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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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Fujino S, Maruyama H, Tsukamoto K, Ono H, Isayama T, Ito Y. Chylothorax Associated with Congenital Complete Atrioventricular Block. AJP Rep 2020; 10:e403-e407. [PMID: 33294285 PMCID: PMC7714619 DOI: 10.1055/s-0040-1715178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Accepted: 05/29/2020] [Indexed: 11/13/2022] Open
Abstract
Introduction Congenital complete atrioventricular block (CCAVB) associated with congenital chylothorax is a rare finding that has been reported in only one case in the literature. We report here the case of an infant with CCAVB complicated by congenital chylothorax. Patient Report We present the case of a male neonate with a birth weight of 2114 g. Fetal bradycardia and right pleural effusion were detected at gestational age of 22 weeks. Maternal serum levels of anti-Sjögren's-syndrome-related antigen A autoantibody were high (4840 U/mL). The neonate was delivered at gestational age of 33 weeks; a temporary external pacemaker was placed immediately after birth that resulted in an improved cardiac output. Milk-colored pleural effusion increased in volume together with the initiation of breast milk feeding. Lymphocytosis and high triglyceride levels in the pleural fluid led to the diagnosis of chylothorax. The pleural effusion resolved in response to prednisolone, octreotide, and total parenteral nutrition. Discussion The causal relationship between CCAVB and congenital chylothorax can be explained by considering the damage to the lymphatic vessels secondary to inflammation due to maternal autoantibodies and venous congestion due to bradycardia. Conclusion In any case of CCAVB associated with atypical pleural effusion, one must consider the possibility of congenital chylothorax.
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Affiliation(s)
- Shuhei Fujino
- Division of Neonatology, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Hidehiko Maruyama
- Division of Neonatology, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Keiko Tsukamoto
- Division of Neonatology, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Hiroshi Ono
- Division of Cardiology, National Center for Child Health and Development, Tokyo, Japan
| | - Tetsuya Isayama
- Division of Neonatology, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Yushi Ito
- Division of Neonatology, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
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Dorsi M, Giuseppi A, Lesage F, Stirnemann J, De Saint Blanquat L, Nicloux M, Assaf Z, Khen Dunlop N, Kermorvant-Duchemin E, Magny JF, Ville Y, Lapillonne A. Prenatal factors associated with neonatal survival of infants with congenital chylothorax. J Perinatol 2018; 38:31-34. [PMID: 29048403 DOI: 10.1038/jp.2017.150] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 08/11/2017] [Accepted: 08/14/2017] [Indexed: 12/27/2022]
Abstract
OBJECTIVES Congenital chylothorax is a rare disease and prognostic factors are key element in properly informing parents. This study aimed at determining the prenatal factors associated with neonatal survival in a cohort of liveborn infants with congenital chylothorax. STUDY DESIGN Observational monocentric cohort study including all liveborn neonates consecutively admitted for congenital chylothorax. RESULTS Neonatal mortality was 32% (16/50). Prematurity (or birth weight), persistence of hydrops at birth and the absence of thoracoamniotic shunt procedure were significantly associated with mortality, whereas prenatal diagnosis of pleural effusion, side of pleural effusion, hydrops fetalis and amniodrainage were not. In case of prenatal diagnosis of hydrops fetalis, the reversal in utero of hydrops fetalis was significantly associated with survival (P=0.001). In case of thoracoamniotic shunting, the interval between thoracoamniotic shunting intervention and delivery was significantly longer for patients who survived (P=0.03). CONCLUSIONS Thoracoamniotic shunting and reversal of hydrops significantly improves survival, whereas prematurity worsened outcome of liveborn infants with congenital chylothorax. Our data also suggest that the interval between thoracoamniotic shunting and birth appears to be crucial; the longer the interval, the more likely is the reversal of antenatal hydrops and neonatal survival.
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Affiliation(s)
- M Dorsi
- Department of Neonatal Intensive Care, APHP Necker Hospital, Paris, France
| | - A Giuseppi
- Department of Neonatal Intensive Care, APHP Necker Hospital, Paris, France
| | - F Lesage
- Department of Pediatric Intensive Care, APHP Necker Hospital, Paris, France
| | - J Stirnemann
- Paris Descartes University (EA 7328), Sorbonne Paris Cite, France.,Department of Obstetrics, APHP Necker Hospital, Paris, France
| | | | - M Nicloux
- Department of Neonatal Intensive Care, APHP Necker Hospital, Paris, France
| | - Z Assaf
- Department of Neonatal Intensive Care, APHP Necker Hospital, Paris, France
| | - N Khen Dunlop
- Paris Descartes University (EA 7328), Sorbonne Paris Cite, France.,Department of Pediatric Surgery, APHP Necker Hospital, Paris, France
| | - E Kermorvant-Duchemin
- Department of Neonatal Intensive Care, APHP Necker Hospital, Paris, France.,Paris Descartes University (EA 7328), Sorbonne Paris Cite, France
| | - J-F Magny
- Department of Neonatal Intensive Care, APHP Necker Hospital, Paris, France.,Paris Descartes University (EA 7328), Sorbonne Paris Cite, France
| | - Y Ville
- Paris Descartes University (EA 7328), Sorbonne Paris Cite, France.,Department of Obstetrics, APHP Necker Hospital, Paris, France
| | - A Lapillonne
- Department of Neonatal Intensive Care, APHP Necker Hospital, Paris, France.,Paris Descartes University (EA 7328), Sorbonne Paris Cite, France
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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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Rhodes LA, Robert SM, Atkinson TP, Dabal RJ, Mahdi AM, Alten JA. Hypogammaglobulinemia after cardiopulmonary bypass in infants. J Thorac Cardiovasc Surg 2014; 147:1587-1593.e1. [PMID: 24035378 PMCID: PMC4260623 DOI: 10.1016/j.jtcvs.2013.07.040] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Revised: 07/11/2013] [Accepted: 07/19/2013] [Indexed: 11/20/2022]
Abstract
BACKGROUND Hypogammaglobulinemia has been reported after cardiac surgery and may be associated with adverse outcomes. We sought to define baseline immunoglobulin (Ig) concentration in neonates and infants with congenital heart disease, determine their course after cardiopulmonary bypass (CPB), and determine if post-CPB hypogammaglobulinemia was associated with increased morbidity. METHODS This was a single-center, retrospective analysis of infants who underwent cardiac surgery with CPB between June 2010 and December 2011. The Ig concentration was obtained from banked plasma of 47 patients from a prior study (pre-CPB, immediately post-CPB, and 24 and 48 hours post-CPB). In addition, any Ig levels drawn for clinical purposes after CPB were included. Ig levels were excluded if drawn after chylothorax diagnosis or intravenous IgG administration. RESULTS The median age was 7 days. Preoperative Ig concentration was similar to that described in healthy children. IgG level decreased to less than 50% of preoperative concentration by 24-hour post-CPB and failed to recover by 7 days. Of 47 patients, 25 (53%) had low IgG (<248 mg/dL) after CPB. Despite no difference in demographics or risk factors between patients with low and normal IgG, low IgG patients had more positive fluid balance at 24 hours and increased proinflammatory plasma cytokine levels, duration of mechanical ventilation, and cardiac intensive care unit length of stay. In addition, low IgG patients had an increased incidence of postoperative infections (40% vs 14%; P = .056). CONCLUSIONS Hypogammaglobulinemia occurs in half of infants after CPB. Its association with fluid overload and increased inflammatory cytokines suggests it may result from capillary leak. Postoperative hypogammaglobulinemia is associated with increased morbidity, including more secondary infections.
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Affiliation(s)
- Leslie A Rhodes
- Section of Cardiac Critical Care, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Ala
| | - Stephen M Robert
- Section of Cardiac Critical Care, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Ala
| | - T Prescott Atkinson
- Division of Allergy, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Ala
| | - Robert J Dabal
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Ala
| | - Alla M Mahdi
- School of Medicine, University of Alabama at Birmingham, Birmingham, Ala
| | - Jeffrey A Alten
- Section of Cardiac Critical Care, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Ala.
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Ergaz Z, Bar-Oz B, Yatsiv I, Arad I. Congenital chylothorax: clinical course and prognostic significance. Pediatr Pulmonol 2009; 44:806-11. [PMID: 19598277 DOI: 10.1002/ppul.21070] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To determine the underlying etiology, associated malformations, clinical course, and prognostic significance of congenital chylothorax. STUDY DESIGN A retrospective analysis of 11 neonates admitted to our neonatal intensive care unit with congenital chylothorax between January 2000 and June 2008. The post-discharge clinical and developmental course was evaluated by a telephone survey performed in July 2008. RESULTS Antenatal diagnosis was established in 9 out of 11 infants by ultrasound examination; 5 had intrauterine pleural drainage. Eight infants had either structural or chromosomal abnormalities. The postnatal treatment included mechanical ventilation, drainage of pleural fluid and feeding with enriched medium chain triglyceride formula. Somatostatin was administered in one case. Six patients developed nosocomial infections. Two patients died after resolution of the chylothorax from deteriorating renal failure. Seven patients were traced for follow up and six of them achieved age appropriate developmental milestones. CONCLUSION The recovery from chylothorax and future prognosis were dependent on the underlying etiology. Chylothorax was often a secondary event, with apparently favorable clinical and developmental prognosis when the underlying or/and associated condition was treatable.
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Affiliation(s)
- Zivanit Ergaz
- Department of Neonatology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
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Abstract
PURPOSE OF REVIEW This review highlights the pathophysiological mechanisms, incidence, clinical features, as well as the diagnosis and treatment of pleural effusions in the neonate. RECENT FINDINGS Pleural effusions are rare except in hydropic neonates. Elevated pleural fluid/serum immunoglobulin G ratio may be a diagnostic marker for congenital chylothorax in utero. Chylothorax may be congenital or acquired. Hydrothoraces may appear at any time during the neonatal period and are related to infectious and noninfectious aetiologies. Haemothorax is defined as the presence of blood in the pleural space. Parenteral nutrition leakage may occur in a newborn with a venous central catheter leading to an effusion that looks like a chylothorax. The value of elevated pleural fluid N-terminal pro-brain natriuretic peptide levels as a marker of congestive heart failure is not yet established in neonates. More recently, in cases of chylothorax that did not resolve with drainage and bowel rest, the use of somatostatin or its analogue octreotide has been described with success. If conservative management fails after 5 weeks, surgical intervention is indicated. SUMMARY Clinicians must be aware of the wide range of disorders causing pleural effusions, the different types and clinical presentations, differential diagnosis, and how to treat each specific case.
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Affiliation(s)
- Gustavo Rocha
- Division of Neonatology, Department of Paediatrics, São João Hospital, Porto, Portugal.
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