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Hägerling R, Van Zanten M, Behncke RY, Ulferts S, Hansmeier NR, Märkl B, Witzel C, Ho B, Keeley V, Riches K, Mansour S, Gordon K, Ostergaard P, Mortimer PS. Erythematous capillary-lymphatic malformations mimicking blood vascular anomalies. JCI Insight 2023; 8:e172179. [PMID: 37698920 PMCID: PMC10619487 DOI: 10.1172/jci.insight.172179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 09/06/2023] [Indexed: 09/14/2023] Open
Abstract
Superficial erythematous cutaneous vascular malformations are assumed to be blood vascular in origin, but cutaneous lymphatic malformations can contain blood and appear red. Management may be different and so an accurate diagnosis is important. Cutaneous malformations were investigated through 2D histology and 3D whole-mount histology. Two lesions were clinically considered as port-wine birthmarks and another 3 lesions as erythematous telangiectasias. The aims were (i) to demonstrate that cutaneous erythematous malformations including telangiectasia can represent a lymphatic phenotype, (ii) to determine if lesions represent expanded but otherwise normal or malformed lymphatics, and (iii) to determine if the presence of erythrocytes explained the red color. Microscopy revealed all lesions as lymphatic structures. Port-wine birthmarks proved to be cystic lesions, with nonuniform lymphatic marker expression and a disconnected lymphatic network suggesting a lymphatic malformation. Erythematous telangiectasias represented expanded but nonmalformed lymphatics. Blood within lymphatics appeared to explain the color. Blood-lymphatic shunts could be detected in the erythematous telangiectasia. In conclusion, erythematous cutaneous capillary lesions may be lymphatic in origin but clinically indistinguishable from blood vascular malformations. Biopsy is advised for correct phenotyping and management. Erythrocytes are the likely explanation for color accessing lymphatics through lympho-venous shunts.
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Affiliation(s)
- René Hägerling
- Institute of Medical and Human Genetics, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin, BIH Center for Regenerative Therapies, Berlin, Germany
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin, BIH Academy, Clinician Scientist Program, Berlin, Germany
- Research Group Development and Disease, Max Planck Institute for Molecular Genetics, Berlin, Germany
| | - Malou Van Zanten
- Molecular and Clinical Sciences Institute, St George’s University of London, London, United Kingdom
- Dermatology and Lymphovascular Medicine, St George’s University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Rose Yinghan Behncke
- Institute of Medical and Human Genetics, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin, BIH Center for Regenerative Therapies, Berlin, Germany
| | - Sascha Ulferts
- Institute of Medical and Human Genetics, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin, BIH Center for Regenerative Therapies, Berlin, Germany
| | - Nils R. Hansmeier
- Institute of Medical and Human Genetics, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin, BIH Center for Regenerative Therapies, Berlin, Germany
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin, BIH Academy, Clinician Scientist Program, Berlin, Germany
- Research Group Development and Disease, Max Planck Institute for Molecular Genetics, Berlin, Germany
| | - Bruno Märkl
- Institute of Pathology and Molecular Diagnostics, University Clinic Augsburg, Augsburg, Germany
| | - Christian Witzel
- Department of Surgery, Campus Charité Mitte and Campus Virchow-Klinikum, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Bernard Ho
- Dermatology and Lymphovascular Medicine, St George’s University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Vaughan Keeley
- Lymphoedema Clinic, Derby Hospitals Foundation NHS Trust, Derby, United Kingdom
| | - Katie Riches
- Lymphoedema Clinic, Derby Hospitals Foundation NHS Trust, Derby, United Kingdom
| | - Sahar Mansour
- Molecular and Clinical Sciences Institute, St George’s University of London, London, United Kingdom
- SW Thames Regional Centre for Genomics, St George’s University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Kristiana Gordon
- Molecular and Clinical Sciences Institute, St George’s University of London, London, United Kingdom
- Dermatology and Lymphovascular Medicine, St George’s University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Pia Ostergaard
- Molecular and Clinical Sciences Institute, St George’s University of London, London, United Kingdom
| | - Peter S. Mortimer
- Molecular and Clinical Sciences Institute, St George’s University of London, London, United Kingdom
- Dermatology and Lymphovascular Medicine, St George’s University Hospitals NHS Foundation Trust, London, United Kingdom
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Mansour S, Josephs KS, Ostergaard P, Gordon K, Van Zanten M, Pearce J, Jeffery S, Keeley V, Riches K, Kreuter A, Wieland U, Hägerling R, Ratnam L, Sackey E, Grigoriadis D, Ho B, Smith F, Rauter E, Mortimer P, Macallan D. Redefining WILD syndrome: a primary lymphatic dysplasia with congenital multisegmental lymphoedema, cutaneous lymphovascular malformation, CD4 lymphopaenia and warts. J Med Genet 2023; 60:84-90. [PMID: 34916230 PMCID: PMC9811088 DOI: 10.1136/jmedgenet-2021-107820] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 11/10/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Primary lymphoedema (PL) syndromes are increasingly recognised as presentations of complex genetic disease, with at least 20 identified causative genes. Recognition of clinical patterns is key to diagnosis, research and therapeutics. The defining criteria for one such clinical syndrome, 'WILD syndrome' (Warts, Immunodeficiency, Lymphoedema and anogenital Dysplasia), have previously depended on a single case report. METHODS AND RESULTS We present 21 patients (including the first described case) with similar clinical and immunological phenotypes. All had PL affecting multiple segments, with systemic involvement (intestinal lymphangiectasia/pleural or pericardial effusions) in 70% (n=14/20). Most (n=20, 95%) had a distinctive cutaneous lymphovascular malformation on the upper anterior chest wall. Some (n=10, 48%) also had hyperpigmented lesions resembling epidermal naevi (but probably lymphatic in origin). Warts were common (n=17, 81%) and often refractory. In contrast to the previous case report, anogenital dysplasia was uncommon-only found in two further cases (total n=3, 14%). Low CD4 counts and CD4:CD8 ratios typified the syndrome (17 of 19, 89%), but monocyte counts were universally normal, unlike GATA2 deficiency. CONCLUSION WILD syndrome is a previously unrecognised, underdiagnosed generalised PL syndrome. Based on this case series, we redefine WILD as 'Warts, Immunodeficiency, andLymphatic Dysplasia' and suggest specific diagnostic criteria. The essential criterion is congenital multisegmental PL in a 'mosaic' distribution. The major diagnostic features are recurrent warts, cutaneous lymphovascular malformations, systemic involvement (lymphatic dysplasia), genital swelling and CD4 lymphopaenia with normal monocyte counts. The absence of family history suggests a sporadic condition, and the random distribution of swelling implicates mosaic postzygotic mutation as the cause.
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Affiliation(s)
- Sahar Mansour
- Lymphovascular Research Unit, Molecular and Clinical Sciences Research Institute, University of London St George's, London, UK,SW Thames Regional Genetics Service, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Katherine S Josephs
- Lymphovascular Research Unit, Molecular and Clinical Sciences Research Institute, University of London St George's, London, UK,SW Thames Regional Genetics Service, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Pia Ostergaard
- Lymphovascular Research Unit, Molecular and Clinical Sciences Research Institute, University of London St George's, London, UK
| | - Kristiana Gordon
- Dermatology and Lymphovascular Medicine, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Malou Van Zanten
- Lymphovascular Research Unit, Molecular and Clinical Sciences Research Institute, University of London St George's, London, UK
| | - Julian Pearce
- Dermatology and Lymphovascular Medicine, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Steve Jeffery
- Lymphovascular Research Unit, Molecular and Clinical Sciences Research Institute, University of London St George's, London, UK
| | - Vaughan Keeley
- Lymphedema Clinic, Derby Hospitals NHS Foundation Trust, Derby, UK
| | - Katie Riches
- Lymphedema Clinic, Derby Hospitals NHS Foundation Trust, Derby, UK
| | - Alexander Kreuter
- Department of Dermatology, Venereology and Allergology, Helios St Elisabeth Hospital Oberhausen, University Witten-Herdecke, Oberhausen, Germany
| | - Ulrike Wieland
- National Reference Center for Papilloma and Polyomaviruses, Institute of Virology, Uniklinik Koln, University of Cologne, Cologne, Germany
| | - René Hägerling
- Institute of Medical and Human Genetics, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Lakshmi Ratnam
- Radiology Department, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Ege Sackey
- Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - Dionysios Grigoriadis
- Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - Bernard Ho
- Dermatology and Lymphovascular Medicine, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Frances Smith
- Viapath Haematology Laboratory, King's College Hospital NHS Foundation Trust, London, UK
| | - Elisabeth Rauter
- Viapath Haematology Laboratory, King's College Hospital NHS Foundation Trust, London, UK
| | - Peter Mortimer
- Dermatology and Lymphovascular Medicine, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Derek Macallan
- Infection Care Group, St George's University Hospitals NHS Foundation Trust, London, UK,Institute for Infection and Immunity, St George's University of London, London, UK
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Gordon K, Moore M, Van Zanten M, Pearce J, Itkin M, Madden B, Ratnam L, Mortimer PS, Nagaraja R, Mansour S. Case Report: Progressive central conducting lymphatic abnormalities in the RASopathies. Two case reports, including successful treatment by MEK inhibition. Front Genet 2022; 13:1001105. [PMID: 36238151 PMCID: PMC9550924 DOI: 10.3389/fgene.2022.1001105] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 09/07/2022] [Indexed: 11/13/2022] Open
Abstract
The RASopathies are a group of genetic conditions resulting from mutations within the RAS/mitogen-activated protein kinase (RAS-MAPK) pathway. Lymphatic abnormalities are commonly associated with these conditions, however central conducting lymphatic abnormalities (CCLA) have only recently been described. CCLAs may be progressive and can result in devastating systemic sequelae, such as recurrent chylothoraces, chylopericardium and chylous ascites which can cause significant morbidity and even mortality. Improvements in imaging modalities of the central lymphatics have enhanced our understanding of these complex abnormalities. Management is challenging and have mainly consisted of diuretics and invasive mechanical drainages. We describe two adult males with Noonan syndrome with a severe and progressive CCLA. In one patient we report the therapeutic role of targeted molecular therapy with the MEK inhibitor 'Trametinib', which has resulted in dramatic, and sustained, clinical improvement. The successful use of MEK inhibition highlights the importance of understanding the molecular cause of lymphatic abnormalities and utilising targeted therapies to improve quality of life and potentially life expectancy.
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Affiliation(s)
- Kristiana Gordon
- Lymphovascular Research Unit, Molecular and Clinical Sciences Research Institute, University of London, London, United Kingdom.,Lymphovascular Clinic, St. George's University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Matthew Moore
- Cardiovascular Department, St. George's University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Malou Van Zanten
- Lymphovascular Research Unit, Molecular and Clinical Sciences Research Institute, University of London, London, United Kingdom
| | - Julian Pearce
- Lymphovascular Clinic, St. George's University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Maxim Itkin
- Division of Interventional Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Brendan Madden
- Cardiovascular Department, St. George's University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Lakshmi Ratnam
- Department of Interventional Radiology, St. George's University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Peter S Mortimer
- Lymphovascular Research Unit, Molecular and Clinical Sciences Research Institute, University of London, London, United Kingdom.,Lymphovascular Clinic, St. George's University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Rani Nagaraja
- Gastroenterology Department, St. George's University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Sahar Mansour
- Lymphovascular Research Unit, Molecular and Clinical Sciences Research Institute, University of London, London, United Kingdom.,SW Thames Regional Genetics Service, St. George's University Hospitals NHS Foundation Trust, London, United Kingdom
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Gordon K, Varney R, Keeley V, Riches K, Jeffery S, Van Zanten M, Mortimer P, Ostergaard P, Mansour S. Update and audit of the St George's classification algorithm of primary lymphatic anomalies: a clinical and molecular approach to diagnosis. J Med Genet 2020; 57:653-659. [PMID: 32409509 PMCID: PMC7525776 DOI: 10.1136/jmedgenet-2019-106084] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 12/30/2019] [Accepted: 03/10/2020] [Indexed: 12/15/2022]
Abstract
Primary lymphatic anomalies may present in a myriad of ways and are highly heterogenous. Careful consideration of the presentation can lead to an accurate clinical and/or molecular diagnosis which will assist with management. The most common presentation is lymphoedema, swelling resulting from failure of the peripheral lymphatic system. However, there may be internal lymphatic dysfunction, for example, chylous reflux, or lymphatic malformations, including the thorax or abdomen. A number of causal germline or postzygotic gene mutations have been discovered. Some through careful phenotyping and categorisation of the patients based on the St George’s classification pathway/algorithm. The St George’s classification algorithm is aimed at providing an accurate diagnosis for patients with lymphoedema based on age of onset, areas affected by swelling and associated clinical features. This has enabled the identification of new causative genes. This update brings the classification of primary lymphatic disorders in line with the International Society for the Study of Vascular Anomalies 2018 classification for vascular anomalies. The St George’s algorithm considers combined vascular malformations and primary lymphatic anomalies. It divides the types of primary lymphatic anomalies into lymphatic malformations and primary lymphoedema. It further divides the primary lymphoedema into syndromic, generalised lymphatic dysplasia with internal/systemic involvement, congenital-onset lymphoedema and late-onset lymphoedema. An audit and update of the algorithm has revealed where new genes have been discovered and that a molecular diagnosis was possible in 26% of all patients overall and 41% of those tested.
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Affiliation(s)
- Kristiana Gordon
- Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK.,Dermatology & Lymphovascular Medicine, St George's Universities NHS Foundation trust, London, UK
| | - Ruth Varney
- Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - Vaughan Keeley
- Lymphedema Clinic, Derby Hospitals NHS Foundation Trust, Derby, UK
| | - Katie Riches
- Lymphedema Clinic, Derby Hospitals NHS Foundation Trust, Derby, UK
| | - Steve Jeffery
- Molecular and Clinical Sciences Research Institute, St George's, University of London, London, UK
| | - Malou Van Zanten
- Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - Peter Mortimer
- Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK.,Dermatology & Lymphovascular Medicine, St George's Universities NHS Foundation trust, London, UK
| | - Pia Ostergaard
- Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - Sahar Mansour
- Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK .,SW Thames Regional Genetics Service, St George's Hospital, London, UK
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Abstract
Background and Study Objective: Australia was one of nine participating countries in the epidemiology Phase II Lymphoedema Impact and Prevalence – International (LIMPRINT) project to determine the number of people with chronic edema (CO) in local health services. Methods and Results: Data collection occurred through questionnaire-based interviews and clinical assessment with provided LIMPRINT tools. Four different types of services across three states in Australia participated. A total of 222 adults participated with an age range from 22 to 102 years, and 60% were female. Site 1 included three residential care facilities (54% of participants had swelling), site 2 was community-delivered aged care services (24% of participants had swelling), site 3 was a hospital setting (facility-based prevalence study; 28% of participants had swelling), and site 4 was a wound treatment center (specific patient population; 100% of participants had swelling). Of those with CO or secondary lymphedema, 93% were not related to cancer, the lower limbs were affected in 51% of cases, and 18% of participants with swelling reported one or more episodes of cellulitis in the previous year. Wounds were identified in 47% (n = 105) of all participants with more than half of those with wounds coming from the dedicated wound clinic. Leg/foot ulcer was the most common type of wound (65%, n = 68). Conclusions: Distances between services, lack of specialized services, and various state funding models contribute to inequities in CO treatment. Understanding the high number of noncancer-related CO presentations will assist health services to provide timely effective care and improve referral pathways.
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Affiliation(s)
- Susan J Gordon
- 1 College of Nursing and Health Sciences, Flinders University, Adelaide, Australia
| | - Susie G Murray
- 2 Centre for Research and Implementation of Clinical Practice, London, United Kingdom
| | - Trudie Sutton
- 3 General Manager Aged Care Housing Group, Mile End, South Australia, Australia
| | | | - Sally J James
- 5 Western Health Chronic Wound Service, St Albans, Australia
| | - Malou Van Zanten
- 6 Flinders Centre for Innovation in Cancer, Flinders University, Adelaide, Australia
| | - Joanne K Lawson
- 3 General Manager Aged Care Housing Group, Mile End, South Australia, Australia
| | - Christine Moffatt
- 7 School of Social Sciences, Nottingham University, Nottingham, United Kingdom
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