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Tanaka H. Advances in pediatric liver transplantation from the pediatric surgeon's perspective. Pediatr Surg Int 2023; 39:253. [PMID: 37624479 DOI: 10.1007/s00383-023-05533-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/06/2023] [Indexed: 08/26/2023]
Abstract
Pediatric liver transplantation is a lifesaving state-of-the-art operation for children with various liver diseases, including cholestatic diseases, metabolic disorders, acute liver failure, and primary malignant liver tumors. Among these indications, transplantation for biliary atresia and hepatoblastoma is discussed in this review because pediatric surgeons are usually involved in their initial treatments. For biliary atresia, pediatric surgeons are advised to keep dissection of the hilar structures to a minimum during Kasai portoenterostomy in order to make total hepatectomy easier at transplantation. Early referral to a transplant team is recommended when worrisome signs of liver dysfunction, cirrhosis, portal hypertension and growth retardation are noted. Hepatoblastoma with multiplicity or located close to major vessels may indicate unresectability, and the transplant team needs to be consulted early after neoadjuvant chemotherapy is started. The graft size, including its thickness, needs to be evaluated before transplantation for small children, as tailoring the shape of the partial graft may be necessary during the transplant procedure.
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Affiliation(s)
- Hideaki Tanaka
- Department of Pediatric Surgery, and Department of Transplantation Medicine, Fukushima Medical University Hospital, 1 Hikarigaoka, Fukushima, Fukushima, 960-1295, Japan.
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Tyagi M, Guaragni B, Dendi A, Tekleab AM, Motta M, Maheshwari A. Use of Cryoprecipitate in Newborn Infants. NEWBORN (CLARKSVILLE, MD.) 2023; 2:11-18. [PMID: 37206579 PMCID: PMC10193588 DOI: 10.5005/jp-journals-11002-0045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
Cryoprecipitate is a transfusion blood product derived from fresh-frozen plasma (FFP), comprised mainly of the insoluble precipitate that gravitates to the bottom of the container when plasma is thawed and refrozen. It is highly enriched in coagulation factors I (fibrinogen), VIII, and XIII; von Willebrand factor (vWF); and fibronectin. In this article, we have reviewed currently available information on the preparation, properties, and clinical importance of cryoprecipitate in treating critically ill neonates. We have searched extensively in the databases PubMed, Embase, and Scopus after short-listing keywords to describe the current relevance of cryoprecipitate.
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Affiliation(s)
- Manvi Tyagi
- Department of Pediatrics, Augusta University, Georgia, USA
| | - Brunetta Guaragni
- Department of Neonatology and Neonatal Intensive Care, Children’s Hospital, ASST-Spedali Civili, Brescia, Italy
| | - Alvaro Dendi
- Department of Neonatology, Centro Hospitalario Pereira Rossell, Universidad de la República, Montevideo, Uruguay
| | - Atnafu Mekonnen Tekleab
- Department of Pediatrics, St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Mario Motta
- Department of Neonatology and Neonatal Intensive Care, Children’s Hospital, ASST-Spedali Civili, Brescia, Italy
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Abstract
Thrombocytopenia is a commonly encountered labora tory abnormality in the intensive care unit setting. Al though moderate degrees of thrombocytopenia may be dismissed as clinically trivial, severe thrombocytopenia can have catastrophic consequences. This review di vides the potential pathogenesis of thrombocytopenia into three pathophysiological categories: (1) produc tive, (2) consumptive, and (3) distributional. The im portant etiologies and appropriate therapies for throm bocytopenia in each of these categories are discussed. We have attempted to emphasize the underlying patho genic mechanisms as well as highlight the diagnostic dilemmas likely to be faced by intensive care unit physi cians. Although this review stresses those thrombocyto penic disorders most likely to be encountered in the intensive care unit, chronic etiologies of thrombocy topenia are also discussed because preexistent throm bocytopenia will further complicate the care of any acutely ill intensive care unit patient.
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Affiliation(s)
- Edward G. Wittels
- Department of Medicine, The Miriam Hospital, and Brown University, Providence, RI
| | - Robert D. Siegel
- Department of Medicine, The Miriam Hospital, and Brown University, Providence, RI
| | - Eric M. Mazur
- Department of Medicine, The Miriam Hospital, and Brown University, Providence, RI
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O'Rafferty C, O'Regan GM, Irvine AD, Smith OP. Recent advances in the pathobiology and management of Kasabach-Merritt phenomenon. Br J Haematol 2015; 171:38-51. [PMID: 26123689 DOI: 10.1111/bjh.13557] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Kasabach-Merritt Phenomenon (KMP) refers to the clinical constellation of thrombocytopenia, consumptive coagulopathy and purpura associated with Kaposiform haemangioedothelioma or tufted angioma, but not the more common infantile haemangioma. It shows a variable and unpredictable response to traditional pharmacological agents, such as steroids, vincristine or interferon alpha 2a or 2b. More recently, the interaction between platelets and endothelial cells and the proangiogenic phenotype that results has been recognized to underly the pathogenesis of this disorder. Recent efforts have attempted to target the platelet by using antiplatelet agents and by the withholding of platelet transfusions even in those patients who have significant thrombocytopenia and laboratory evidence of coagulopathy. Excellent response rates and prompt results have been achieved by combining antiplatelet therapy with vincristine, without the need for steroid use. This synergistic approach moves away from the conventional wisdom of treating the underlying lesion to control the coagulopathy. Sirolimus, which is directed against the PI3/AKT/mTOR downstream signalling pathway involved in lymphangiogenesis, has also shown promising results, although further study is needed.
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Affiliation(s)
- Ciara O'Rafferty
- Department of Haematology, Our Lady's Children's Hospital, Dublin, Ireland
| | - Grainne M O'Regan
- Department of Dermatology, Our Lady's Children's Hospital, Dublin, Ireland
| | - Alan D Irvine
- Department of Dermatology, Our Lady's Children's Hospital, Dublin, Ireland.,Trinity College, Dublin, Dublin, Ireland
| | - Owen P Smith
- Department of Haematology, Our Lady's Children's Hospital, Dublin, Ireland.,Trinity College, Dublin, Dublin, Ireland
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Bell AJ, Chisholm M, Hickton M. Reversal of coagulopathy in Kasabach-Merritt syndrome with tranexamic acid. ACTA ACUST UNITED AC 2009. [DOI: 10.1111/j.1600-0609.1986.tb02305.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Parmar J, Shaygi B, Nelson M. Non-traumatic splenic rupture in a patient with Kasabach-Merritt syndrome. BMJ Case Rep 2009; 2009:bcr08.2008.0792. [PMID: 21686627 DOI: 10.1136/bcr.08.2008.0792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
This report presents a case illustrating the complications of Kasabach-Merritt syndrome in a 22-year-old man. The patient presented with acute abdominal pain and profound anaemia; a CT scan revealed intraperitoneal bleeding from spontaneous splenic rupture. The patient underwent initial emergency laparotomy and splenectomy, with a subsequent further laparotomy to control haemorrhage. Blood products requirements were extensive: 28 units red blood cells, 14 units fresh frozen plasma, 10 units platelets, 10 units cryoprecipitate and 2× Novo VII. He was then transferred to a nearby tertiary care unit for further management to control his coagulaopathy and he made a full recovery after 4 weeks.
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Affiliation(s)
- Jitesh Parmar
- St Mary's Hospital, General Surgery, Parkhurst Road, Newport, Isle of Wight PO30 5TG, UK
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Meguro M, Soejima Y, Taketomi A, Ikegami T, Yamashita YI, Harada N, Itoh S, Hirata K, Maehara Y. Living donor liver transplantation in a patient with giant hepatic hemangioma complicated by Kasabach-Merritt syndrome: report of a case. Surg Today 2008; 38:463-8. [PMID: 18560973 DOI: 10.1007/s00595-007-3623-4] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2007] [Accepted: 07/16/2007] [Indexed: 02/07/2023]
Abstract
We herein present a case of unresectable giant hepatic hemangiomas with Kasabach-Merritt syndrome which was successfully treated by living donor liver transplantation using a left lobe graft. The patient was a 45-year-old woman who complained of abdominal distension. Two sessions of transarterial embolization were performed, but failed to reduce the size of the tumor. The hepatic tumors were thus judged untreatable and the only option for a cure was to offer living donor liver transplantation, because of the tumor size, its location, and the association with Kasabach-Merritt syndrome. A left lobe graft with the middle hepatic vein donated by her 47-year-old brother was transplanted under venovenous bypass. The postoperative course of the recipient was complicated by small-for-size graft syndrome, which developed after episodes of acute cellular rejection on postoperative day 8 and sepsis on day 31. The patient successfully recovered from the complications and was discharged on day 72, and she remains well at 10 months after transplantation. In conclusion, living donor liver transplantation was found to be an effective option for the treatment of a patient with unresectable giant hepatic hemangiomas complicated by Kasabach-Merritt syndrome.
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Affiliation(s)
- Makoto Meguro
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Abstract
In this review we examine the diagnosis and treatment of pediatric liver tumors- both malignant and benign. The two most common malignant tumors are hepatoblastoma and hepatocellular carcinoma. Hepatoblastoma is seen in younger children, hepatocellular carcinoma in older children. Other malignant liver tumors are quite rare and include biliary rhabdomyosarcoma, angiosarcoma, rhabdoid tumor, and undifferentiated sarcoma. The commonly seen benign liver tumors in children are infantile hemangioma, mesenchymal hamartoma, and focal nodular hyperplasia. Rare benign tumors are hepatic adenoma, which is occasionally seen in teenage girls, and teratoma which is a very rare liver tumor in infants.
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Affiliation(s)
- Rebecka L Meyers
- Chief Pediatric Surgery, University of Utah, Primary Children's Medical Center, 100 North Medical Drive, Suite 2600, Salt Lake City, UT 84113, USA.
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George M, Singhal V, Sharma V, Nopper AJ. Successful surgical excision of a complex vascular lesion in an infant with Kasabach-Merritt syndrome. Pediatr Dermatol 2002; 19:340-4. [PMID: 12220282 DOI: 10.1046/j.1525-1470.2002.t01-1-00097.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Kasabach-Merritt syndrome, the association of a vascular lesion and consumptive coagulopathy, can represent a diagnostic and therapeutic challenge to clinicians. We describe an infant with a large complex vascular lesion of the left forearm that was successfully surgically excised. We propose surgical excision as an appropriate therapeutic option for some cases of Kasabach-Merritt syndrome.
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Affiliation(s)
- Manju George
- Children's Mercy Hospital, University of Missouri-Kansas City, Kansas City, Missouri 64108, USA
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Chen CE, Ko JY, Wang CJ. Kasabach-Merritt syndrome complicating the treatment of a femoral shaft fracture in an adult. THE JOURNAL OF TRAUMA 2002; 52:789-92. [PMID: 11956406 DOI: 10.1097/00005373-200204000-00035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Chin-En Chen
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Kaohsiung Medical Center, Kaohsiung, Taiwan.
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Hesselmann S, Micke O, Marquardt T, Baas S, Bramswig JH, Harms E, Willich N. Case report: Kasabach-Merritt syndrome: a review of the therapeutic options and a case report of successful treatment with radiotherapy and interferon alpha. Br J Radiol 2002; 75:180-4. [PMID: 11893644 DOI: 10.1259/bjr.75.890.750180] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
We describe the successful treatment of a neonate with Kasabach-Merritt syndrome who received local irradiation and interferon alpha therapy after failure of corticosteroid treatment. A male neonate, born after an uneventful pregnancy, had a huge haemangioma involving the upper right cervical region as well as severe thrombocytopenia. He was treated with corticosteroids, interferon alpha and radiotherapy. Prednisolone therapy (5 mg kg(-1) day(-1)) was started at 41 days of age. No therapeutic effect was observed after 2 weeks. At this time the tumour size had increased dramatically, platelet counts had decreased progressively and coagulation abnormalities had developed. Because corticosteroid therapy had been ineffective and the child was in a life-threatening condition, irradiation was delivered up to a total dose of 9.5 Gy in five fractions. Simultaneously, prednisolone therapy was slowly decreased and interferon alpha therapy (3 million U m(-2) day(-1)) was started and continued for 6 weeks. After irradiation with 9.5 Gy and beginning interferon alpha therapy, the tumour decreased in size and coagulation parameters normalized within 4 weeks. 6 months later, platelet counts and coagulation parameters were still normal. The tumour had further decreased in size. No acute severe side effects were observed. Radiation therapy combined with interferon alpha treatment is an alternative treatment modality when high dose corticoid steroid therapy has been ineffective in patients with Kasabach-Merritt syndrome, despite the risks of growth delay and secondary malignancy. In children showing no response to corticosteroids, radiotherapy and/or interferon alpha should be considered in Kasabach-Merritt syndrome.
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Affiliation(s)
- S Hesselmann
- Departments of Radiotherapy and Pediatrics, University Hospital Muenster, Albert-Schweitzer-Strasse 33, D-48149 Muenster, Germany
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Abstract
There is a remarkable diversity of conditions encompassed by benign liver masses in infants and toddlers. The most common benign hepatic tumor in this age group is infantile hepatic hemangioendothelioma. Other commonly seen benign tumors are mesenchymal hamartoma and focal nodular hyperplasia. Hepatic adenoma is almost exclusively a disease of older children; primary hepatic teratoma is exceedingly rare. There are several distinguishing characteristics of these benign tumors on radiographic evaluation; however, imaging techniques such as ultrasound scan, computed tomography, and angiography are not always reliable in differentiating benign from malignant tumors. The differential diagnosis of benign hepatic tumors includes nonneoplastic cystic masses including biliary and simple hepatic cysts, hematoma, parasitic cysts, and pyogenic and amebic liver abscess. Choledochal cyst presents with a classic triad of abdominal pain, cholestatic jaundice, and a palpable abdominal mass. They are classified anatomically into 5 subtypes with the most popular types being type I and type IV. Treatment is with complete cyst excision with hepaticojejunostomy reconstruction.
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Affiliation(s)
- R L Meyers
- Department of Surgery, University of Utah School of Medicine, Primary Children's Medical Center, Salt Lake City, USA
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Abstract
The most frequent benign tumours of the liver include haemangioma, liver cell adenoma and focal nodular hyperplasia. Patients may undergo hepatic resection because of a preoperative diagnosis of malignancy or uncertainty in diagnosis despite an extensive work-up.
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Affiliation(s)
- M F Chen
- Department of Surgery, Chang Gung University, Chang Gung Memorial Hospital, Taipei, Taiwan.
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16
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Walker S. Acquired Bleeding Disorders Associated with Disease and Medications. Diagn Pathol 2000. [DOI: 10.1201/b13994-31] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Verheul HM, Panigrahy D, Flynn E, Pinedo HM, D'Amato RJ. Treatment of the Kasabach-Merritt syndrome with pegylated recombinant human megakaryocyte growth and development factor in mice: elevated platelet counts, prolonged survival, and tumor growth inhibition. Pediatr Res 1999; 46:562-5. [PMID: 10541319 DOI: 10.1203/00006450-199911000-00012] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Kasabach-Merritt Syndrome (KMS) is seen in children with large vascular tumors. KMS is characterized by very low platelet counts and a consumption of coagulation factors causing life-threatening complications. It has been proposed that thrombopenia in these patients is caused by intratumoral trapping of platelets. The truncated form of the cMpl-receptor ligand thrombopoietin, pegylated human megakaryocyte growth and development factor (Peg-rHuMGDF), is an agent that stimulates platelet production. We hypothesized that stimulation of the platelet production would prevent the life-threatening complications of patients with KMS owing to low platelet counts. In a mouse model of KMS, with tumors derived from a hemangioendothelioma cell line, we studied the effect of Peg-rHuMGDF. Treatment with Peg-rHuMGDF (10 microg/kg/day intraperitoneally) increased platelet counts by 7-8-fold compared with control tumor-bearing mice after 11 d of treatment (p < 0.001, n = 8). Survival was significantly increased, with 50% of treated animals alive at 1 mo versus 0% in untreated controls. Interestingly, we also observed an inhibition of tumor growth by 75% (p < 0.001, n = 8). Hematoxylin and eosin staining showed fresh fibrin clots in the treated tumors, suggesting that higher platelet counts caused intravascular thrombosis of tumor vessels. We conclude that increased platelet production in this model of KMS resulted in an antivascular tumor effect via platelet trapping. Further, we propose that thrombopoietin may be of critical value in preventing life-threatening complications from KMS.
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Affiliation(s)
- H M Verheul
- The Department of Medical Oncology, Academic Hospital Vrije Universiteit, Amsterdam, The Netherlands
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Debulking of a gastrointestinal hemangioma alleviates coagulopathy associated with Kasabach-Merritt syndrome. Surgery 1999. [DOI: 10.1016/s0039-6060(99)70272-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Affiliation(s)
- G Singh
- Department of Medicine, St John's Medical College, Bangalore, India
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Sarkar M, Mulliken JB, Kozakewich HP, Robertson RL, Burrows PE. Thrombocytopenic coagulopathy (Kasabach-Merritt phenomenon) is associated with Kaposiform hemangioendothelioma and not with common infantile hemangioma. Plast Reconstr Surg 1997; 100:1377-86. [PMID: 9385948 DOI: 10.1097/00006534-199711000-00001] [Citation(s) in RCA: 269] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Children with a large vascular tumor and associated Kasabach-Merritt coagulopathy respond inconsistently to therapy and have a high mortality rate. For this reason, we undertook a retrospective study of 21 such patients, and focused on clinical, radiographic, and histopathologic features. The male to female ratio was 1:1.6. Tumor was noted at birth in 50 percent of patients; the remainder appeared throughout infancy. The location was cervicofacial (n = 2), shoulder/upper limb (n = 4), trunk including retroperitoneum (n = 11), and lower limb (n = 4). These tumors grew rapidly to large size and were characterized by cutaneous purpura, edema, and an advancing ecchymotic margin. In contrast to common hemangioma, magnetic resonance imaging showed diffuse enhancement with ill-defined margins, cutaneous thickening, stranding of subcutaneous fat, hemosiderin deposits, and small feeding and draining vessels. All tumors were Kaposiform hemangioendothelioma (KHE); none were infantile hemangioma. Light microscopy showed irregular lobules or sheets of poorly formed, small vascular channels infiltrating and entrapping normal tissues. Characteristic features included spindle-shaped endothelial cells, diminished pericytes and mast cells, microthrombi, and hemosiderin deposits. Wide endothelial intercellular gaps and incomplete basement membranes were seen by electron microscopy. Dilated, hyperplastic, lymphaticoid channels were prominent in one tumor. KHE in 14 infants was treated with interferon alpha-2a: 6 had accelerated regression; 2 had stabilization of growth; and 6 evidenced no response. The mortality rate was 24 percent (5 of 21); this included three infants with retroperitoneal KHE. Kasabach-Merritt phenomenon does not occur with common hemangioma. Rather it is associated with the more aggressive KHE and rarely with other vascular neoplasms. Variable response to current pharmacologic therapy underscores our inadequate knowledge of the pathogenesis of thrombocytopenia in KHE.
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Affiliation(s)
- M Sarkar
- Department of Pathology, Children's Hospital and Harvard Medical School, Boston, Mass. 02115, USA
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Mitsuhashi N, Furuta M, Sakurai H, Takahashi T, Kato S, Nozaki M, Saito Y, Hayakawa K, Niibe H. Outcome of radiation therapy for patients with Kasabach-Merritt syndrome. Int J Radiat Oncol Biol Phys 1997; 39:467-73. [PMID: 9308952 DOI: 10.1016/s0360-3016(97)00140-5] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE The efficacy of radiation therapy for Kasabach-Merritt syndrome, which is characterized by a huge hemangioma with consumption coagulopathy, remains controversial. In this study, we retrospectively investigated the treatment outcome of radiation therapy for seven neonates with Kasabach-Merritt syndrome. METHODS AND MATERIALS During the past 25 years we have seen seven children with Kasabach-Merritt syndrome who were treated with radiation therapy. Their ages ranged from 1 day to 5 months, with a median age of 1 month. The hemangioma was located in the extremities in four of seven children. Tumor sizes ranged from 70 cm to more than 150 cm in greatest diameter. Initial platelet counts were all less than 40,000/mm3 except for one patient. In principle, the total dose applied to the hemangioma was 8-10 Gy, with a daily dose of 1 Gy five times a week. RESULTS Four of seven hemangiomas responded dramatically, with a concomitant rise of the platelet count to radiation therapy. Although the remaining three hemangiomas, all of which were ill circumscribed by widespread overlying shiny, dusky purple skin, became less tense during radiation therapy. Disseminated intravascular coagulopathy was not improved, but they have responded favorably to two or three courses of radiation therapy with an extended radiation field by 1.5 years of age. As a result, all seven patients are now surviving with no evidence of hemangioma or hematological abnormalities. Shortening of the extremity was observed in three patients who received multiple courses of radiation therapy. CONCLUSIONS Radiation therapy appears to be one of the effective treatment options for Kasabach-Merritt syndrome despite the risk of growth delay and malignancy.
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Affiliation(s)
- N Mitsuhashi
- Department of Radiology and Radiation Oncology, Gunma University School of Medicine, Japan
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Enjolras O, Wassef M, Mazoyer E, Frieden IJ, Rieu PN, Drouet L, Taïeb A, Stalder JF, Escande JP. Infants with Kasabach-Merritt syndrome do not have "true" hemangiomas. J Pediatr 1997; 130:631-40. [PMID: 9108863 DOI: 10.1016/s0022-3476(97)70249-x] [Citation(s) in RCA: 261] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE In 1940 Kasabach and Merritt described an infant with a vascular anomaly, extensive purpura, and thrombocytopenia; they called his lesion "capillary hemangioma." Hemangioma is a benign tumor that grows in infancy and is characterized by proliferation of endothelial cells and regression during childhood. Although Kasabach-Merritt syndrome (KMS) is frequently mentioned as a possible complication of hemangioma, our experience suggests that the anatomic vascular lesion underlying the thrombocytopenia is not a "true," classic, involuting type of hemangioma of infancy and childhood. STUDY DESIGN We reviewed the clinical and hemostasis data and the response to treatment in 22 cases of KMS, and we analyzed the biopsy specimens of 15 of them. RESULTS Clinically none of the 22 patients had classic hemangioma. There was no female preponderance. All patients had severe thrombocytopenia (lowest platelet count = 3000/mm3) and consumption of fibrinogen. Histologically, none had the typical "capillary," involuting type of hemangioma of infancy: they exhibited either a tufted angioma or a kaposiform hemangioendothelioma pattern; all specimens also contained numerous abnormal lymphatic-like vessels; lymphatic malformation was the major component in two patients. The infants exhibited a heterogeneous response to a number of therapeutic regimens, as noted in other reports. Severe morbidity was present; three of our patients died, and one had leg amputation. "Residua" were, in fact, residual vascular neoplasia, variable in duration, and not a stable fibrofatty residuum, as in classic involuted hemangioma; only the hematologic phenomenon was "cured" after a period of years. CONCLUSIONS KMS is a distinctive disease of infancy, but the underlying vascular lesion is not a "true," classic, involuting type of hemangioma of infancy. This is a different vascular tumor with a resemblance pathologically to either tufted angioma or kaposiform hemangioendothelioma in association with lymphatic-like vessels. Whether the underlying lesion in KMS is a single anatomic entity or heterogeneous cannot be definitely concluded from this study. We need a better understanding of the pathogenesis of KMS to improve our therapeutic management.
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Affiliation(s)
- O Enjolras
- Department of Dermatology, Hôpital, Tarnier, Paris France
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Affiliation(s)
- S J Kempin
- Desert Hospital Comprehensive Cancer Center, Palm Springs, California 92262, USA
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Raman S, Ramanujam T, Lim CT. Prenatal diagnosis of an extensive haemangioma of the fetal leg: a case report. J Obstet Gynaecol Res 1996; 22:375-8. [PMID: 8870422 DOI: 10.1111/j.1447-0756.1996.tb00992.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- S Raman
- Department of Obstetrics and Gynaecology, University Hospital, Kuala Lumpur, Malaysia
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Esterly NB. Cutaneous hemangiomas, vascular stains and malformations, and associated syndromes. CURRENT PROBLEMS IN PEDIATRICS 1996; 26:3-39. [PMID: 8932511 DOI: 10.1016/s0045-9380(96)80023-5] [Citation(s) in RCA: 64] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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About I, Capdeville J, Bernard P, Lazorthes F, Boneu B. [Unresectable giant hepatic hemangioma and Kasabach-Merritt syndrome]. Rev Med Interne 1994; 15:846-50. [PMID: 7863122 DOI: 10.1016/s0248-8663(05)82844-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The Kasabach-Merritt syndrome was first described in children with cutaneous hemangiomas, but it can exceptionally be associated with visceral hemangiomas, especially in adults. Clotting and fibrinolysis within the hemangioma are thought to cause the coagulopathy observed in the so-called Kasabach-Merritt syndrome. This localised form of intra-vascular coagulation can progress to a secondary increased systemic fibrinolysis with fatal outcome for 20 to 30% of the patients. A transient control of hematologic abnormalities can frequently be obtained with blood product support (platelets, fibrinogen, fresh plasma, cryoprecipitates) and heparinotherapy. But in the adult, the only radical alternative is surgical excision if technically feasible. We reported here the case of a 43 year-old woman with a giant unresectable hepatic hemangioma complicated with a Kasabach-Merritt syndrome.
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Affiliation(s)
- I About
- Service de médecine interne A, hôpital de Foix, France
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Teillac-Hamel D, De Prost Y, Bodemer C, Andry P, Enjolras O, Sebag G, Brunelle F, Hubert P, Nihoul-Fekete C. Serious childhood angiomas: unsuccessful alpha-2b interferon treatment. A report of four cases. Br J Dermatol 1993; 129:473-6. [PMID: 8217766 DOI: 10.1111/j.1365-2133.1993.tb03181.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Over a 4-year period, we managed four children with alarming haemangiomas (two cases of Kasabach-Merritt syndrome and two life-threatening haemangiomas). Systemic steroid therapy was ineffective. Other treatments (radiotherapy, anti-platelet drugs) were also ineffective in the Kasabach-Merritt patients. On the basis of recent reports on the effects of interferon on endothelial cells, we used alpha-2 interferon therapy, but obtained no response.
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Affiliation(s)
- D Teillac-Hamel
- Service de Dermatologie, Hôpital Necker-Enfants Malades, Paris, France
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29
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Congenital Coagulopathies in the Pediatric Population. Crit Care Nurs Clin North Am 1993. [DOI: 10.1016/s0899-5885(18)30549-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Blei F, Orlow SJ, Geronemus RG. Supraumbilical midabdominal raphe, sternal atresia, and hemangioma in an infant: response of hemangioma to laser and interferon alfa-2a. Pediatr Dermatol 1993; 10:71-6. [PMID: 8493175 DOI: 10.1111/j.1525-1470.1993.tb00020.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
We cared for an infant girl with the clinical constellation of supraumbilical midabdominal raphe, sternal atresia, and cutaneous facial and upper trunk hemangioma. This is the first report of this clinical association in the dermatologic literature. The vascular component of the disorder responded to flashlamp-pumped pulsed dye laser therapy and to systemic interferon alfa-2a (Roferon-A).
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Affiliation(s)
- F Blei
- Department of Pediatrics, New York University Medical Center, NY 10016
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32
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Klein C, Hauser M, Hadorn HB. Interferon alpha-2a therapy of consumptive coagulopathy in Kasabach-Merritt syndrome. Eur J Pediatr 1992; 151:919. [PMID: 1473549 DOI: 10.1007/bf01954133] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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33
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Abstract
Two neonates with a giant hemangioma associated with thrombocytopenia (Kasabach-Marritt syndrome) have been managed at Kure National Hospital. The first case was initially difficult to distinguish from overwhelming infection or other tumors but improved after radiotherapy. The second case was resistant to radiation and steroid therapy. Magnetic resonance imaging determined a tumor extending into the surrounding soft tissues better than did enhanced computed tomography. Subtotal excision of the tumor and various drugs were effective only transiently and 51Cr-labeled platelets sequestrated into the residual hemangioma. Severe thrombocytopenia persisted for approximately 15 months requiring extra care for head and body contusions, but finally improved by treatment with platelet-active drugs such as acetylsalicylic acid, dipyridamole, and pentoxifylline.
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Affiliation(s)
- O Doi
- Department of Pediatric Surgery, Mothers' and Children's Medical Center, Kure National Hospital, Japan
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Luks FI, Yazbeck S, Brandt ML, Bensoussan AL, Brochu P, Blanchard H. Benign liver tumors in children: a 25-year experience. J Pediatr Surg 1991; 26:1326-30. [PMID: 1812268 DOI: 10.1016/0022-3468(91)90612-w] [Citation(s) in RCA: 51] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The most common benign liver tumors are hemangiomas and hamartomas, both of mesenchymal origin. Mortality for patients with these tumors has traditionally been substantial despite benign histology. Between 1965 and 1989, 22 patients were treated for a benign liver tumor. This represents 42% of all primary neoplasms of the liver observed during this period. Incidental findings of liver tumors at autopsy were excluded from this series. There were 9 boys and 13 girls with a mean age at presentation of 2.3 years (range, birth to 14 years). Sixteen had hemangiomas and presented earlier in life (mean age, 4.4 months). In this subgroup, high-output cardiac failure was present in 58% of the newborns. Seven hemangiomas were resected, four were observed, three were treated with digitalis, diuretics, and steroids, and one received epsilon-aminocaproic acid. Nonhemangiomatous tumors included four hamartomas, one focal nodular hyperplasia, and one nodular transformation. All six were resected. There was one death early in the series. At a mean follow-up of 38 months, 21 of the 22 patients are cured or asymptomatic. In the past, mortality rates of close to 90% have prompted many investigators to advocate resection of every symptomatic hemangioma. With the availability of more sophisticated imaging techniques and refinements in the treatment of cardiac failure, surgery can be used more selectively. Hepatic resections, once considered heroic, can now be performed with minimal morbidity and virtually no mortality. The 96% survival in this series of benign liver tumors contrasts with high mortality rates reported in the literature and illustrates the spectacular improvements that have been made in the diagnosis and management of these once ill-reputed tumors.
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Affiliation(s)
- F I Luks
- Department of Surgery, Hôpital Sainte-Justine, Montreal, Quebec, Canada
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36
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Death from an exsanguinating pelvic mass in a 77-year-old man. Am J Med 1991; 91:539-46. [PMID: 1951416 DOI: 10.1016/0002-9343(91)90192-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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37
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Abstract
Disseminated intravascular coagulation (DIC) is a clini-copathological syndrome secondary to an underlying disease. Characteristic laboratory abnormalities of DIC should suggest, much like the recognition of fever, anemia, or congestive heart failure, that an inciting disease process must be searched for. The clinical and laboratory consequences of DIC can be ascribed to the unregulated and unbalanced formation of thrombin, the main clot-forming enzyme, and plasmin, the main clot-lysing enzyme. If too much plasmin is formed in relation to thrombin, a hemorrhagic state, which appears in 60 to 75% of patients with deep vein thrombosis, will occur. Alternatively, if too much thrombin is formed in relation to the degree of secondary fibrinolysis, a thrombotic condition, which appears in 25 to 40% of patients with DIC, will become manifest. The diagnosis of DIC is dependent on the presence of an appropriate clinical situation with concurrent laboratory evidence of thrombin and plasmin formation. Thrombin formation, plasmin formation, or both, can be assessed by detection of fibrin monomer, fibrin/fibrinogen degradation products, and D-dimer or E fragment, respectively. Treatment of DIC should initially be addressed to treatment of the primary, underlying condition inciting the disorder. If treatment for DIC is specifically needed, blood product replacement is the first order of therapy. This replacement should be tailored to each patient's specific needs (i.e., platelets, fibrinogen, or plasma proteins). Heparin has a definite but limited use in conditions associated with acral cyanosis and dermal ischemia. Other specific therapies for DIC may be of use in individualized situations.
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Affiliation(s)
- Alvin H. Schmaier
- Departments of Thrombosis and Pathology, Temple University School of Medicine, 3400 North Broad St, Philadelphia, PA 19140
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Abstract
Vascular lesions in the neonate and infant are categorized as hemangiomas or malformations. Although their appearances may be similar, the pathobiology, natural history, and prognosis of these lesions are different. Selected important syndromes that are characterized as hemangiomas and vascular malformations are discussed, and an update on what is new in treatment, including laser therapy, is presented.
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Affiliation(s)
- R A Silverman
- Department of Dermatology, Case Western Reserve University, Cleveland, Ohio
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Abstract
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.
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Affiliation(s)
- R F Maceyko
- Department of Dermatology, Cleveland Clinic Foundation, Ohio 44195-5032
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Stahl RL, Henderson JM, Hooks MA, Martin LG, Duncan A. Therapy of the Kasabach-Merritt syndrome with cryoprecipitate plus intra-arterial thrombin and aminocaproic acid. Am J Hematol 1991; 36:272-4. [PMID: 1901445 DOI: 10.1002/ajh.2830360409] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
A patient with the Kasabach-Merritt syndrome with disseminated intravascular coagulopathy and congestive heart failure due to a giant hepatic cavernous hemangioma achieved thrombosis of his tumor with a combination of cryoprecipitate plus intra-arterial thrombin and epsilon aminocaproic acid. This was documented by an absence of Indium 111-labelled platelet sequestration, marked decrease in thrombin:antithrombin complex generation, and normalization of platelet count and fibrinogen. Interventional angiography with aminocaproic acid and thrombin is advocated in patients whose tumors are amenable to such an approach so as to avoid a systemic antifibrinolytic state.
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Affiliation(s)
- R L Stahl
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
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41
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Affiliation(s)
- S Gengenbach
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA 02115
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Hofhuis WJ, Oranje AP, Bouquet J, Sinaasappel M. Blue rubber-bleb naevus syndrome: report of a case with consumption coagulopathy complicated by manifest thrombosis. Eur J Pediatr 1990; 149:526-8. [PMID: 2347349 DOI: 10.1007/bf01957684] [Citation(s) in RCA: 27] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Blue rubber-bleb naevus (BRBN) syndrome is a rare disorder characterized by subcutaneous and gastrointestinal haemangiomas. The latter may lead to bleeding complications. A case is reported in which a process of chronic intravascular coagulation resulted in serious thrombotic complications. In the presence of a chronic consumption coagulopathy, it remains uncertain whether antiplatelet drugs are of prophylactic antithrombotic value.
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Affiliation(s)
- W J Hofhuis
- Department of Paediatrics, Erasmus University, Rotterdam, The Netherlands
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43
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Gozal D, Saad N, Bader D, Berger A, Jaffe M. Diffuse neonatal haemangiomatosis: successful management with high dose corticosteroids. Eur J Pediatr 1990; 149:321-4. [PMID: 2311628 DOI: 10.1007/bf02171557] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
We report two cases of diffuse neonatal haemangiomatosis. The multiple cutaneous lesions were associated with massive hepatic involvement and congestive heart failure in one, while in the other laryngeal haemangiomas caused stridor and inspiratory distress. A significant regression in vascular lesions was achieved with high dose corticosteroid therapy.
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Affiliation(s)
- D Gozal
- Department of Paediatrics, Bnai Zion Medical Centre, Haifa, Israel
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Rabinovici R, Heyman A, Kluger Y, Shinar E. Convulsions induced by aminocaproic acid infusion. DICP : THE ANNALS OF PHARMACOTHERAPY 1989; 23:780-1. [PMID: 2815855 DOI: 10.1177/106002808902301008] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Aminocaproic acid is a widely used antifibrinolytic agent. Serious adverse effects associated with its use are rare, but we report on a patient with liver disease and cirrhosis who experienced a grand mal seizure during the intravenous administration of aminocaproic acid. Clinicians should be alert to the occurrence of this adverse effect in patients with no previous neurological problems.
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Affiliation(s)
- R Rabinovici
- Department of Surgery, Hadassah University Hospital, Jerusalem, Israel
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46
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Poon MC, Kloiber R, Birdsell DC. Epsilon-aminocaproic acid in the reversal of consumptive coagulopathy with platelet sequestration in a vascular malformation of Klippel-Trenaunay syndrome. Am J Med 1989; 87:211-3. [PMID: 2547315 DOI: 10.1016/s0002-9343(89)80699-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- M C Poon
- Department of Medicine, University of Calgary, Alberta, Canada
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47
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Affiliation(s)
- S B Mallory
- University of Arkansas for Medical Sciences, Little Rock
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48
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Abstract
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.
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Affiliation(s)
- S Ozsoylu
- Hacettepe University Faculty of Medicine, Department of Paediatrics, Ankara, Turkey
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49
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Machin GA, Kent S. Pulmonary thromboembolism from a large hemangioma in a 4-week-old infant. PEDIATRIC PATHOLOGY 1989; 9:73-8. [PMID: 2717500 DOI: 10.3109/15513818909022333] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
A female infant with an extensive congenital hemangioma of the left knee region was treated medically for consumption coagulopathy; the hemangioma began to shrink, the coagulopathy improved, and the infant was clinically well when she died suddenly at the age of 4 weeks. The cause of death was a saddle pulmonary thromboembolus which had originated in the hemangioma. This is the first documented case of fatal thromboembolism complicating a conservatively managed extensive neonatal hemangioma. Causes of neonatal thromboembolism are reviewed.
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Affiliation(s)
- G A Machin
- Department of Pathology, Victoria General Hospital, British Columbia, Canada
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50
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Ortel TL, Onorato JJ, Bedrosian CL, Kaufman RE. Antifibrinolytic therapy in the management of the Kasabach Merritt syndrome. Am J Hematol 1988; 29:44-8. [PMID: 3177369 DOI: 10.1002/ajh.2830290111] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
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.
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Affiliation(s)
- T L Ortel
- Department of Medicine, Duke University Medical Center, Durham, North Carolina 27710
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