Hydrops and pleural effusions in congenital myotonic dystrophy

Chylothorax as a complication of congenital myotonic dystrophy: A retrospective cohort study

BACKGROUND

The association between congenital myotonic dystrophy (CMD) and chylothorax is poorly recognized.

AIMS

To evaluate the proportion of chylothorax in infants with CMD compared to its prevalence in infants without CMD.

STUDY DESIGN

Single-center, retrospective, cohort study.

SUBJECTS

Infants managed at a neonatal intensive care unit from 2003 to 2019.

OUTCOME MEASURES

CMD was diagnosed using Southern blot for the quantification of CTG repeats in the dystrophia myotonica protein kinase (DMPK) gene. Prenatal and postnatal data of eligible infants with CMD were collected from the patients' medical records. The primary outcome was the proportion of chylothorax.

RESULTS

While the proportion of chylothorax in eligible infants without CMD was 0.25% (27/10714), that in infants with CMD was 50% (5/10; odds ratio (OR), 386.3; 95% confidence interval (CI), 84.4-1850.8; P < 0.001). The variables that were significantly different between infants with CMD with chylothorax and those without chylothorax were as follows: maternal age (33.0 vs. 24.8; P = 0.005), polyhydramnios (5/5 vs 1/5; P = 0.034), number of CTG repeats (1980 vs. 1500; P = 0.038), duration of invasive mechanical ventilation (220 vs. 2, P = 0.009), and duration of hospitalization (217.2 vs 68.0; P = 0.014). The mortality rate of all eligible infants with CMD was 5/10 (50%). No variables were significantly associated with mortality.

CONCLUSIONS

The proportion of chylothorax in infants with CMD was significantly higher than that in infants without CMD. Furthermore, the proportion was higher than that reported in previous studies on congenital chylothorax. This suggests that chylothorax may be frequently experienced in the clinical course of CMD.

Clinical study of a patient with congenital myotonic dystrophy reveals chylothorax as neonatal presentation of the disease

Congenital myotonic dystrophy type 1 presents with severe generalized weakness, hypotonia and respiratory involvement after birth with high mortality and poor outcome among survivors. We report on a patient that prenatally showed polyhydramnios and arthrogypotic attitude. Postnatal examination was compatible with the diagnosis of congenital myopathy. A rare finding associated with the patient was chylothorax. Genetic testing confirmed the diagnosis of myotonic dystrophy. Few prenatal and neonatal cases of congenital myotonic dystrophy associated with chylothorax have been reported in the literature. We reviewed all cases reported to date showing congenital myopathic weakness in association with chylothorax to delineate the clinical manifestations that allow an early diagnosis and management of this syndrome. Possible mechanisms to explain the association between myopathy and chylothorax are also discussed.

A premature baby with bilateral pleural effusions, Turner syndrome (monosomy X) and myotonic dystrophy

Respiratory distress in the premature neonate has a variety of causes, some more common than others. Sometimes it may not be apparent that rare underlying conditions may be associated with common clinical presentations. In this case report, we describe an extremely premature neonate presenting with severe respiratory distress who was subsequently diagnosed with both myotonic dystrophy and Turner syndrome (monosomy X; 45, X0). A literature review correlating this neonate’s particular presentation with these diagnoses has been included.

A case report on 30-week premature twin babies with congenital myotonic dystrophy conceived by in vitro fertilization

Congenital myotonic dystrophy type 1 (DM1) presents severe generalized weakness, hypotonia, and respiratory compromise after delivery with high mortality and poor prognosis. We presented a congenital DM1 of premature twins in the 30th week of gestation. These twins were conceived by in vitro fertilization (IVF). Both babies presented apnea and hypotonia and had characteristic facial appearance. They were diagnosed DM1 by genetic method. They were complicated by chylothorax and expired at 100 and 215 days of age, respectively. Mother was diagnosed DM1 during the evaluation of babies. This is the first report on congenital DM1 which accompanied the chylothorax. More investigation on the association with chylothorax and congenital DM1 is recommended. With a case of severe neonatal hypotonia, congenital DM1 should be differentiated in any gestational age. Finally, since DM1 is a cause of infertility, we should consider DM1 in infertility clinic with detailed history and physical examination.

X-linked myotubular myopathy and chylothorax

X-linked myotubular myopathy usually presents at birth with hypotonia and respiratory distress. Phenotypic presentation, however, can be extreme variable. We report on a newborn baby, who presented with the severe form of the disease. In the second week of life, he developed a clinically relevant chylothorax, needing drainage and treatment with octreotide acetate. Pleural effusions are frequently described in patients with congenital myotonic dystrophy. To our knowledge, the association of chylothorax and X-linked myotubular myopathy has not been described to date. As chylothorax could not be attributed to any evident condition in this child, perhaps it may be added to the clinical spectrum of X-linked myotubular myopathy.

Pleural effusions in the neonate

INTRODUCTION

Pleural effusions are rare in the neonate and may be associated to several clinical conditions. Only a few series of pleural effusions in the fetus and newborn are described in the literature.

AIM

This study was undertaken to determine more accurately the causes and prognostic significance of pleural effusions in a population of high-risk neonates.

MATERIALS AND METHODS

A retrospective chart review of 62 neonates admitted to the neonatal intensive care unit of six medical centers in the north of Portugal, between 1997 and 2004, that presented the diagnosis of pleural effusion.

RESULTS

33M/29F newborns; preterms 47 (76%); GA 33 (25-40) wk; BW 1830 (660-4270) g; C-section 39 (63%). Pleural effusions were congenital in 20 (32%) newborns and acquired in 42 (68%). Congenital pleural effusions occurred as fetal hydrops in 11 (18%) patients and as chylothorax in 9 (15%). In four cases of hydrops, the cause was a congenital chylothorax. Congenital chylothorax (n=13) was the most common (65%) congenital pleural effusion in this study. The incidence of congenital chylothorax was 1:8.600 deliveries and male:female ratio was 2:1. Mortality occurred in five newborns due to pulmonary hypoplasia. Traumatic (iatrogenic) were the most frequent (n=31) acquired pleural effusions. These included 8 (13%) cases of hemothorax and 8 (13%) cases of total parenteral nutrition leakage. Pleural effusions after intra-thoracic surgery were mainly (79%) chylothoraces. There were 11 (26%) non-iatrogenic acquired pleural effusions. No mortality was associated with acquired pleural effusions.

CONCLUSIONS

Congenital pleural effusions usually occur as hydrops or congenital chylothorax. Traumatic (iatrogenic) are the most frequent acquired pleural effusions in a tertiary NICU. Pleural effusions after intra-thoracic surgery are mainly chylothoraces. Non-iatrogenic acquired pleural effusions are associated to several clinical conditions, and mortality is usually associated to the underlying condition.

Non-immune hydrops fetalis associated with impaired fetal movement: a case report and review

Non-immune hydrops fetalis (NIHF) is due to many different causes. Fetal hypomobility has been alluded to as a possible cause. We present a preterm fetus with NIHF secondary to fetal hypomobility. Fetal movements were undetected after the 20th week of gestation. The infant was born 8 weeks later and was edematous, had pleural effusions, and no spontaneous movements. He died on day four of life. Diffuse massive central nervous system (CNS) destruction found on post-mortem examination was thought to be the origin of the hypomobility. As all other causes of NIHF were eliminated, we propose that the NIHF in this infant was due to the hypomobility. This case then gives support to the assertion that fetal hypomobility is another cause of NIHF. The cause of the CNS catastrophy remains unelucidated.

Brain lesions of fetal onset in encephalopathic infants with nonimmune hydrops fetalis

Nonimmune hydrops fetalis (NIHF) comprised 79% (45/57) of all infants with hydrops fetalis at our institution over a 6-year period. Thirty-seven infants with NIHF were liveborn. One or more electroencephalograms were performed on 40% of liveborn infants (15/37); the majority (87%) were moderately to markedly abnormal, including burst suppression, lack of background, multifocal sharp waves, excessive discontinuity, and disorganization reflecting significant neonatal encephalopathies. Postmortem neuropathologic examinations were performed in 86% of infants with NIHF who died or were stillborn, 81% of whom demonstrated intrauterine brain insults including microcalcifications, cerebral and/or cerebellar hypoplasia, microcephaly, encephalomalacia, cavitary lesions, astrocytosis, polymicrogyria, and severe neuronal loss. Cranial ultrasonography failed to document the diverse pathologic lesions that were later noted on postmortem examination. Ten infants survived the neonatal period, but 6 were neurologically abnormal at the time of discharge. Infants with NIHF are at risk for antepartum brain injury, and electroencephalographic abnormalities reflect in part a fetal brain disorder. A prospective clinical study is needed to fully assess the prevalence, incidence, spectrum of central nervous system involvement, contribution of intrapartum and neonatal stress, and long-term outcome in surviving infants with NIHF.

Duchenne muscular dystrophy associated with fetal pleural effusion and polyhydramnios

A case of fetal pleural effusion in a fetus affected with Duchenne muscular dystrophy (DMD) is reported. This case is discussed in the context of the previous observation of frequent stillbirths among male fetuses in DMD families.

DNA confirmation of congenital myotonic dystrophy in non-immune hydrops fetalis

We report on the prenatal diagnosis of congenital myotonic dystrophy in a case of non-immune hydrops fetalis. DNA analysis of amniocytes revealed expansion of the trinucleotide (CTG) repeat within the myotonin PK gene, associated with myotonic dystrophy. The fetus was found to have approximately 1730 copies, while the normal population has between 5 and 27 copies, and minimally affected individuals have at least 50 copies.

Hydrops fetalis associated with congenital myotonic dystrophy

We report a case of congenital myotonic dystrophy in a newborn infant who presented with hydrops fatalis. Clinical features were hypotonia, generalized edema, pleural effusion, respiratory distress, scalp hematomas, and tented mouth facies. Review of literature shows that congenital myotonic dystrophy is not a rare cause of nonimmune hydrops fetalis as previously thought.

Hydrops revisited: literature review of 1,414 cases published in the 1980s

This paper reviews 47 series of hydrops fetalis (804 cases) and 610 individual cases published since 1980. From this large number of cases, guidelines are derived for prenatal diagnosis and management.