Kasabach-Merritt syndrome in two neonates

A Rare Presentation of Isolated Congenital Splenic Hemangioma With Kasabach-Merritt Syndrome

INTRODUCTION

Splenic hemangiomas (SHs) are the most common benign neoplasms of the spleen. However, they are rare in the newborn period. We present an extremely rare case of congenital SH complicated by Kasabach-Merritt syndrome.

CASE PRESENTATION

A 2.93 kg male infant was delivered at term with a prenatal diagnosis of a left infrarenal mass diagnosed by ultrasound at 35 weeks of gestation. Magnetic resonance imaging demonstrated a well-defined splenic mass with multiple flow voids and scattered areas of high intensity suggestive of hemorrhage. He developed anemia, thrombocytopenia, and coagulopathy which required transfusion with packed red cells, platelets, cryoprecipitate, and fresh frozen plasma. Excision biopsy of the spleen led to resolution of anemia, thrombocytopenia, and coagulopathy. The diagnosis of SH was confirmed by histopathology. At 2 months outpatient follow-up, the patient was growing well without any evidence of tumor recurrence.

CONCLUSIONS

Congenital SH is a rare entity that can be fatal if the potential complication of Kasabach-Merritt syndrome is not anticipated, evaluated, and promptly treated. Our patient had a favorable outcome with early surgical excision of the SH.

Kasabach-Merritt syndrome: dangers of interferon and successful treatment with pentoxifylline

A girl aged 3 months presented with thrombocytopenia and bruising around a large vascular malformation of her posterior abdominal wall. Treatment was started with corticosteroids and platelet replacement, but with no improvement and a platelet count persistently less than 10 x 10(9)/L over 3 weeks, alpha-interferon was added. There was an immediate increase in bruising, a fall in platelet count, and an increase in platelet transfusion requirement until interferon was discontinued 11 days later. After a further week, the platelet count returned to the levels before interferon, but the patient did not develop any further symptoms. The platelet count remained low with no clinical change until pentoxifylline was started at the age of 15 months. The platelet count rose to 117 x 10(9)/L within 4 days and remained more than 100 x 10(9)/L thereafter. The patient is now 7 years old and has had no recurrence since stopping the pentoxifylline at the age of 5 years. Although thrombocytopenia is a recognized side effect of interferon therapy, this very dangerous complication has not been previously reported using interferon for the Kasabach-Merritt syndrome.

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.

Kasabach-Merritt syndrome: identification of platelet trapping in a tufted angioma by immunohistochemistry technique using monoclonal antibody to CD61

Kasabach-Merritt syndrome (KMS) consists of large and rapidly growing vascular tumors associated with thrombocytopenia, generalized petechiae, and bleeding. The cause of the thrombocytopenia is thought to be related to the trapping of platelets by the abnormal endothelium of the tumor. We report an infant with KMS that developed in association with a large tufted angioma. In this case we directly demonstrated platelet trapping in the vascular lumen of the tumor by an immunohistochemical technique using a monoclonal antibody against CD61, a marker of platelets and megakaryocytes.

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.

-Neonatal Kasabach-Merritt syndrome healed by complete surgical excision of the angioma-

BACKGROUND

Kasabach-Merritt syndrome is an infrequent combination of a giant hemangioma and severe thrombocytopenia. This syndrome may be life-threatening. There are various but no definitive methods of treatment. We describe here a neonatal case cured by total excision of the tumor.

CASE REPORT

A boy was admitted at birth with a giant hemangioma of the back with thrombocytopenia. Tumor compression, corticosteroids, acetylsalicylic acid and ticlopidine were ineffective. Total surgical excision was performed on day 51, resulting in complete recovery.

CONCLUSION

Total surgical excision of a localized hemangioma in a non-functional area is probably the most appropriate and justified treatment for the Kasabach-Merritt syndrome.

Purpura in infants and children

Hemorrhage into the skin (purpura) may result from abnormalities in any of the three components of hemostasis: platelets, plasma coagulation factors, and blood vessels. The morphology, size, and distribution of the hemorrhagic lesions are helpful diagnostic features. The main causes of purpura in the newborn and the more common hemorrhagic disorders in children are reviewed.

Efficacy of bleomycin treatment for symptomatic hemangiomas in children

Five children aged 5-19 years had pain in massive, inoperable hemangiomas. They were treated with intralesional injections of 2 mg bleomycin as a 0.4 mg/ml solution in the painful area. The injections were repeated after 4 -6 weeks for a total of 6 -10 times. All children were relieved of pain, and the swelling was reduced in all cases. There were no complications or side effects. Bleomycin therapy of painful, massive hemangiomas can be recommended in older children.

Pentoxifylline

Pentoxifylline (oxpentifylline) is a methylxanthine derivative with potent hemorrheologic properties. In the United States it is marketed for the treatment of intermittent claudication. Human and animal studies have shown that pentoxifylline therapy results in a variety of physiological changes at the cellular level, which may be important in treating a diverse group of human afflictions. Immune modulation includes increased leukocyte deformability and chemotaxis, decreased endothelial leukocyte adhesion, decreased neutrophil degranulation and release of superoxides, decreased production of monocyte-derived tumor necrosis factor, decreased leukocyte responsiveness to interleukin 1 and tumor necrosis factor, inhibition of T and B lymphocyte activation, and decreased natural killer cell activity. Hypercoagulable states improve through decreased platelet aggregation and adhesion, increased plasminogen activator, increased plasmin, increased antithrombin III, decreased fibrinogen, decreased alpha 2-antiplasmin, decreased alpha 1-antitrypsin, and decreased alpha 2-macroglobulin. Wound healing and connective tissue disorders may respond to an increase in fibroblast collagenases and decreased collagen, fibronectin, and glycosaminoglycan production. Fibroblast responsiveness to tumor necrosis factor is also diminished. Potential medical uses of pentoxifylline are reviewed.