A gene missense mutation in diffuse pulmonary lymphangiomatosis with thrombocytopenia: A case report

INTRODUCTION

Diffuse pulmonary lymphangiomatosis (DPL) is a rare condition. Most patients with DPL present dyspnea, cough, expectoration, and hemoptysis. There are few reports of DPL accompanied by thrombocytopenia, whose cause remains unknown.

PATIENT CONCERNS

An 18-year-old male patient presented with recurrent cough, expectoration, and dyspnea for 5 years, and thrombocytopenia was observed during a 2-month follow-up.

DIAGNOSIS

Chest computed tomography showed diffuse patchy shadows in both lungs, and pleural and pericardial effusions. Immunohistochemical lung tissue staining showed lymphatic and vascular endothelial cells positive for D2-40, CD31 and CD34. Routine blood test revealed platelets at 62 × 10 cells/L during follow-up. Bone marrow biopsy was normal. Ultrasound revealed no hepatosplenomegaly. Finally, the patient was diagnosed with DPL accompanied by thrombocytopenia.

INTERVENTIONS

He was treated by subtotal pericardial resection, thoracocentesis, and anti-infective therapy. Oral prednisone was administered for 2 months.

OUTCOMES

The symptoms of cough and shortness of breath were improved, but thrombocytopenia persisted. We investigated the cause of thrombocytopenia. Whole-exome sequencing identified a mutation in exon 3 of the TNFRSF13B gene in this patient.

CONCLUSION

DPL may present with thrombocytopenia and DIC. Patients with thrombocytopenia but not DIC and splenomegaly should be screened for gene mutations.

Diffuse pulmonary lymphangiomatosis: A rare case report in an adult

RATIONALE

Diffuse pulmonary lymphangiomatos (DPL) is a rare aggressive lymphatic disorder characterized by proliferation of anastomozing lymphatic vessels and extremely rare in adult patients.

PATIENT CONCERNS

We report a case of diffuse pulmonary lymphangiomatosis in 59-year-old man presented with cough and sputum for 2 months.

DIAGNOSES

Combining clinical manifestations with results of radiological, bronchoscopy, and surgical lung biopsy, it was consistent with the diagnosis of DPL.

INTERVENTIONS

After bronchoalveolar lavage and biopsy, symptom of cough got worse suddenly accompanied by excessive chyloptysis. The patient received an emergency surgical intervention and low fat medium chain fat treatment.

OUTCOMES

The patient was discharged with a much better health condition.

LESSONS

This case report is the oldest patient reported in the English literature, to the best of our knowledge. Serious complications of bronchoscopy should be considered, especially in DPL patients with severely enlarged mediastinum or with thin-walled translucent vesicles under endoscopy.

Acquired Lymphangiectasia of the Scrotum

A 56-year-old man presented with multiple, skin-colored, raised eruptions of the scrotum that had been present for 2 years. Their onset had been gradual, and they had been increasing in size, resulting in cosmetic disfigurement. A year previously, he had been operated on for a bilateral vaginal hydrocele with partial excision and eversion of the sac (Jabouley method).¹ There had been no extramarital or unprotected sexual contact, other hospitalizations, or major surgery, swelling of the legs, or long periods of incumbency. Cutaneous examination revealed multiple, discrete and/or coalescing verrucous papules distributed on the upper portion of the scrotum and associated with edema of the penis (Figure 1). The inguinal lymph nodes were not enlarged. Complete blood counts and ultrasonography of the abdomen were normal. Tissue sections stained with hematoxylin and eosin showed hyperkeratosis and multiple ectatic vessels, primarily confined to the papillary dermis, abutting the overlying epidermis, and demarcated by a single endothelial lining. The dilated vessels contained homogenous eosinophillic material (Figure 2).

Hyperplasia of Lymphoid Follicles and Lymphangiectasia in the Parietal Pleura in Bucillamine-induced Yellow Nail Syndrome

Yellow nail syndrome (YNS) pleurisy is often difficult to control, and pathological examinations have rarely been reported. We herein report a case of bucillamine-induced YNS in which histopathology of the parietal pleura revealed hyperplasia of the lymphoid follicles and lymphangiectasia. Even after the discontinuation of bucillamine, the pleurisy and lymphedema showed no change. Based on the histopathological findings showing similarity to rheumatoid pleurisy, we administered corticosteroid treatments, and both the pleurisy and lymphedema improved. The findings in the present case suggest that, in bucillamine-induced YNS, pleurisy may be related to inflammation caused by rheumatoid arthritis in addition to abnormalities in lymphatic vessels.

Protein-losing Enteropathy Caused by Intestinal or Colonic Lymphangiectasia Complicated by Sporadic Lymphangioleiomyomatosis: A Report of Two Cases

This report describes two patients with sporadic lymphangioleiomyomatosis complicated by protein-losing enteropathy (PLE). Imaging studies indicated retroperitoneal lymphangioleiomyomas and abnormalities of the adjacent digestive tract. Endoscopic mucosal biopsy revealed colonic lymphangiectasia in one patient; whereas the site in the other patient was intestinal. Treatment with sirolimus led to the complete resolution of PLE within several months; additionally, marked shrinkage was observed in the lymphangioleiomyomas of both cases. These findings suggest that colonic or intestinal lymphatic congestion due to neighboring lymphangioleiomyomas was the mechanism for the development of PLE. At the time of writing this report, the beneficial effect of sirolimus has lasted for more than 3 years.

Lymphangiectatic Variant of Eccrine Spiradenoma - A Diagnostic Challenge

Conventional eccrine spiradenoma is a benign, slow growing and painful tumor of the skin. While the tumor does not usually present a diagnostic dilemma, a rare variant with marked stromal lymphedema can be a challenge to interpret. We present a case of lymphangiectatic variant of eccrine spiradenoma in an 82-year-old white male who presented with a persistent left flank lesion for several months. The patient was initially asymptomatic and subsequently developed a suspected abscess that was excised to reveal a 6.5 cm subcutaneous mass. Microscopic examination reveals strands and cords of dark, epithelial, round to oval cells with inconspicuous nucleoli streaming between prominently dilated and congested vascular spaces. Within the cystic component there are small ductular structures. Additionally, prominent stromal lymphedema is present. To the best of our knowledge, there is only one reported case of this entity in the English literature. This case represents a diagnostic challenge and the purpose of reporting it is to alert surgical pathologists, dermatopathologists and dermatologists of the existence of this unusual variant of eccrine spiradenoma.

Noonan Syndrome Complicated by Primary Pulmonary Lymphangiectasia

Noonan syndrome is a genetic disorder that has several features common to other conditions, making diagnosis a challenge. This column summarizes the case of a neonate with an atypical presentation of Noonan syndrome involving a fatal type of lymphangiectasia resulting in persistent pleural effusions. Radiographic features of this condition are presented along with the complexities of diagnosis and treatment.

Uncommon renal masses: Perirenal extramedullary hematopoiesis and multiple lymphangiomatosis with a perirenal lymphangioma

OBJECTIVE

To present two cases of infrequent renal masses, trying to achieve the diagnosis before surgery.

METHODS

We describe a case referred from the Department of Hematology in which bilateral perirrenal masses were described in the CT scan; after biopsy they where classified as extramedullary hematopoietic tissue. The other case was a patient presenting to the emergency room with dyspnea. CT Scan showed lungs with multiple cysts, chylothorax and a cystic-solid mass in the left perirenal space. In the lung biopsy they reported lung lymphangiomatosis, so we didn't perform renal biopsy.

RESULTS

Most renal masses are renal carcinomas (856%). The less common diagnosis are sarcomas, lymphomas, upper urinary tract transitional cell carcinomas, metastases of other primary tumors, the Erdheim-Chester disease, the Castleman disease and benign tumors. All these diseases might show similar images in the CT scan and MRI, being the biopsy and histological study necessary for the diagnosis

CONCLUSIONS

Perirenal extramedullary hematopoiesis and perirenal lymphangioma are rare diseases that need a pathologic study for their diagnosis.

Congenital pulmonary lymphangiectasia in a newborn: a response to autologous blood therapy

Congenital pulmonary lymphangiectasia is a rare condition that may present antenatally with pleural effusions and hydrops, and the prognosis is reported to be very poor. Treatments for lymphangiectasia have included corticosteroids for patients with primary inflammatory conditions, dietary modifications, surgical resection for isolated lesions, octreotide, antiplasmin therapy and fibrin glue pleurodesis. However, there is no experience with pleurodesis by autologous blood therapy in the literature. We present a newborn with primary pulmonary lymphangiectasis who developed progressively profuse chylous pleural effusions after enteral full feeding from the 8th day of life and improved with pleurodesis by autologous blood therapy.

MRI findings of renal lymphangiectasia

We present the case of a 20-year-old male with renal lymphangiectasia who presented with hypertension and hematuria. We discuss the role of magnetic resonance imaging (MRI) with gadolinium-enhanced MR urography in confirming the diagnosis, extensions of this rare benign entity, and associated conditions.

Congenital pulmonary lymphangiectasia presenting as nonimmune fetal hydrops and severe respiratory distress at birth: not uniformly fatal

Pulmonary lymphangiectasia is a rare cause of respiratory distress in the newborn associated with a very poor outcome. We describe three premature newborns presenting at birth with nonimmune hydrops, bilateral chylothorax, and severe respiratory distress in the immediate newborn period secondary to pulmonary lymphangiectasia. We review the similarities of these cases and discuss their antenatal and neonatal course. One patient survived and is thriving at 9 months of age. With continuing advances in antenatal and neonatal care, an improved outcome may be possible in what was previously described as a uniformly fatal condition.

Management of newborn lymphangiectasia and chylothorax after cardiac surgery with octreotide infusion

Postoperative chylothorax compromises nutrition, immune function, coagulation, and fluid status. We report rapid short-term suppression of chylothorax by octreotide in an infant after surgery for complex congenital heart disease complicated by lymphangiectasia.

Clinicopathologic study of conjunctivochalasis

OBJECTIVE

To clarify the structural features of conjunctivochalasis histopathologically.

METHODS

A biopsy of redundant conjunctiva from the same anatomic location of 44 +/- 7.5 years (mean +/- SD, 50.87 years), underwent conjunctivoplasty (termed tear meniscus reconstruction).

RESULTS

In all 44 cases, histologic examination disclosed normal conjunctival epithelium and negligible inflammation and lymphocyte infiltration; 39 patients manifested microscopic lymphangiectasia. Elastica van Gieson staining demonstrated elastic fiber fragmentation and sparsely assembled collagen fibers in all 44 cases. There was no discernible difference between specimens from patients with and without complications including tear-deficient dry eye, meibomian gland dysfunction, and clinically observable lymphangiectasia and/or pinguecula.

CONCLUSION

Based on our histopathologic findings, we hypothesize that mechanical forces between the lower lid and conjunctiva gradually interfered with lymphatic flow. Chronic, prolonged mechanical obstruction of lymphatic flow may result in lymphatic dilation and eventually give rise to clinical conjunctivochalasis.

[Acquired lymphangiectasias or mammary dermolytic blisters with spontaneous resolution]

INTRODUCTION

Spontaneous occurrence of hemorrhagic blisters on the lower side of the breasts is an unusual clinical presentation of acquired lymphangiectasia.

CASE REPORT

A 64 Year-old and a 85 Year-old woman had developed recurrent bleeding blisters in the sub-mammary region for several Months. Histological, immunohistochemical and electron microscopic examination revealed a subpapillary dermal bullous dehiscence, parallel to the epidermis, which was connected to lymphangiectasias of the superficial dermis. Their extreme dilatation and rupture were probably responsible for the clinical inflammatory and bleeding aspect of the lesions, which have not recurred after 1 and 3 Years, respectively.

DISCUSSION

The presence of subpapillary inflammatory lymphangiectasias might be responsible for recurrent dermal blister formation. The reason for the presence of these hemorrhagic lymphangiectasias, restricted to the sub-mammary location and their spontaneous regression after several flare-ups, remain unclear. The unusual clinical presentation of the lesions observed in these two women constitutes a differential diagnosis of acquired dermolytic blisters.

Chyloptysis in Adults

Chyloptysis is a rare finding, and the accompanying respiratory symptoms are usually nonspecific. The recognition of the chylous nature of the sputum is requisite for proper diagnosis, especially if chyloptysis is not accompanied by chylous pleural effusion. The key to the differential diagnosis of chyloptysis is to consider illnesses that can induce reflux of chyle into the bronchial tree. There are two mechanisms postulated: the first requires the presence of an abnormal communication between the bronchial tree and the lymphatic channels, and the second requires a bronchopleural fistula in the context of a chylous pleural effusion. Chyloptysis in adults should prompt assessment for evidence of lymphatic obstruction from trauma, radiation, and malignancy, and to exclude diseases with known association with chyloptysis, ie, lymphangioleiomyomatosis, yellow nail syndrome, or thoracic lymphangiectasis. A lymphangiogram is recommended to define the abnormality. In the case of lymphangiectasis, patients respond to either dietary modification and/or ligation of the thoracic duct.

[Congenital pulmonary lymphangiectasia revealed by cardiac arrest]

Congenital pulmonary lymphangiectasia is a rare cause of respiratory distress in the neonatal period. Cardiac arrest may be its first manifestation.

CASE REPORT

We report the case of a full term newborn who suffered at 30 min of life a sudden cardiac arrest. Despite intensive support, the patient died 5 h later. Lung examination showed pulmonary lymphangiectasia.

CONCLUSION

Congenital pulmonary lymphangiectasia may be revealed by a sudden neonatal cardiac arrest. Pulmonary lymphangiectasia should be suspected in any newborn who develops early in life an unexplained refractory hypoxemia with radiographic reticulonodular images and uni or bilateral pneumothorax. The diagnosis is established at lung microscopy.

Drainage of subcutaneous lymphatic fluid for the management of respiratory distress in a case of generalized lymphangiectasia in an infant

A 10-month-old girl was referred to our hospital because of congenital and persistent bilateral chylothorax and generalized lymphedema as well as long-standing respiratory disturbance. Radiological studies showed a diffuse network of superficial lymphatic vessels without major trunks throughout her entire body as well as the lung. She was diagnosed with systemic lymphangiomatosis complicated with pulmonary lymphangiectasia. Percutaneous puncture in the lower leg was performed to discharge the lymphatic fluid and proved to be effective for the respiratory disturbance. This procedure is safe and easy and effectively improves the quality of life of the patient and the family in case of such a persistent disease.

Thoracic lymphangiectasis presenting with chyloptysis and bronchial cast expectoration

A 70-year-old man with recurrent undiagnosed episodes of bronchial cast expectoration and pulmonary infiltrates on chest radiography for 15 years is described. The diagnosis of chyloptysis was established by chemical analysis of the bronchial aspiration. We emphasize the radiological findings of this rare observation. The CT-associated lymphangiography showed mediastinal lymphangiectasis with retrograde opacification of mediastinal and hilar lymph nodes as well as submucosal lymphatic vessels protruding into the lumen of the tracheo-bronchial tree without evidence of thoracic duct obstruction as well as a "crazy-paving appearance." Congenital incompetence of the valves of the lymphatic vessels originating from the thoracic duct is held to be the cause. Chyloptysis and pulmonary lymphatic disorder should be sought in cases of bronchial cast expectoration.

Lymphedema-lymphangiectasia-mental retardation (Hennekam) syndrome: a review

The Hennekam syndrome is an infrequently reported heritable entity characterized by lymphedema, lymphangiectasia, and developmental delay. Here we add an additional 8 patients, and compare their findings to the 16 cases from the literature. The lymphedema is usually congenital, can be markedly asymmetrical, and, often, gradually progressive. Complications such as erysipelas are common. The lymphangiectasias are present in the intestines, but have also been found in the pleura, pericardium, thyroid gland, and kidney. Several patients have demonstrated congenital cardiac and blood vessel anomalies, pointing to a disturbance of angiogenesis in at least some of the patients. Facial features are variable, and are chiefly characterized, in a typical patient, by a flat face, flat and broad nasal bridge, and hypertelorism. Facial features are thought to mirror the extent of intrauterine facial lymphedema, or may be caused by lymphatic obstruction that affects the early migration of neural crest tissue. Other anomalies have included glaucoma, dental anomalies, hearing loss, and renal anomalies. The psychomotor development varies widely, even within a single family, from almost normal development to severe mental retardation. Convulsions are common. The existence of 10 familial cases, equal sex ratio, increased parental consanguinity rate (4/20 families), and absence of vertical transmission are consistent with an autosomal recessive pattern of inheritance. It seems likely that most (but not all) manifestations of the entity can be explained as sequences of impaired prenatal and postnatal lymphatic flow, suggesting that the causative gene(s) should have a major function in lymphangiogenesis.

Morphologic and functional changes of the microlymphatic network in patients with advancing stages of primary lymphedema

Using fluorescent microlymphography, we examined the morphology andfunctional characteristics of the microlymph-vascular network in 36 subjects including 9 patients with "compressible" lymphedema (Group I), 14 with minimally compressible lymphedema (Group II), 9 with noncompressible lymphedema (Group III), and 4 healthy individuals. As lymphedema progressedfrom early to advanced stages (Group I-III), an increasingly greater lymphatic capillary density and diameter were depicted and eventually fibrosis/sclerosis with lymphangiectasia, fragmentation and a gradual decrease in the number of microlymphatics. Concomitantly, there was a prolongation in transport and disappearance of fluorescent dye and a progressive increase in endolymphatic and interstitial hydrostatic pressures.

Chylous reflux into localized pulmonary lymphangiectasis

Spontaneous chylothorax is uncommon and may originate from different etiologies either pleural, pulmonary, or mediastinal. Chyloptysis is a still rarer clinical problem and always of pulmonary origin. We report 2 cases: the first, a 63-year-old woman presenting with a chylothorax, and the second, a 28-year-old man with chyloptysis. Both were successfully treated with a medium chain triglyceride diet. Lymphangiograms demonstrated an identical origin for the 2 cases: reflux from the thoracic duct into right lower lobe lung lymphangiectasis. In our experience, chylous reflux into pulmonary lymphangiectasis is not as rare as believed and many cases probably remain undiagnosed.

Congenital pulmonary lymphangiectasia with chylothorax

A 5-year-old boy with dyspnea was diagnosed through thoracentesis as having chylothorax. After conservative management failed, open thoracotomy was performed. Lung biopsy confirmed the diagnosis of congenital pulmonary lymphangiectasia. Chylothorax was successfully controlled by fibrin glue pleurodesis in this patient.

[Cervical lymphangiectasia--case report]

A case-report of a patient with paraesthesia of the left upper extremity caused by a tumor localized in the left supraclavicular area is presented. The patient underwent an operation. Two formations--a lipoma and cyst--were found. Both were removed and histologically examined. The diagnosis of lipoma and neck lymphangiectasia was made. On the third postoperative day the patient was discharged home with no more paraesthetic complaints. A check-up after three months did not reveal any complaints present before operation. In the paper the differential diagnosis of neck tumors with a view to resistance associated with the lymphatic system especially lymphangioma, lymphangiectasia and hygroma coli cysticum is discussed. Lymphangioma is a benign oncogenic affection of lymphatic vessels developing during the postnatal period of life. Lymphangiectasia is a congenital disease without proliferating activity. Hygroma coli cysticum is a congenital extensive multioccular formation localized in the neck area. All three affections are often incorrectly mistaken for each other. Histological examination is decisive for the correct diagnosis.

End-stage renal disease in a patient with congenital lymphangiectasia and lymphedema

Congenital lymphangiectasia with lymphedema is a disorder constituting the main defect in many different genetic syndromes. Herein we describe a 23-year-old male patient with congenital lymphangiectasia and severe lymphedema of the right leg, scrotum, and abdominal wall, who presented with end-stage renal disease, presumably due to cystic renal lymphangiectasia, and is undergoing chronic hemodialysis treatment.

Progressive melorheostosis in the peripheral and axial skeleton with associated vascular malformations: imaging findings over three decades

A 28-year old woman presented with Léri's disease (melorheostosis) and the rare combination of complex vascular malformations and lymphatic anomalies. Multifocal melorheostosis was segmental and unilateral, located in the left axial and peripheral skeleton, fifth thoracic vertebral body, fifth rib. left upper limb and lumbosacral spine (third lumbar body to first sacral segment). Sacral involvement was associated with spinal canal stenosis. Additionally the patient had multiple nevi and had suffered from left hemiplegia since birth. Lymphangiectasia of the mesentery and thorax led to chylothorax resistant to therapy for which the patient underwent a pleuropericardiectomy. Death ensued due to respiratory failure.

Cystic renal lymphangiectasia presenting as renal insufficiency in childhood

Cystic renal lymphangiectasia is an unusual cause of cystic renal disease in childhood. We present a case of bilateral cystic renal lymphangiectasia in a 7-year-old boy who presented with asymptomatic renal insufficiency and anemia with decreased erythropoietin production. The clinical features of this condition and the diagnostic approach are reviewed. Although rare, this disorder should be considered in the differential diagnosis of cystic renal disease.

A case of Noonan syndrome with pulmonary and abdominal lymphangiectasia

Noonan syndrome is characterised by a Turner-like phenotype and a normal karyotype. Although it is reported to be associated with abnormalities of the lymphatic system, involvement of the pulmonary lymphatics is rare. We present a case of Noonan syndrome where a whole body scintigraphy revealed lymphangiectasia of the lower extremities, abdomen and lungs.

Pleuroperitoneal shunt in the management of chylothorax caused by thoracic lymphatic dysplasia

Three cases of intractable chylothorax secondary to thoracic lymphatic dysplasia were treated by pleuroperitoneal shunt insertion. These cases included one with Gorham's syndrome, and one case with a bilateral chylothorax and chylous ascites. Pleuroperitoneal shunts allowed an adequate internal drainage in all cases, alleviating protein and lymphocyte losses caused by recurrent pleural taps. In the third case with chylous ascites, valved shunts were used to avoid reflux between the peritoneal cavity and the pleural space. Such palliative therapy did not change the bad prognosis of these patients with lymphatic disorders but improved the children's quality of life.

Hypoplastic left heart syndrome with restrictive atrial septal defect and congenital pulmonary lymphangiectasis

The presence of a restrictive atrial septal defect in hypoplastic left heart syndrome represents a surgical emergency and may negatively affect survival after operation. A neonate with such a disease association, requiring septectomy upon birth developed intractable respiratory failure due to congenital pulmonary lymphangiectasis. The therapeutic implications of this rare pathologic condition are discussed.

Atrial fibrillation with neonatal pulmonary lymphangiectasia

A female infant born at 28 weeks' gestation was found to have mild hydrops foetalis. Initial echocardiography showed a structurally normal heart. During the first week of life, episodic atrial tachycardia with 1:1 or 2:1 conduction was seen, requiring therapy with digoxin. The infant remained ventilator dependent, with a persistent, chylous pleural effusion which contained a preponderance of lymphocytes. Congenital pulmonary lymphangiectasia (CPL) was confirmed histologically. Worsening episodes of atrial tachycardia, including episodes of atrial fibrillation, were further investigated and a repeat echocardiogram revealed thickening of the entire right atrial wall. The cardiac findings of a thickened right atrial wall with the histological signs of myocarditis were thought to be the cause of paroxysms of atrial fibrillation, an extremely rare arrhythmia in the neonatal period. To the authors' knowledge there have been no previous reports of CPL in association with the cardiac abnormalities described herein.

Low energy fluence CO2 laser treatment of lymphangiectasia

Lymphangiectasia is an uncommonly reported complication of lymphatic insufficiency. These dilatations of lymphatic vessels may be symptomatic, necessitating treatment. While CO2 laser ablation has been used with success in the treatment of lymphangiectasia, it is infrequently reported and previous laser protocols have relied on high irradiances. The successful use of low fluence CO2 laser in the treatment of multiple lymphangiectases on the lower limb of a middle-aged Caucasian woman with unilateral chronic lymphoedema is described.

Lymphoscintigraphy and lymphangiography of lymphangiectasia

Chronic genital edema secondary to lymphangiectasia and chylous reflux in a 23-yr-old man with Noonan syndrome was investigated by 99mTc sulfur nanocolloid lymphoscintigraphy and bipedal contrast lymphangiography. Lymphoscintigraphy showed a delayed lymphatic flow pattern in the pelvis, abdomen and chest consistent with lymphangiectasia and abnormal lymphatic flow dynamics. Lymphangiography showed dilated and tortuous abnormal lymphatics in the abdomen and pelvis. Ligation of incompetent retroperitoneal lymph vessels and lymphaticovenous anastamosis were performed, resulting in clinical improvement. Lymphangiectasia has been described previously in Noonan syndrome, but it is relatively uncommon below the diaphragm. This case demonstrates the use of lymphoscintigraphy and lymphangiography in providing important physiological and anatomical information before surgical intervention. Careful presurgical planning using such tests also allows the most appropriate operation to be performed.

[Congenital pulmonary lymphangiectasia with chylothorax. Different evolution of 2 cases with severe neonatal respiratory distress]

The Authors report on 2 cases of congenital pulmonary lymphangiectasia with chylothorax and severe respiratory distress which were characterized by a different clinic course. One of the newborns, in fact, died after a few days of life, while the other has survived with the complete regression of chylothorax. The Authors also add some physiopathologic remarks about pulmonary lymphatic circulation, in order to focus the different evolution of the 2 cases and the pulmonary lymphangiectasia treatment.

Generalised lymphangiectasia: pulmonary presentation in an adult

A 25 year old man presented with dyspnoea and was found to have generalised, but predominantly pulmonary, lymphangiectasis without gastrointestinal symptoms. This is an unusual presentation of a disorder previously diagnosed only in childhood.

Mucosal lymphangiectasia in gastric adenocarcinoma

OBJECTIVE

To describe the occurrence and significance of mucosal lymphangiectasia in gastric adenocarcinoma.

DESIGN

One hundred consecutive gastrectomies for adenocarcinoma were reviewed, using 25 consecutive gastroscopically biopsied gastrectomy specimens with peptic ulcers as negative controls.

SETTING

The specimens were collected over a period of 25 months in two general hospitals and processed according to a standard protocol.

PATIENTS

Chinese living in Hong Kong.

RESULTS

Twenty cases of adenocarcinoma were found to show mucosal lymphangiectasia, which was arbitrarily defined as the presence of ectatic lymphatic channels in the lamina propria having maximum dimensions greater than that of a foveolar gland. The ectatic lymphatics were lined by simple endothelium, devoid of fibromuscular wall, and they either were optically empty or contained scant mononuclear leukocytes. None of the patients had preoperative evidence of malabsorption syndrome or protein-losing enteropathy. Lymphangiectasia was most readily seen in the superficial lamina propria near the main tumor. In 10 cases (50%), lymphangiectasia extended to the nonneoplastic part of the gastric mucosa, at a distance of at least 2 cm away from the main tumor. Tumor emboli were seen in the ectatic lymphatics in 11 cases (55%). In two cases (10%), the distal line of resection was involved by intramucosal lymphatic spread. The tumor permeating the lymphatics did not evoke any inflammatory or desmoplastic reaction in the perilymphatic lamina propria, similar to the phenomenon of so-called lymphangitis carcinomatosa. In eight cases (40%), there were foci beyond the main tumor where mucosal lymphangiectasia was present, but without tumor in its immediate vicinity. All (100%) of the 20 stomachs with mucosal lymphangiectasia had metastases in regional lymph nodes, whereas only 59 of the 80 cases (73.75%) without lymphangiectasia were node-positive (P < .025). All node-negative cases did not show lymphangiectasia. Twenty-five consecutive gastrectomies for peptic ulcer disease that had undergone preoperative mucosal biopsies showed no lymphangiectasia, suggesting that mucosal biopsy was not the cause of mucosal lymphangiectasia.

CONCLUSIONS

(1) Gastric mucosal lymphangiectasia is associated with carcinoma but not peptic ulcer, (2) Mucosal lymphangiectasia in gastric carcinoma signifies lymph node metastases, and (3) Gastric carcinoma can spread along the mucosa via intramucosal lymphatics.