Effective Initial Treatment of Diffuse Pulmonary Lymphangiomatosis with Sirolimus and Propranolol: A Case Report

Diffuse pulmonary lymphangiomatosis (DPL), an exceptionally rare disease, mainly occurs in children and young adults of both sexes. Even though DPL is considered to be a benign disease, its prognosis is relatively poor. Because of its rarity, little guidance on diagnosis and treatment is available, which makes working with patients with DPL challenging for clinicians. We present here a case of a young man with DPL in whom treatment with sirolimus and propranolol rapidly achieved positive radiological and clinical effects.

[Clinical analysis of intestinal lymphangiectasia in 47 children]

Objective: To analyze the clinical manifestations, diagnosis, treatment and prognosis of intestinal lymphangiectasia (IL) in children in order to improve the skills of diagnosis and treatment of IL. Method: Clinical manifestations, laboratory findings, gastroscopic findings, histopathological examinations and lymphatic radionuclide imaging assessments were analyzed retrospectively among 47 IL patients who were hospitalized in the Gastroenterology Department of Beijing Children's Hospital Affiliated to Capital Medical University from June 2007 to December 2015. All patients were followed up by telephone. According to the various causes, the patients were divided into the primary intestinal lymphangiectasia (PIL) group and secondary IL group, and their clinical manifestations were compared by t test, Rank sum test or Chi-square test. Result: In 47 IL patients, there were 38 children (81%) younger than 3 years old. There were 43 PIL patients (91%) and 4 secondary IL patients (9%). Between PIL and secondary IL, there were statistical differences in serum albumin (t=-3.950, P<0.005) , globulin(t=-2.850, P=0.007), age of onset(U=27.000, P=0.024), age at diagnosis(U=29.000, P=0.030) and course of disease(U=26.500, P=0.023), whereas there were no statistical differences in lymphocyte count, IgG, lymphatic radionuclide imaging, histopathology and gender(all P>0.05). Edema (44 cases, 94%), diarrhea (42 cases, 89%), accompanied with infection (35 cases, 74%) and ascites (30 cases, 64%) were the main clinical manifestations. In 47 IL patients, 45 patients were done gastroscopy and histopathological examinations, and there were 31 patients' histopathological examinations(69%) were positive. Forty patients were done lymphatic radionuclide imaging, and there was evidence of protein losing from gut via lymphatic radionuclide imaging in 39 patients(98%). Among 47 patients, 35 patients (74%) were followed up, 32 patients had good prognosis, 2 patient failed to show evidence of improvement, 1 patient died and no patient experienced a relapse till the end of the follow-up. In 35 patients, 28 patients were treated with medium chain triglycerides (MCT) dietary therapy, 26 patients showed improvement in symptoms, and 2 patients had no improvement. Among 35 patients with follow-up, there were 6 patients received surgical treatment, and their symptoms were improved. Conclusion: PIL are the majority of IL in children younger than 3 years old. The main clinical manifestations are edema, diarrhea, accompanied with infection and ascites. For the patients without the evidence of lymphangiectasia from duodenum histopathological examination, further consideration of lymphatic radionuclide imaging, clinical manifestations, and laboratory studies are needed to make a final diagnosis. MCT dietary therapy is the cornerstone of IL medical management.

Tumour vascularization: sprouting angiogenesis and beyond

Tumour angiogenesis is a fast growing domain in tumour biology. Many growth factors and mechanisms have been unravelled. For almost 30 years, the sprouting of new vessels out of existing ones was considered as an exclusive way of tumour vascularisation. However, over the last years several additional mechanisms have been identified. With the discovery of the contribution of intussusceptive angiogenesis, recruitment of endothelial progenitor cells, vessel co-option, vasculogenic mimicry and lymphangiogenesis to tumour growth, anti-tumour targeting strategies will be more complex than initially thought. This review highlights these processes and intervention as a potential application in cancer therapy. It is concluded that future anti-vascular therapies might be most beneficial when based on multimodal anti-angiogenic, anti-vasculogenic mimicry and anti-lymphangiogenic strategies.

A ten-year observation on experimental infection of periodic Brugia malayi in man

This paper reports the results of 10 years of observations on the clinical manifestations, pathology and immunity to filariasis and aetiological biology of filariae in three volunteers (first author and his family members) who were inoculated experimentally with infective larvae of periodic Brugia malayi in 1981. The changes in clinical symptoms and signs were recorded systematically. Microfilariae were first detected at 41 and 46 weeks after inoculation in two subjects and remained detectable in small numbers until 8-8.5 years after infection. The microfilarial density fluctuated at 1-2 mf 120 microliters-1. Thereafter no microfilariae were detected in 12 blood sample examinations, suggesting that the adult reproductive period of periodic B. malayi could last up to 8-9 years in the human body. Eosinophilia occurred mainly before and at the initial stage of microfilaraemia. An increase in the lymphocytes was observed to some extent at 2-156 weeks after infection. Biopsy at the inoculation site 6 weeks after inoculation showed infiltration of the lymph node by inflammatory cells, mainly eosinocytes, lymphocytes and monocytes. Lymphangiectasis and lymphostasis were observed in both limbs and pelvic regions by lymphangiogram taken 11 weeks after inoculation. Antibodies against B. malayi first appeared at 2-5 weeks after infection, peaked at 12-56 weeks and thereafter declined gradually. Subjects A and C became antibody free but subject B remained positive to antibody against B. malayi 10 years after infection. E-rosette forming lymphocytes became lower than normal at 11 weeks and recovered to normal within 10 years after infection.

Intra-uterine closure of the atrial septum

Two newborn babies with an intact atrial septum are described. In one, the two components of the atrial septum appeared to have become fused after relatively normal initial development; the left side of this heart was hypoplastic. In the other baby the formation of the atrial septum appeared to have been completely anomalous; this heart showed mitral atresia, absence of the left ventricle, and transposition of the great vessels. There was also pulmonary lymphangiectasis in the second case, and it is suggested that this was due to the cardiac malformation obstructing pulmonary venous drainage.

The Relationship between Human Endocardial Fibroelastosis and Obstruction of the Cardiac Lymphatics

Two patients with marked ventricular endocardial fibroelastosis and evidence of obstruction of cardiac lymphatic vessels lend support to the hypothesis derived from dog experiments that chronic impairment of the cardiac lymph flow leads to endocardial fibroelastosis. One patient, aged 52 years, developed chronic myocarditis 7 years prior to her death. The other patient, a 6-month-old infant, had congenital lymphangiectasis with diffuse involvement of the gastrointestinal tract, lymph nodes, and heart. Microscopic examination of the hearts revealed markedly dilated and tortuous lymphatic channels throughout the myocardium and epicardium, a finding present with long-standing obstruction to lymph flow. It is concluded that chronic obstruction of cardiac lymph flow, from whatever cause, results in ventricular endocardial fibroelastosis.