Chylothorax with multiple lymphangiomata of the bone

Gorham-Stout disease of skull base leading to cranial settling and rhinorrhea: a case-based review

PURPOSE

Gorham-Stout disease (GSD) is a rare progressive osteolytic disorder, theoretically caused by lymphovascular endothelial proliferation. Spinal involvement carries a dismal prognosis because of neurological consequences. Lesions of the skull base are extremely rare and entail even more devastating prognosis due to cervical instability and cerebrospinal fluid (CSF) leakage. Due to scarcity of this condition, the aim of this study was to give an overview of skull base GSD and review the cases with such condition reported in the literature.

METHODS

In this case-based review, different aspects of skull base GSD are discussed, and a sample clinical case of GSD leading to cranial settling and rhinorrhea is presented. The characteristics, symptoms, and managements of all English-language PubMed-reported cases were reviewed, and different features of presentation and methods of treatments were analyzed.

RESULTS

Based on the literature review, most of the cases encountered serious problems in the course of the disease. Meningitis/CSF leakage was detected in 12 of 26 collected cases, followed by hearing loss/tinnitus/otitis media in 10 cases, headache in 8, and neck pain/stiffness in 8 patients. Despite a variety of treatments, improvement was only observed in 8 of 26 collected cases. The reminders showed either stable condition or worsening and death.

CONCLUSION

All cases of GSD of the skull base should be evaluated for rhinorrhea/otorrhea and cranial settling, both of them being among the most life-threatening conditions. Since definite treatment, in order to stop disease progression, is sometimes impossible, symptomatic and supportive treatment should be started as possible.

A case report of Gorham-Stout disease diagnosed during the course of recurrent meningitis and cholesteatoma

Background

Gorham-Stout disease is a rare bone disorder. Here, we present a case of Gorham-Stout disease diagnosed during follow-up of a patient with cholesteatoma; the disease affected the temporal bone and other sites of the skull. To the best of our knowledge, this is the first report of Gorham-Stout disease diagnosed with recurrent cerebrospinal leakage after surgery to treat cholesteatoma.

Case presentation

A 25-year-old male patient re-presented to our department for the first time in 7 years with otorrhea in the right ear and recurrent meningitis. The patient had a history of multiple surgeries for cholesteatoma and suffered from recurrent cerebrospinal fluid leakage, which initially was thought to be caused by recurrence of cholesteatoma. Therefore, skull base reconstruction was planned. However, the underlying cause was identified eventually as defects in the temporal bone caused by massive osteolysis due to Gorham-Stout disease. Skull base reconstruction was abandoned because the osteolysis was considered to be progressive. Conservative treatment with infectious control was implemented as an alternative.

Conclusion

This case describes unusual temporal bone osteolysis after cholesteatoma surgery and the importance of considering the possibility of multiple concurrent diseases in such individuals. The distinguishing features of this case are the fact that the temporal bone had disappeared, and deconstruction was complicated by infection and inflammation caused by cholesteatoma, surgical invasion, and Gorham-Stout disease. Appropriate diagnosis saved the patient from ineffective multiple surgeries for cerebrospinal fluid leakage or cholesteatoma, and improved his quality of life.

A Child with Early-Onset Gorham-Stout Disease Complicated by Chylothorax: Near-Complete Regression of Bone Lesions with Interferon and Bisphosphonate Treatment

We report a case of Gorham-Stout disease (GSD) complicated by chylothorax and treated with a combination therapy with interferon and bisphosphonates. This treatment may be helpful in improving the usually unfavorable prognosis of GSD beginning with a chylothorax before 1 year of age, and in reducing bone lesions. Moreover, the use of bisphosphonates appears to be useful in treating pain.

Left Functional Pneumonectomy Caused by a Very Rare Giant Intrathoracic Cystic Lesion in a Patient with Gorham-Stout Syndrome: Case Report and Review of the Literature

Gorham-Stout syndrome is an uncommon entity, with few cases reported in bibliography. It consists of osteolytic manifestations affecting various bones and replacing them with lymphangiomatous tissue. With pathophysiology unknown, Gorham-Stout disease affects also cardiorespiratory system usually causing lytic lesions to the bones of the thoracic cage or directly invading the thoracic duct. This is a case report of a unique respiratory manifestation of the disease and a review of its cardiorespiratory complications.

CT features of generalized lymphangiomatosis in adult patients

OBJECTIVE

The objective was to present computed tomographic (CT) findings of generalized lymphangiomatosis in young adults that was at first misdiagnosed with malignancy.

MATERIALS AND METHODS

We reviewed the clinical and radiological findings of three young adults who had histologically confirmed generalized lymphangiomatosis.

RESULTS

Bony lesions were cystic forms and appeared as variably sized, well-circumscribed, irregular, microlobulated-contour, multiseptated masses. Lymphangiomas involving soft tissue were similar to bony lesions on CT.

CONCLUSION

CT features of generalized lymphangiomatosis may be useful to prevent invasive procedures in young subjects. Generalized lymphangiomatosis involving bones in young adults shows less extensive and aggressive osteolytic pattern than known features in child.

Acquired vulvar lymphangioma circumscriptum: a comparison of 12 cases with Crohn's associated lesions or radiation therapy induced tumors

BACKGROUND

Lymphangioma circumscriptum (LC) is a benign lesion of lymphatic origin. Vulvar involvement occurs in various clinical settings.

METHODS

We present 12 cases, and compare lesions in patients with Crohn's disease and those associated with pelvic radiation.

RESULTS

The average age at presentation was 49 years. Thirty-three percent of the patients had Crohn's disease, 58% had radiation therapy and 9% had no significant medical history. Sixty-seven percent of the patients had multifocal lesions in anatomically distinct regions. Patients presented on average 16 years after onset of predisposing factors. Presenting complaints were pruritus, wetness and vulvar edema. Lesions were clinically heterogeneous, often found on the labia majora. Lesions consisted of dilated lymphatic channels at the junction of the reticular and papillary dermis. The cells lining these spaces lacked cytologic atypicality or mitotic activity. All lesions so examined were immunoreactive for D240. Patients were most often treated with surgical excision followed by laser ablation. Four of twelve patients, all with radiation-associated lesions, experienced disease progression necessitating additional surgery.

CONCLUSIONS

Patients with LC secondary to radiation, when compared to those with Crohn's disease, were 10 years younger, more likely to have associated co-morbidities, and frequently experienced disease progression needing additional surgeries. Acquired vulvar LC has multiple causes with differing prognosis.

Bilateral chylothorax complicating massive osteolysis (Gorham's syndrome)

Chylothorax may rarely occur in osteolysis. A fatal case of bilateral chylothorax complicating massive osteolysis is described and the pathogenesis and management are discussed.

Massive chylothorax associated with lymphangiomatosis of the bone

Chylothorax in the absence of tumor or trauma is uncommon. Lymphangiomatosis of the bone, although extremely rare, has been associated with chylothorax. The authors describe the case of a 12-year-old boy who presented with a symptomatic left chylothorax associated with lymphangiomatosis of the ribs, scapula, and clavicle. Despite tube thoracostomies and the initiation of total parenteral nutrition, massive losses of chyle persisted, resulting in hypoproteinemia and severe lymphopenia. Control of the chylothorax was achieved by a parietal pleurectomy and application of fibrin glue (Tisseel). In the literature there are 16 cases of chylothorax associated with lymphangiomatosis of the bone. Their presentation, treatment, and outcome are reviewed. Conservative treatments such as dietary manipulations or thoracenteses were rarely successful. Thoracotomy with parietal pleurectomy on the side of the effusion is usually effective in controlling the chylothorax. Lymphangiomatosis should be considered a diagnostic possibility for any child who presents with a chylothorax.

Chylothorax in Gorham's syndrome. A common complication of a rare disease

One hundred forty-six cases of Gorham's syndrome are documented in the literature. Twenty-five (17 percent) patients have been reported to have chylothorax as a complication. To our knowledge, this high incidence of chylothorax has not been reported previously. We describe two such patients treated by thoracic duct ligation and compared our results with others to support early surgical intervention via a low right-sided thoracotomy in these cases.

Case report: computed tomography of generalized lymphangiomatosis and chylothorax

The diagnosis of lymphangiomatosis can often be made on clinical grounds with the aid of plain radiography. In children with intractable chylothorax computed tomography (CT) of the thorax may reveal the presence of a mediastinal mass but frequently in lymphangiomatosis will not demonstrate any specific features. Abdominal CT, on the other hand, may suggest the diagnosis by the association with intraabdominal lymphangioma.

Diffuse pulmonary lymphangiomatosis

Angiomatous lesions of the lung are uncommon and not well characterized. We describe nine cases of a distinct lymphatic vascular lesion that we have termed "diffuse pulmonary lymphangiomatosis." Extrathoracic lymphangiomatous lesions were not identified. The patients comprised seven males and two females with a mean age at presentation of 10 years (age range, 1 month to 33 years). Six patients were younger than 10 years of age. Symptoms included "wheezing" or "asthma" (44%) and dyspnea (22%) present for 3 months to 20 years. Chest radiographs showed bilateral interstitial infiltrates, often greatest in the lower lobes. Pleural or pericardial effusions were present or developed in six patients. Pulmonary function tests showed in two patients and mixed obstruction and restriction in five patients. Open lung biopsies (nine patients) and autopsy (one patient) showed anastomosing endothelial lined spaces along pulmonary lymphatic routes (especially pleural and interlobular septal) accompanied by asymmetrically spaced bundles of spindle cells, which were prominent in six cases. Hemosiderin deposition often was present in the spindle cell areas and in the adjacent lung. The lining cells were positive for factor VIII-related antigen (eight cases) and Ulex europaeus I agglutinin (four cases). The spindle cells were reactive with antibodies to vimentin (nine cases), desmin (six cases), actin (seven cases), progesterone receptor (seven cases), and proliferating cell nuclear antigen (one case); they were negative for estrogen receptor (seven cases), keratin, (eight cases), and HMB-45 (eight cases). Diffuse pulmonary lymphangiomatosis was progressive in eight cases and was most aggressive in the youngest children. Two of the children have died, one of pulmonary hemorrhage and the other after heart-lung transplantation. Diffuse pulmonary lymphangiomatosis is distinct from lymphangiectasis, lymphangioleiomyomatosis, pulmonary capillary hemangiomatosis, Kaposi's sarcoma, and kaposiform hemangioendothelioma. Due to its distribution and histology, a lymphatic origin of the lesion is favored.

Lymphography--still useful in the diagnosis of lymphangiomatosis

Lymphangiomatosis is diagnosed by lymphography in two patients. One case presented with life threatening pleural effusion and was found to have skin haemangiomata, underlying lymphangiomatosis and massive osteolysis of the pelvic bones in the same topographic distribution. The aetiology of this condition is discussed and the role of lymphography emphasized.

Generalized lymphangiomatosis and chylothorax in the pediatric age group

Four patients with generalized lymphangiomatosis presenting with chylothoraces are described. All four had bone involvement, two had involvement of the spleen, and one of the pericardium. The diagnosis was confirmed by typical radiology, histology, and in three patients by immunohistochemistry. Treatment was mainly palliative. Three patients died within 1/2 to three years of presentation.

Spinal cord arteriovenous malformation with an associated lymphatic anomaly. Case report

Spinal cord arteriovenous malformations (AVM's), like other vascular anomalies of the central nervous system, can be associated with similar vascular lesions of the skin and viscera. A 7-year-old girl, who presented with rapidly progressing paraplegia, was found to have a spinal cord AVM, cutaneous angioma, and a chylous malformation of the lymphatic system. She had previously undergone treatment for a posterior thoracic cutaneous angioma. At surgery, upon incision of the paravertebral muscle fascia, viscous pale fluid was encountered emanating from a foramen in the thoracic lamina. The spinal AVM was resected in spite of concern that the abnormality represented spinal osteomyelitis. Postoperatively, there was full return of function in the lower extremities, along with recurrent episodes of chylothorax, which slowly came under control with dietary manipulation. A review of the anatomy of the thoracic duct and nontraumatic causes of chylothorax is presented, and the association of cutaneous and central angiomas is discussed. Finally, the treatment of chylothorax is delineated.

Intrathoracic lymphangioma

Of 14 cases of intrathoracic lymphangioma, 4 occurred in the anterior, 5 in the superior, and 4 in the posterior mediastinum. One lesion was diffuse and associated with disappearing bone disease (Gorham's disease). The anterior mediastinal lymphangiomas occurred in adults and seemed to arise from the mediastinum. They could not be distinguished from other anterior mediastinal lesions on plain film roentgenograms. The lesions of the superior mediastinum were extensions from cystic hygromas of the neck and occurred primarily in children. Recurrence was common because complete resection was not possible. Computed tomography was helpful in detecting the cervical extension and cystic nature of these lesions. Although two of the four posterior compartment lesions were isolated lymphangiomas, the other two were part of a much more extensive and generalized lymphangiomatosis that included bone lesions and subdiaphragmatic extension. Both of these latter cases were complicated by chylothorax after attempted removal of the mediastinal lymphangioma. Computed tomography and lymphangiography were helpful in determining the extent of the disease and the cystic and lymphatic nature of the mass. The patient with Gorham's disease had extensive lymphangiomatosis of the thorax and recurrent chylothorax; surgical treatment was unsuccessful. Although lymphangioma is a benign tumor, its infiltrative tendency complicates its removal and contributes to its postoperative recurrence.

Primary lymphatic dysplasia in children: chylothorax, chylous ascites, and generalized lymphatic dysplasia

Primary lymphatic "dysplasia", a congenital maldevelopment, interferes with function of the lymphatic system and causes effusion of chyle or lymph into the limbs and pleural or peritoneal cavity. Between 1955 and 1982, 38 Mayo Clinic patients were found to have a chylous effusion or dysplasia of the lymphatic system. In 22, the condition was secondary to surgery or other medical problems and in 16 it was primary. These cases were separated into three categories: chylothorax, chylous ascites, and generalized lymphatic dysplasia. Conservative therapy, such as a restricted fat diet or total parenteral nutrition with repeated thoracentesis or paracentesis, was effective in the children with isolated abnormalities of the lymphatic system (75% resolution rate, no deaths). All five children with documented generalized dysplasia reported in the literature had died; of the three reported here, one has died and two have become progressively worse.

Neonatal chylothorax: a report and discussion of nine consecutive cases

We here report the clinical findings and management of 9 consecutive cases of chylothorax, 5 of which occurred spontaneously. One cases followed cardiac surgery. Three cases occurred in low-birth-weight, premature infants concurrently with other symptoms of the superior vena cava syndrome secondary to central intravenous nutrition. To our knowledge, this is the first description of chylothorax as a possible complication of total parenteral nutrition in newborn babies. In our treatment of chylothorax in the newborn, we employed diagnostic thoracentesis followed by chest tube drainage and a medium chain triglyceride diet.