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Resch B, Sever Yildiz G, Reiterer F. Congenital Chylothorax of the Newborn: A Systematic Analysis of Published Cases between 1990 and 2018. Respiration 2021; 101:84-96. [PMID: 34515211 DOI: 10.1159/000518217] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 06/28/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Congenital chylothorax (CCT) of the newborn is a rare entity but the most common cause of pleural effusion in this age-group. We aimed to find the optimal treatment strategy. MATERIAL AND METHODS A PubMed search was performed according to the PRISMA criteria. All cases were analyzed according to prenatal, perinatal, and postnatal treatment modalities and follow-ups. RESULTS We identified 753 cases from 157 studies published between 1990 and 2018. The all-cause mortality rate was 28%. Prematurity was present in 71%, male gender dominated 57%, mean gestational age was 34 weeks, and birth weight was 2,654 g. Seventy-nine percent of newborns had bilateral CCT, the most common associated congenital anomalies with CCT were pulmonary lymphangiectasia and pulmonary hypoplasia, and the most common chromosomal aberrations were Down, Noonan, and Turner syndromes, respectively. Mechanical ventilation was reported in 381 cases for mean 17 (range 1-120) days; pleural punctuations and drainages were performed in 32% and 64%, respectively. Forty-four percent received total parenteral nutrition (TPN) for mean 21 days, 46% medium-chain triglyceride (MCT) diet for mean 37 days, 20% octreotide, and 3% somatostatin; chemical pleurodesis was performed in 116 cases, and surgery was reported in 48 cases with a success rate of 69%. In 462 cases (68%), complete restitution was reported; in 34 of 44 cases (77%), intrauterine intervention was carried out. CONCLUSION Respiratory support, pleural drainages, TPN, and MCT diet as octreotide remain to be the cornerstones of CCT management. Pleurodesis with OK-432 done prenatally and povidone-iodine postnatally might be discussed for use in life-threatening CCT.
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Affiliation(s)
- Bernhard Resch
- Research Unit for Neonatal Infectious Diseases and Epidemiology, Medical University of Graz, Graz, Austria.,Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Gülsen Sever Yildiz
- Research Unit for Neonatal Infectious Diseases and Epidemiology, Medical University of Graz, Graz, Austria
| | - Friedrich Reiterer
- Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
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2
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Jelin AC, Sobreira N, Wohler E, Solomon B, Sparks T, Sagaser KG, Forster KR, Miller J, Witmer PD, Hamosh A, Valle D, Blakemore K. The utility of exome sequencing for fetal pleural effusions. Prenat Diagn 2020; 40:590-595. [PMID: 31994743 DOI: 10.1002/pd.5650] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 01/06/2020] [Accepted: 01/07/2020] [Indexed: 01/23/2023]
Abstract
OBJECTIVE We sought to evaluate the performance of exome sequencing (ES) in determining an underlying genetic etiology for cases of fetal pleural effusions. STUDY DESIGN We examined a prospective cohort series of fetal pleural effusions visualized sonographically between 1 April 2016 and 31 August 2017. Fetal pleural effusions attributed to twin sharing, anemia, or structural anomalies were excluded, as were all cases with a genetic diagnosis established by karyotype or chromosomal microarray analysis. The remaining cases with pleural effusions of unclear etiology were offered ES. ES was performed by clinical sequencing and/or sequencing under the Baylor-Hopkins Center for Mendelian Genomics' (BHCMG) research platform. All cases were evaluated for novel genes or phenotypic expansion of disease-causing genes. RESULTS ES was performed on six probands affected by pleural effusions. A pathogenic variant was identified in one case (16.7%). Four additional cases had variants of uncertain significance (VUS) in candidate genes of pathological interest. Neither clinical nor candidate genes were evident in the final case. CONCLUSION ES should be considered in the evaluation of prenatally detected idiopathic pleural effusions when other diagnostic workup for a genetic etiology has failed.
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Affiliation(s)
- Angie C Jelin
- Department of Gynecology and Obstetrics, Division of Maternal Fetal Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA.,McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Nara Sobreira
- McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University, Baltimore, MD, USA.,Baylor-Hopkins Center for Mendelian Genomics, Baltimore, MD, USA
| | - Elizabeth Wohler
- McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University, Baltimore, MD, USA.,Baylor-Hopkins Center for Mendelian Genomics, Baltimore, MD, USA
| | | | - Teresa Sparks
- Department of Obstetrics, Gynecology & Reproductive Sciences, Division of Maternal Fetal Medicine, University of California, San Francisco, CA, USA
| | - Katelynn G Sagaser
- Department of Gynecology and Obstetrics, Division of Maternal Fetal Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Katherine R Forster
- Department of Gynecology and Obstetrics, Center for Fetal Therapy, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Jena Miller
- Department of Gynecology and Obstetrics, Center for Fetal Therapy, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - P Dane Witmer
- McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University, Baltimore, MD, USA.,Baylor-Hopkins Center for Mendelian Genomics, Baltimore, MD, USA
| | - Ada Hamosh
- McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University, Baltimore, MD, USA.,Baylor-Hopkins Center for Mendelian Genomics, Baltimore, MD, USA
| | - David Valle
- McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University, Baltimore, MD, USA.,Baylor-Hopkins Center for Mendelian Genomics, Baltimore, MD, USA
| | - Karin Blakemore
- Department of Gynecology and Obstetrics, Division of Maternal Fetal Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA.,McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University, Baltimore, MD, USA
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Abbasi N, Ryan G. Fetal primary pleural effusions: Prenatal diagnosis and management. Best Pract Res Clin Obstet Gynaecol 2019; 58:66-77. [PMID: 30737016 DOI: 10.1016/j.bpobgyn.2019.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 01/07/2019] [Accepted: 01/08/2019] [Indexed: 02/07/2023]
Abstract
Fetal pleural effusions can be associated with significant perinatal morbidity and mortality. When diagnosed antenatally, referral to a tertiary fetal medicine center is recommended for a detailed ultrasound evaluation for additional structural abnormalities or features suggestive of congenital infections or fetal anemia. The effusions should be characterized as unilateral or bilateral, and presence of hydrops and/or mediastinal shift should be documented. Additional testing should include fetal echocardiography, maternal testing for blood group and screen, hemoglobinopathies, and congenital infections. Invasive genetic testing is recommended with infectious testing on amniotic or pleural fluid. Pleuroamniotic shunting is recommended for large primary pleural effusions with significant mediastinal shift or hydrops, as several large series have demonstrated improvement in perinatal survival, particularly in hydropic fetuses. Delivery should occur in a tertiary care center with neonatal expertise, and infants should be followed up long-term for respiratory and neurodevelopmental outcomes.
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Affiliation(s)
- Nimrah Abbasi
- Fetal Medicine Unit, Department of Obstetrics & Gynaecology, Mount Sinai Hospital, University of Toronto, Canada.
| | - Greg Ryan
- Fetal Medicine Unit, Department of Obstetrics & Gynaecology, Mount Sinai Hospital, University of Toronto, Canada.
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Mon RA, Treadwell MC, Berman DR, Day L, Kreutzman J, Mychaliska GB, Perrone EE. Outcomes of fetuses with primary hydrothorax that undergo prenatal intervention (prenatal intervention for hydrothorax). J Surg Res 2017; 221:121-127. [PMID: 29229117 DOI: 10.1016/j.jss.2017.08.034] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 08/08/2017] [Accepted: 08/16/2017] [Indexed: 12/26/2022]
Abstract
BACKGROUND Primary hydrothorax is a congenital anomaly affecting 1 in 10,000-15,000 pregnancies. The natural history of this condition is variable with some fetuses having spontaneous resolution and others showing progression. The associated pulmonary hypoplasia leads to increased perinatal morbidity and mortality. Optimal prenatal intervention remains controversial. METHODS After obtaining the Institutional Review Board approval, a retrospective review of all patients evaluated for a fetal pleural effusion in the Fetal Diagnosis and Treatment Center at The University of Michigan, between 2006 and 2016 was performed. Cases with secondary etiologies for an effusion or when families decided to pursue elective termination were excluded. RESULTS Pleural effusions were identified in 175 patients. Primary hydrothorax was diagnosed in 15 patients (8%). The effusions were bilateral in 13/15 cases (86%) and 10/15 (66%) had hydrops at presentation. All 15 patients with primary hydrothorax underwent prenatal intervention. Thoracentesis was performed in 14/15 cases (93%). Shunt placement was performed in 10/15 cases (66%). Shunt migration was seen in four patients (40%) and all of these underwent prenatal shunt replacement. Overall survival was 76%. The rates of prematurity and preterm premature rupture of membranes were 69% and 35%, respectively. CONCLUSIONS Fetal intervention for the treatment of primary hydrothorax is effective, and it appears to confer a survival advantage. Both the fetuses and the mothers tolerated the procedures well. Preterm labor and preterm premature rupture of membranes remain an unsolved problem. Further studies are needed to understand the mechanisms behind the development of fetal hydrothorax.
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Affiliation(s)
- Rodrigo A Mon
- Section of Pediatric Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan; University of Michigan Health System, Fetal Diagnosis and Treatment Center, Ann Arbor, Michigan
| | - Marjorie C Treadwell
- University of Michigan Health System, Fetal Diagnosis and Treatment Center, Ann Arbor, Michigan; Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Michigan Health System, Ann Arbor, Michigan
| | - Deborah R Berman
- University of Michigan Health System, Fetal Diagnosis and Treatment Center, Ann Arbor, Michigan; Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Michigan Health System, Ann Arbor, Michigan
| | - Lori Day
- University of Michigan Health System, Fetal Diagnosis and Treatment Center, Ann Arbor, Michigan; Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Michigan Health System, Ann Arbor, Michigan
| | - Jeannie Kreutzman
- Section of Pediatric Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan; University of Michigan Health System, Fetal Diagnosis and Treatment Center, Ann Arbor, Michigan
| | - George B Mychaliska
- Section of Pediatric Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan; University of Michigan Health System, Fetal Diagnosis and Treatment Center, Ann Arbor, Michigan
| | - Erin E Perrone
- Section of Pediatric Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan; University of Michigan Health System, Fetal Diagnosis and Treatment Center, Ann Arbor, Michigan.
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5
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Pleural disease in infants and children: management updates. CURRENT PULMONOLOGY REPORTS 2016. [DOI: 10.1007/s13665-016-0134-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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6
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O''Brien B, Kesby G, Ogle R, Rieger I, Hyett JA. Treatment of Primary Fetal Hydrothorax with OK-432 (Picibanil): Outcome in 14 Fetuses and a Review of the Literature. Fetal Diagn Ther 2015; 37:259-66. [DOI: 10.1159/000363651] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2013] [Accepted: 05/10/2014] [Indexed: 11/19/2022]
Abstract
Background: Primary fetal hydrothorax (PFHT) is an uncommon condition with an estimated prevalence of 1 in 10,000/15,000 pregnancies. Therapeutic interventions include thoracocentesis, thoraco-amniotic shunting (TAS), and pleurodesis using OK-432. Methods: A review of the literature was performed to identify all cases of PFHT treated with TAS and OK-432. All cases of PFHT referred to the Fetal Maternal Unit at Royal Prince Alfred Hospital between 2002 and 2012 were retrospectively reviewed. In the cohort of fetuses treated with OK-432, the main perinatal outcomes evaluated were termination of pregnancy, live birth, neonatal death, and fetal death in utero. Secondary outcomes included gestational age (GA) at diagnosis, GA at treatment, GA at resolution, birth weight, and GA at birth. The development of the children was screened using the Ages and Stages Questionnaires, Version 3 (ASQ-3, 2009). Results: Primary hydrothorax was diagnosed in 31 fetuses, of which 14 had treatment with OK-432. One pregnancy terminated after treatment with OK-432. Survival was 85% (11/13): 100% in fetuses treated with OK-432 without hydrops, and 78% in those treated with hydrops. This compares well to the cases of TAS in the literature with an average survival of 63%: 85% in fetuses without hydrops and 55% with hydrops. The mean GA at birth was 36+4 weeks and mean birth weight 3,007 g. Eight of the 9 children screened with ASQ-3 scored well within the normal range. Conclusion: OK-432 appears to be a valid treatment option in fetuses with PFHT, particularly in those diagnosed at early GAs.
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Reiterer F, Grossauer K, Pfleger A, Häusler M, Resch B, Eber E, Popper H, Urlesberger B. Severe primary pulmonary lymphangiectasis in a premature infant: management and follow up to early childhood. Pediatr Int 2015; 57:166-9. [PMID: 25711257 DOI: 10.1111/ped.12416] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Revised: 04/16/2014] [Accepted: 05/09/2014] [Indexed: 11/27/2022]
Abstract
Primary pulmonary lymphangiectasis (PPL) is a rare congenital developmental abnormality of the lung with a generally poor prognosis. Only a limited number of patients with neonatal-onset PPL have been reported to survive. We present the case of a male preterm infant (gestational age 34 weeks 6 days) with histologically confirmed PPL, complicated by hydrops fetalis, bilateral hydrothorax (treated in utero with pleuro-amniotic shunts), and immediate respiratory distress at birth. He survived after extensive neonatal intensive care therapy and was discharged home at the age of 7 months. At last follow up he was 3 years 7 months old, still requiring assisted ventilation via tracheostomy, having recurrent episodes of wheezing and had mild global developmental delay. This case demonstrates that survival beyond the neonatal period is possible even with severe PPL but long-term morbidity may be relevant, and multidisciplinary management and close follow up are essential.
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8
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Reiterer F, Grossauer K, Morris N, Uhrig S, Resch B. Congenital pulmonary lymphangiectasis. Paediatr Respir Rev 2014; 15:275-80. [PMID: 24997116 DOI: 10.1016/j.prrv.2014.05.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Accepted: 05/09/2014] [Indexed: 12/31/2022]
Abstract
Congenital pulmonary lymphangiectasis (CPL) is a rare vascular malformation causing dilated lymph vessels and disturbed drainage of lymph fluid. Based on the pathogenesis and clinical phenotype it can be classified as primary or secondary CPL. Associated genetic syndromes with or without lymphedema, familial occurrence and gene mutations have been described. In utero, it may present as non-immune hydrops with pleural effusions. At birth neonates may have respiratory failure due to chylothorax and pulmonary hypoplasia, causing very high short term mortality rates. Other cases may become symptomatic any time later in childhood or even during adult life. CPL is usually diagnosed based on the combination of clinical signs, imaging and histological findings. Open-lung biopsy is considered the gold standard for the diagnosis of CPL. Treatment is primarily supportive featuring aggressive mechanical ventilation and the management of problems associated with congenital chylothorax including chest-drainage, medium-chain triglycerides (MCT) diet, and octreotide.
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Affiliation(s)
- Friedrich Reiterer
- Division of Neonatology, Department of Paediatrics, Medical University of Graz, Austria.
| | - Karin Grossauer
- Division of Neonatology, Department of Paediatrics, Medical University of Graz, Austria
| | - Nicholas Morris
- Division of Neonatology, Department of Paediatrics, Medical University of Graz, Austria
| | - Sabine Uhrig
- Institute of Human Genetics, Medical University of Graz, Austria
| | - Bernhard Resch
- Division of Neonatology, Department of Paediatrics, Medical University of Graz, Austria; Research Unit for Neonatal Infectious Diseases and Epidemiology, Medical University of Graz, Austria
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9
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Derderian SC, Trivedi S, Farrell J, Keller RL, Rand L, Goldstein R, Feldstein VA, Hirose S, MacKenzie TC. Outcomes of fetal intervention for primary hydrothorax. J Pediatr Surg 2014; 49:900-3; discussion 903-4. [PMID: 24888831 DOI: 10.1016/j.jpedsurg.2014.01.020] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Accepted: 01/27/2014] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Primary hydrothorax is a rare congenital anomaly with outcomes ranging from spontaneous resolution to fetal demise. We reviewed our experience with fetuses diagnosed with primary hydrothorax to evaluate prenatal management strategies. METHODS We reviewed the records of patients evaluated for fetal pleural effusions at our Fetal Treatment Center between 1996 and 2013. To define fetuses with primary hydrothorax, we excluded those with structural or genetic anomalies, diffuse lymphangiectasia, immune hydrops, and monochorionic diamniotic twin gestations. RESULTS We identified 31 fetuses with primary hydrothorax, of whom 24 had hydrops. Hydropic fetuses were more likely to present with bilateral effusions. Of all fetuses with primary hydrothorax, 21 had fetal interventions. Survival without hydrops was 7/7 (100%), whereas survival with hydrops depended on whether or not the patient had fetal intervention: 12/19 (63%) with intervention and 1/5 (20%) without intervention. Premature delivery was common (44%) among those who had fetal intervention. CONCLUSIONS Fetal intervention for primary hydrothorax may lead to resolution of hydrops, but preterm birth and neonatal demise still occur. Understanding the pathophysiology of hydrops may provide insights into further prenatal management strategies, including targeted therapies to prevent preterm labor.
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Affiliation(s)
- S Christopher Derderian
- Fetal Treatment Center, University of California, San Francisco, CA, USA; Department of Surgery, University of California, San Francisco, CA, USA
| | - Shivika Trivedi
- Fetal Treatment Center, University of California, San Francisco, CA, USA; Department of Surgery, University of California, San Francisco, CA, USA
| | - Jody Farrell
- Fetal Treatment Center, University of California, San Francisco, CA, USA
| | - Roberta L Keller
- Fetal Treatment Center, University of California, San Francisco, CA, USA; Department of Neonatology, University of California, San Francisco, CA, USA
| | - Larry Rand
- Fetal Treatment Center, University of California, San Francisco, CA, USA; Department of Obstetrics, University of California, San Francisco, CA, USA
| | - Ruth Goldstein
- Fetal Treatment Center, University of California, San Francisco, CA, USA; Department of Radiology, University of California, San Francisco, CA, USA
| | - Vickie A Feldstein
- Fetal Treatment Center, University of California, San Francisco, CA, USA; Department of Radiology, University of California, San Francisco, CA, USA
| | - Shinjiro Hirose
- Fetal Treatment Center, University of California, San Francisco, CA, USA; Department of Surgery, University of California, San Francisco, CA, USA
| | - Tippi C MacKenzie
- Fetal Treatment Center, University of California, San Francisco, CA, USA; Department of Surgery, University of California, San Francisco, CA, USA.
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Abstract
BACKGROUND The purpose of this study was to evaluate the clinical outcomes and usefulness of OK-432 (Picibanil) sclerotherapy as a new option in the conservative treatment of patients with malleolar bursitis of the ankle. METHODS Retrospectively, we reviewed a total of 20 consecutive patients (20 feet) in whom OK-432 sclerotherapy had been performed between March 2009 and June 2010. After aspiration of fluid in the malleolar bursal sac, 0.05 mg of OK-432 was injected into the malleolar bursal sac. We evaluated the clinical outcomes and side effects at the following time points: 2 weeks, 1 month, 3 months, 6 months, and 1 year after OK-432 sclerotherapy. The responses to the treatment were assessed according to the degree of fluctuation, shrinkage of the bursal sac, and soft tissue swelling. RESULTS Complete resolution was observed in 19 patients (95%) after the first or second application of OK-432 sclerotherapy, and a partial response was observed in 1 patient (5%) after a second application of OK-432 sclerotherapy. The physical component scores of SF-36 improved from 70.0 ± 6.8 to 76.5 ± 7.3 at the last follow-up (P = .0002). CONCLUSION OK-432 sclerotherapy was a useful procedure for patients not responding to the usual conservative treatment of malleolar bursitis of the ankle. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
- Kwang Hwan Park
- Department of Orthopaedic Surgery, Yonsei University College of Medicine, Seoul, Korea
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Singh P, Ahmed F. Congenital pulmonary lymphangiectasis resulting in pleural effusions managed by thoracoamniotic shunting. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2013. [DOI: 10.1016/j.epsc.2013.05.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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van Mieghem T, Baud D, Devlieger R, Lewi L, Ryan G, De Catte L, Deprest J. Minimally invasive fetal therapy. Best Pract Res Clin Obstet Gynaecol 2012; 26:711-25. [DOI: 10.1016/j.bpobgyn.2012.03.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2012] [Accepted: 03/21/2012] [Indexed: 12/31/2022]
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Kim JE, Lee C, Park KI, Park MS, Namgung R, Park IK. Successful pleurodesis with OK-432 in preterm infants with persistent pleural effusion. KOREAN JOURNAL OF PEDIATRICS 2012; 55:177-80. [PMID: 22670153 PMCID: PMC3362732 DOI: 10.3345/kjp.2012.55.5.177] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/06/2011] [Revised: 10/28/2011] [Accepted: 11/28/2011] [Indexed: 12/20/2022]
Abstract
OK-432 (picibanil) is an inactivated preparation of Streptococcus pyogenes that causes pleurodesis by inducing a strong inflammatory response. Intrapleural instillation of OK-432 has recently been used to successfully treat neonatal and fetal chylothorax. Here we report a trial of intrapleural instillation of OK-432 in two preterm infants who were born with hydrops fetalis and massive bilateral pleural effusion. Both cases showed persistent pleural effusion, refractory to conservative treatment, up to postnatal days 26 and 46, respectively. An average of 80 to 140 mL of pleural fluid was drained daily. In case 1, the infant was treated with OK-432 during the fetal period at gestation 28 weeks and 4 days of gestation, but showed recurrence of pleural effusion and progressed into hydrops. Within two to three days after OK-432 injection, the amount of pleural fluid drainage was dramatically decreased and there was no reaccumulation. We did not observe any side effects related to OK-432 injection. We suggest that OK-432 should be considered as a therapeutic option in infants who have persistent pleural effusion for more than four weeks, with the expectation of the early removal of the chest tube and a good outcome.
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Affiliation(s)
- Jeong Eun Kim
- Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
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Genome-wide gene expression analysis implicates the immune response and lymphangiogenesis in the pathogenesis of fetal chylothorax. PLoS One 2012; 7:e34901. [PMID: 22529953 PMCID: PMC3329545 DOI: 10.1371/journal.pone.0034901] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2011] [Accepted: 03/06/2012] [Indexed: 11/22/2022] Open
Abstract
Fetal chylothorax (FC) is a rare condition characterized by lymphocyte-rich pleural effusion. Although its pathogenesis remains elusive, it may involve inflammation, since there are increased concentrations of proinflammatory mediators in pleural fluids. Only a few hereditary lymphedema-associated gene loci, e.g. VEGFR3, ITGA9 and PTPN11, were detected in human fetuses with this condition; these cases had a poorer prognosis, due to defective lymphangiogenesis. In the present study, genome-wide gene expression analysis was conducted, comparing pleural and ascitic fluids in three hydropic fetuses, one with and two without the ITGA9 mutation. One fetus (the index case), from a dizygotic pregnancy (the cotwin was unaffected), received antenatal OK-432 pleurodesis and survived beyond the neonatal stage, despite having the ITGA9 mutation. Genes and pathways involved in the immune response were universally up-regulated in fetal pleural fluids compared to those in ascitic fluids. Furthermore, genes involved in the lymphangiogenesis pathway were down-regulated in fetal pleural fluids (compared to ascitic fluid), but following OK-432 pleurodesis, they were up-regulated. Expression of ITGA9 was concordant with overall trends of lymphangiogenesis. In conclusion, we inferred that both the immune response and lymphangiogenesis were implicated in the pathogenesis of fetal chylothorax. Furthermore, genome-wide gene expression microarray analysis may facilitate personalized medicine by selecting the most appropriate treatment, according to the specific circumstances of the patient, for this rare, but heterogeneous disease.
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Lo T, Lau W, Lam Y, Tang M, Leung T, Leung W. Successful Treatment of Severe Fetal Chylothorax Resistant to Repeated Pleuroamniotic Shunting by OK-432 Pleurodesis. Fetal Diagn Ther 2012; 31:260-3. [DOI: 10.1159/000336125] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2011] [Accepted: 12/23/2011] [Indexed: 12/26/2022]
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Yang YS, Ma GC, Shih JC, Chen CP, Chou CH, Yeh KT, Kuo SJ, Chen TH, Hwu WL, Lee TH, Chen M. Experimental treatment of bilateral fetal chylothorax using in-utero pleurodesis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2012; 39:56-62. [PMID: 21584887 DOI: 10.1002/uog.9048] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/04/2011] [Indexed: 05/30/2023]
Abstract
OBJECTIVE To assess the use and efficacy of in-utero pleurodesis for experimental treatment of bilateral fetal chylothorax. METHODS This was a study of 78 fetuses with bilateral pleural effusion referred to three tertiary referral centers in Taiwan between 2005 and 2009. Fetuses were karyotyped following amniocentesis and the lymphocyte ratio in the pleural effusion was determined following thoracocentesis. Forty-nine (62.8%) fetuses had a normal karyotype and were recognized to have fetal chylothorax; of these, 45 underwent intrapleural injection of 0.1KE OK-432 per side per treatment. We evaluated clinical (hydrops vs. no hydrops) and genetic (mutations in the reported lymphedema-associated loci: VEGFR3, PTPN11, FOXC2, ITGA9) parameters, as well as treatment outcome. Long-term survival was defined as survival to 1 year of age. RESULTS The overall long-term survival rate (LSR) was 35.6% (16/45); the LSR for non-hydropic fetuses was 66.7% (12/18) and for hydropic fetuses it was 14.8% (4/27). If we included only fetuses with onset of the condition in the second trimester, excluding those with onset in the third trimester, the LSR decreased to 29.4% (10/34). Notably, 29.6% (8/27) of hydropic fetuses had mutations in three of the four loci examined. CONCLUSIONS OK-432 pleurodesis appeared to be an experimental alternative to the gold-standard technique of thoracoamniotic shunting in non-hydropic fetal chylothorax. In hydropic fetuses, pleurodesis appeared less effective.
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Affiliation(s)
- Y-S Yang
- Department of Obstetrics and Gynecology, National Taiwan University, Taipei, Taiwan
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Szakszon K, Veres ZL, Boros M, Kiss SS, Nagy B, Bálega E, Papp Á, Németh E, Pataki I, Szabó T. Successful surgical intervention in a case of spontaneous chylothorax in an infant unresponsive to conservative therapy. Interv Med Appl Sci 2010. [DOI: 10.1556/imas.2.2010.4.6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
We report a case of an infant with spontaneous chylothorax due to the congenital malformation of a small lymph vessel of the chest wall. Conservative therapy with omitting long-chain fatty acids from the diet, fat-free nutrition, total parenteral nutrition and intravenous somatostatin did not result in the decrease of pleural effusion. Thoracic surgical intervention performing thoracic duct ligation and using fibrin sealants was applied after 10 days of unsuccessful conservative therapy, and resulted in the complete recovery of the patient. Our experience support the already existing observations, that in cases where the daily loss of chyle exceeds 100 ml per age years and/or lasts longer than 2 weeks, early surgical intervention is recommended.
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Affiliation(s)
- K. Szakszon
- 1 Institute of Pediatrics, University of Debrecen, Medical & Health Science Centre, Debrecen, Hungary
| | - Z. L. Veres
- 2 Department of Surgery, Thoracic Surgery Unit, University of Debrecen, Medical & Health Science Center, Debrecen, Hungary
| | - M. Boros
- 1 Institute of Pediatrics, University of Debrecen, Medical & Health Science Centre, Debrecen, Hungary
| | - S. Sz. Kiss
- 2 Department of Surgery, Thoracic Surgery Unit, University of Debrecen, Medical & Health Science Center, Debrecen, Hungary
| | - B. Nagy
- 1 Institute of Pediatrics, University of Debrecen, Medical & Health Science Centre, Debrecen, Hungary
| | - E. Bálega
- 1 Institute of Pediatrics, University of Debrecen, Medical & Health Science Centre, Debrecen, Hungary
| | - á. Papp
- 1 Institute of Pediatrics, University of Debrecen, Medical & Health Science Centre, Debrecen, Hungary
| | - E. Németh
- 1 Institute of Pediatrics, University of Debrecen, Medical & Health Science Centre, Debrecen, Hungary
| | - I. Pataki
- 1 Institute of Pediatrics, University of Debrecen, Medical & Health Science Centre, Debrecen, Hungary
| | - T. Szabó
- 1 Institute of Pediatrics, University of Debrecen, Medical & Health Science Centre, Debrecen, Hungary
- 3 Institute of Pediatrics, University of Debrecen, Medical & Health Science Center, Nagyerdei krt. 98, H-4012, Debrecen, Hungary
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Taweevisit M, Thorner PS. Hydrops fetalis in the stillborn: a series from the central region of Thailand. Pediatr Dev Pathol 2010; 13:369-74. [PMID: 20233068 DOI: 10.2350/09-12-0771-oa.1] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The purpose of this study was to analyze the cause of hydrops fetalis (HF) among fetal deaths in the central region of Thailand. Autopsy reports diagnosed as HF from 1999 to 2008 at King Chulalongkorn Memorial Hospital were retrieved, and the pathologic findings, clinical information, fetal ultrasonographic studies, and laboratory investigations were reviewed. There were 78 stillborn autopsies during this 10-year period; the mean gestational age was 28 weeks. The causes of fetal hydrops were identified in 88.5%; no cases of immune hydrops were detected. Anemia was the predominant cause of HF (n = 33; 42.2%): related to homozygous α-thalassemia (n = 17; 21.8%), twin-twin transfusion syndrome (n = 8; 10.2%), hemoglobin H (n = 3; 3.8%), lung hemorrhage (n = 1; 1.3%), adrenal hemorrhage (n = 1; 1.3%), and 3 cases of unspecified etiology (3.8%). Other causes of high-output failure included mass lesions resulting in vascular shunting (n = 2; 2.6%) and 1 case each (1.3% each) of maternal diabetes mellitus, intestinal lymphangiectasia, and Beckwith-Wiedemann syndrome. Causes resulting in low-output cardiac failure were congenital heart disease (n = 16; 20.5%) and thoracic space-occupying lesions (n = 7; 9%). The remaining causes included fetal infection (n = 5; 6.4%), congenital abnormalities suggestive of a chromosomal or genetic basis (n = 2; 2.6%), and 1 case (1.3%) of placental vascular thrombosis. Nine cases (11.5%) had no identifiable cause. Thus, the most common cause of HF in this series was homozygous α-thalassemia, reflecting the geographic location of this series.
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Affiliation(s)
- Mana Taweevisit
- Department of Pathology, Chulalongkorn University, Pathumwan, Bangkok, 10330 Thailand.
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Bennet L, Cowie RV, Stone PR, Barrett R, Naylor AS, Blood AB, Gunn AJ. The neural and vascular effects of killed Su-Streptococcus pyogenes (OK-432) in preterm fetal sheep. Am J Physiol Regul Integr Comp Physiol 2010; 299:R664-72. [PMID: 20484698 DOI: 10.1152/ajpregu.00116.2010] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Fetal exposure to inflammatory mediators is associated with a greater risk of brain injury and may cause endothelial dysfunction; however, nearly all the evidence is derived from gram-negative bacteria. Intrapleural injections of OK-432, a killed Su-strain of Streptococcus pyogenes, has been used to treat fetal chylothorax. In this study, we evaluated the neural and cardiovascular effects of OK-432 in preterm fetal sheep (104 +/- 1 days, term 147 days). OK-432 (0.1 mg, n = 6) or saline vehicle (n = 7) was infused in the fetal pleura, and fetuses were monitored for 7 days. Blood samples were taken routinely for plasma nitrite measurement. Fetal brains were taken for histological assessment at the end of the experiment. Between 3 and 7 h postinjection, OK-432 administration was associated with transient suppression of fetal body and breathing movements and electtroencephalogram activity (P < 0.05), increased carotid and femoral vascular resistance (P < 0.05), but no change in blood pressure. Brain activity and behavior then returned to normal except in one fetus that developed seizures. OK-432 fetuses showed progressive, sustained vasodilatation (P < 0.05), with lower blood pressure after 4 days (P < 0.05), but normal heart rate. There were no changes in plasma nitrite levels. Histological studies showed bilateral infarction in the dorsal limb of the hippocampus of the fetus that developed seizures, but no injury in other fetuses. We conclude that a single low-dose injection of OK-432 can be associated with risk of focal cerebral injury in the preterm fetus and chronic central and peripheral vasodilatation that does not appear to be mediated by nitric oxide.
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Affiliation(s)
- L Bennet
- Department of Physiology, The University of Auckland, New Zealand.
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Tanaka Y, Takakura Y, Kumai T, Sugimoto K, Taniguchi A, Hattori K. Sclerotherapy for intractable ganglion cyst of the hallux. Foot Ankle Int 2009; 30:128-32. [PMID: 19254507 DOI: 10.3113/fai-2009-0128] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND We devised a method of sclerotherapy using OK432. The present study comprised a retrospective followup of sclerotherapy outcomes. MATERIALS AND METHODS Eighteen feet in 18 consecutive patients (seven men, 11 women; mean age, 55 years) were treated with sclerotherapy. Previous surgery had been performed one to four times for seven feet. After aspirating the contents of the ganglion cysts, 0.2 to 0.3 ml of suspension of OK432 (lyophilized strep pyogenes) was injected. The volume of fluid aspirated was from 0.2 to 2.5 ml, with an average of 0.9 ml. Mean duration of followup was 3 years 6 months. Clinical evaluation was performed using the AOFAS hallux scale. RESULTS All ganglion cysts disappeared after sclerotherapy. However, recurrences were observed in eight feet. Mean duration until recurrence was 13 months. Sclerotherapy was again performed for all patients with recurrence. Re-recurrence occurred in three feet. A third sclerotherapy was performed for all three patients. All ganglion cysts had disappeared by final followup. Mean AOFAS score improved from 75 points before therapy to 95 points at followup. Six patients had complications with local redness and pain for 1 to 6 days after injection. CONCLUSION Sclerotherapy using OK432 is a minimally invasive treatment of symptomatic ganglion cysts of the hallux. Recurrence is common but complications are infrequent and self-limited.
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Affiliation(s)
- Yasuhito Tanaka
- Department of Orthopaedic Surgery, Nara Medical University, Kashihara, Nara, 634-8522, Japan.
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Ma GC, Liu CS, Chang SP, Yeh KT, Ke YY, Chen TH, Wang BBT, Kuo SJ, Shih JC, Chen M. A recurrentITGA9missense mutation in human fetuses with severe chylothorax: possible correlation with poor response to fetal therapy. Prenat Diagn 2008; 28:1057-63. [DOI: 10.1002/pd.2130] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Abstract
The clinical course of primary fetal hydrothorax is unpredictable. Whereas smaller unilateral effusions might remain stable or even regress, this is rarely the case with larger collections. Bilateral effusions, hydrops, preterm delivery and the lack of antenatal therapy are all associated with poor outcome. Once structural and chromosomal anomalies have been excluded, optimal management depends on gestational age, rate of progression, the development of hydrops and associated maternal symptoms. For very large effusions with mediastinal shift, hydrops and/or hydramnios, or when there is rapid enlargement of the effusion, fetal intervention is warranted. Survival can be maximized by pleuroamniotic shunting, which can reverse hydrops and hydramnios and prevent pulmonary hypoplasia. Pleuroamniotic shunting can also be used for the treatment of other large cystic lung lesions, such as a macrocystic congenital cystic adenomatoid malformation or bronchopulmonary sequestration, especially when associated with hydrops.
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Affiliation(s)
- Yoav Yinon
- Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
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