the fetal leg: a case report

Extensive haemangioma with platelet consumption (Kasabach-Merritt syndrome) is rare. The lesion is usually a single cutaneous cavernous haemangioma similar to that found in our patient. Multiple superficial strawberry naevi were also seen all over the rest of the body. This condition was diagnosed antenatally in this patient with the use of colour Doppler. There is one recent report where the thrombocytopaenia was diagnosed by cordocentesis. Unfortunately the baby developed heart failure with intractable coagulopathy and died 2 days later.

Disseminated intravascular coagulation. Objective criteria for diagnosis and management

Current concepts of the cause, pathophysiology, clinical and laboratory diagnosis, and management of fulminant and low-grade DIC have been presented. Considerable attention has been devoted to interrelationships within the hemostasis system. Only by clearly understanding these pathophysiological interrelationships can the clinician and laboratory scientist appreciate the divergent and wide spectrum of often confusing clinical and laboratory findings in patients with DIC. In this discussion, objective clinical and laboratory criteria for a diagnosis of DIC have been delineated, thus eradicating unnecessary confusion and empirical decisions regarding the diagnosis. Many therapeutic decisions to be made are controversial and will remain so until more is published about specific therapeutic modalities and survival patterns. Also, therapy must be highly individualized depending on the nature of DIC, age, cause of DIC, site and severity of hemorrhage or thrombosis, and hemodynamic and other clinical parameters. Also presented are clear criteria for severity of DIC and objective criteria for defining a response to therapy. Also, because it is often difficult for the individual physician to decide when to stop often extensive therapy, objective criteria whereby therapy may be stopped, as continuation is likely fruitless, have been presented as a guideline. Lastly, it should be appreciated that many syndromes that are often organ specific share common pathophysiology with DIC but are typically identified as an independent disease entity, such as hemolytic uremic syndrome, adult shock lung syndrome, eclampsia, and many other isolated organ-specific disorders.

Capillary hemangioma (infantile periocular hemangioma)

Capillary hemangiomas are the most common orbital tumors in children. They typically arise early in life, grow rapidly during a proliferative phase and then slowly regress in an involutional phase. The tumors may present as small isolated lesions of minimal clinical significance or as large disfiguring masses that can cause visual impairment and systemic symptomatology. Capillary hemangiomas are managed effectively by establishing a secure diagnosis, outlining the extent of the tumor, and understanding the natural history of the lesion, as well as its response to therapy. The ophthalmic and systemic manifestations of capillary hemangiomas are discussed in detail, as are the histopathology, radiologic findings, differential diagnosis, and therapeutic alternatives.

Kasabach-Merritt syndrome

The Kasabach-Merritt syndrome includes the triad of vascular tumors, thrombocytopenia, and a hemorrhagic diathesis. The vascular tumors are usually benign but the associated coagulopathy may be life threatening. We describe a patient whose clinical course illustrates the potential difficulties in management.

High dose intravenous methylprednisolone for Kassabach-Merritt syndrome

Kassabach-Merritt syndrome involving the sternum in a 2-month-old child is described. Treatment with high dose intravenous methylprednisolone resulted in normalization of the platelet count and disappearance of haemangioma.

Diffuse cavernous hemangioma of the rectosigmoid--CT scan, a new diagnostic modality, and surgical management using sphincter-saving procedures. Report of three cases

Diffuse cavernous hemangioma of the rectosigmoid is a rare lesion. Preoperative recognition has been recorded but, because of lack of awareness and inconsistent diagnoses, inappropriate therapy still persists. Surgical therapy is the hallmark of treatment. Abdominoperineal resection has been advocated. Three cases of diffuse cavernous hemangiomas of the rectosigmoid, recognized preoperatively and treated successfully with sphincter-saving procedures, are reported. Use of the CT scan as a consistent diagnostic tool will be presented for the first time.

Antifibrinolytic therapy in the management of the Kasabach Merritt syndrome

The Kasabach Merritt syndrome consists of thrombocytopenia, microangiopathic hemolytic anemia, and a localized consumption coagulopathy that develops within the abnormal vascular channels of a hemangioma. In general, these patients demonstrate only mild abnormalities of screening clotting tests, but they can potentially develop life-threatening complications. We present a patient who developed a severe anemia that was refractory to erythrocyte transfusions. Treatment with epsilon-aminocaproic acid to inhibit fibrinolysis and cryoprecipitate to replenish his deficient circulating fibrinogen interrupted the cycle of his systemic coagulopathy and enabled us to transfuse him to a normal hematocrit.

Large-bowel hemangiomas

A case of large-bowel hemangioma is presented, and radiologic and histologic abnormalities are illustrated. Ultrasonographic features, not previously described, are reported. The literature is reviewed and the frequency of misdiagnosis is emphasized. Pathologic classification, epidemiologic factors, and etiology are considered. Clinical manifestations and current approaches to recognition and management are summarized. Vascular tumors are serious, albeit uncommon, intestinal lesions. Greater awareness of the condition and earlier consideration of the diagnosis are prerequisites to lessened morbidity and improved survival.

Intratumoral consumption of indium-111 labeled platelets in a patient with hemangiomatosis and intravascular coagulation (Kasabach-Merritt syndrome)

Previous studies regarding sites of platelet destruction in patients with the Kasabach-Merritt syndrome are conflicting. The authors recently studied an adult patient with multiple large hemangiomata, thrombocytopenia, and intravascular coagulation by external imaging following the injection of autologous Indium-111 labeled platelets. Sequential images showed prompt accumulation of platelet-associated radioactivity in areas within the right hemithorax which corresponded to certain tumors noted on the chest roentgenogram. Despite the presence of multiple other lesions in bone and soft tissues, platelet radioactivity was otherwise normally confined to liver and spleen. Using data obtained from serial images, it was shown that radioactivity within the thoracic masses actually increased over time. These data indicate that platelet consumption occurred as an active process and that localization was not a result of tumor vascularity. It is concluded that platelets are locally consumed within certain hemangiomata. However, within the same individual, there may exist considerable heterogeneity among these tumors with respect to platelet-trapping ability. In similar patients with multiple tumors, indium-platelet scanning might be used to direct local therapy to particular lesions in an effort to correct the thrombocytopenia.

Successful treatment of skeletal hemangioma and Kasabach-Merritt syndrome with aminocaproic acid. Is fibrinolysis "defensive"?

A young man presented with a disabling skeletal hemangioma. Fibrinolysis seemed to be a major component of coagulopathy and persisted after steroid therapy and irradiation of the lesions. Three weeks after therapy with epsilon-aminocaproic acid, there was dramatic alleviation of pain and eventual disappearance of laboratory evidence of fibrinolysis. Epsilon-aminocaproic acid therapy was discontinued. The patient remained free from symptoms and coagulopathy. There was evidence of new bone formation nine months later. Fibrinolysis may be a primary or sustaining feature of hemangioma. Epsilon-aminocaproic acid may be beneficial in the treatment of selected patients with these lesions.

Hereditary hemorrhagic telangiectasia and disseminated intravascular coagulation: a new clinical syndrome

In summary, 47 patients with documented HHT and a bleeding problem were referred to San Joaquin Hematology Oncology Medical Group over a 2-year period. Fifty-one percent of patients were noted to have an associated DIC syndrome and of these 24 patients, 19 had acute DIC episodes, six had chronic DIC, six presented with diffuse, recurrent deep venous thrombosis and of these six, three suffered pulmonary emboli. Other defects were also noted and were thought to be coincidental defects. This syndrome should be readily considered and searched for when seeing patients with HHT, especially if significant hemorrhage or thrombosis is present. It should further be appreciated that many patients with HHT and bleeding are candidates for the development of acute or chronic DIC and thus a "mini" Kasabach-Merritt syndrome. When patients with HHT present with undue bleeding, this syndrome should be appreciated, searched for from the clinical and laboratory standpoint and, when found, treated in the appropriate manner with supportive therapy, mini-heparin or antiplatelet therapy as the clinical situation dictates.

Immune thrombocytopenia in severe neonatal infections

Thrombocytopenia occurs frequently in newborn infants with sepsis, but the exact mechanism remains obscure in those infants who do not have evidence of disseminated intravascular coagulation. Since recent work has suggested a possible immune mechanism for thrombocytopenia observed in adults with sepsis, we have investigated the role of platelet-associated immunoglobulin in severe neonatal infections. To detect PAIgG we use a method employing protein A and peroxidase-antiperoxidase as a labeled antibody. PAIgG was quantitated by phase contrast microscopy and expressed as a reactive index. Our control group included 16 normal newborn infants whose mean RI was 0.65 +/- 0.01 SE. In addition to the control group, five infants with nonimmune thrombocytopenia were included; their mean RI was 0.66 +/- 0.01 SE. Seventeen newborn infants with severe infections were assayed for PAIgG. Eight of nine infants with bacterial infections had increased RI, with a mean of 1.16 +/- 0.03 SE (P less than 0.01). Six of the eight infants with viral infections had elevated RI, with a mean of 1.23 +/- 0.03 SE (P less than 0.01). These findings suggest that an immune mechanism may be involved in the thrombocytopenia of severe neonatal infection.

Microangiopathic hemolytic anemia associated with radiation-induced hemangiosarcomas

A retrospective study of red blood cell parameters in 53 dogs with experimental radiation-induced hemangiosarcoma showed 24 had anemia. Morphologic alterations in red blood cells in peripheral blood films from anemic dogs included signs of regeneration (anisocytosis and polychromasia), hypochromasia, red cell fragmentation and acanthocytosis. The degree and type of red cell changes varied from dog to dog and generally correlated with the principal site of tumor involvement. Blood from dogs with tumors principally involving liver had red cell regeneration, fragmentation and acanthocytosis. Blood from dogs with tumors primarily involving the heart had only red cell fragmentation. Blood films from dogs with skeletal and pulmonary hemangiosarcomas were similar to blood films from dogs with hepatic hemangiosarcoma except that red cell alterations generally were less severe. Scanning and transmission electron micrographic evaluation of neoplastic tissue showed large amounts of fibrin within neoplastic vascular sinuses and disruption and distortion of red blood cells traversing these abnormal vascular beds. The red blood cell fragmentation syndrome associated with radiation-induced hemangiosarcomas therefore was considered to be a microangiopathic hemolytic anemia of localized origin.

Hypercoagulation and thrombosis

As knowledge of blood coagulation has advanced we have begun to examine not only the clinical entities associated with hemorrhage but also a group in which thrombosis represents the major problem. Thrombotic disorders believed to be associated with coagulation are recognized clinically but seldom investigated in the laboratory. The present approach to the problem is based on theoretical and experimental knowledge and a rapidly developing body of clinical information related to the role of platelets and antithrombin III in the initiation and control of thrombosis.

Intravascular coagulation. 2. Underlying conditions and therapy

Therapy for intravascular coagulation is directed primarily against the underlying disorder. If the latter is not readily correctable or if the patient is bleeding actively, anticoagulation with intermittent administration of heparin by the intravenous route is indicated. If thrombocytopenia is present, heparinization must be accompanied by platelet transfusion. The efficacy of therapy is judged by the cessation of bleeding or thrombosis, improvement of organic dysfunction, and correction of the levels of the coagulation factors, particularly factor V and fibrinogen.

Consumption coagulopathy and microangiopathic hemolytic anemia with an axillo-femoral graft

Consumption coagulopathy and microangiopathic hemolytic anemia occurred as a complication of insertion of an axillofemoral, preclotted dacron graft. Treatment with heparin followed by dipyridamole and aspirin normalized the hematologic and coagulation abnormalities over a two month period. The mechanism of consumption coagulopathy associated with prosthetic grafts is discussed and a possible role for treatment with antiplatelet agents is suggested.

Solitary hepatic hemangioma in a newborn infant complicated by cardiac failure, consumption coagulopathy, microangiopathic hemolytic anemia, and obstructive jaundice. Case report and review of the literature

A newborn infant with a large hepatic hemangioma developed congestive heart failure, consumption coagulopathy, microangiopathic hemolytic anemia, and obstructive jaundice. The patient was mildly heparinized (250 units per kg and day) and underwent successful resection of the tumor without lobectomy at the age of 3 days. Blood volume increased from 93.9 ml/kg at the age of 5 h to 124.2 ml/kg prior to surgery. Red-cell mass simultaneously decreased from 53.8 to 39.4 ml/kg. The increase of blood volume is explained by congestive heart failure, the decrease of red-cell mass by intravascular coagulation within the tumor resulting in formation of thrombi and microangiopathic hemolytic anemia. A review of the literature on infants with symptoms caused by an intrahepatic hemangioma during the first month of life confirms that surgical intervention is the treatment of choice for infants with giant solitary hemangioma of the liver.

The management of patients with the Kasabach-Merritt syndrome

The Kasabach-Merritt syndrome comprises consumption coagulation associated with giant haemangioma. A case is reported of disseminated intravascular coagulation complicating dental extraction in a 36-year-old male with this syndrome. The pre-operative management with anticoagulant therapy is discussed and the relevant literature reviewed.