Kasabach-Merritt Syndrome, an underdiagnosed swollen leg in newborn with anemia and jaundice

Key Clinical Message

Kasabach-Merritt syndrome is a rare disease. Early recognition, timely transfer, and proper management are crucial in reducing bleeding complication and mortality.

Abstract

The authors report a rare case of Kasabach-Merritt syndrome in a Cambodian neonate presenting with anemia and jaundice at Day 5 of life. Since the mass was not recognized at birth, the diagnosis and treatment were delayed, thus leading to demise.

Kaposiform hemangioendothelioma complicated by Kasabach-Merritt phenomenon in an infant girl

Key Clinical Message

We report a successful treatment course of an infant with mediastinal Kaposiform hemangioendothelioma. As the current complex of diseases is rare and calls for highly specialized treatment, large prospective studies are lacking. This case provides an example of balanced treatment complicated by Kasabach-Merritt phenomenon, life-threatening infections, and pericardial effusion.

Abstract

Kaposiform hemangioendothelioma (KHE) and tufted angioma are vascular benign tumors that can be associated with the rare condition Kasabach-Merritt Phenomenon (KMP). KMP is characterized by consumption coagulopathy with severe thrombocytopenia, hypofibrinogenemia, and elevated D-dimer. We here report successful treatment of a female infant with a mediastinal KHE where treatment was complicated by KMP, life-threatening infections, and pericardial effusion. Due to the absence of randomized clinical trials, there is currently no standardized treatment protocol available for KHE. In our case, the infant was treated successfully with prednisolone, vincristine, and sirolimus.

A case of neonate effectively treated with everolimus for giant hepatic hemangioma complicated with congenital duodenal atresia and Kasabach-Merritt syndrome

BACKGROUND

Disseminated intravascular coagulation (DIC) with Kasabach-Merrit syndrome from a large hepatic hemangioma is life-threatening. We report a case of giant hepatic hemangioma of the newborn with KMS.

RESULTS

The patient was born at 37 gestational weeks and 2 days via cesarean section; weight at birth was 2952 g. Congenital duodenal atresia was noted during the fetal period. DIC developed after delivery and a giant liver hemangioma was diagnosed via abdominal CT. The cause of DIC was Kasabach-Merritt syndrome owing to a giant hepatic hemangioma. First, combination therapy of 2 mg/kg/day of prednisolone and 0.2 mg/kg/day of propranolol was initiated form enterostomy. However, the size of the hepatic hemangioma did not alter, as observed via image evaluation. Therefore, 0.3 mg/kg/day of everolimus was administered frorm enterostomy. Subsequently, the size of the hepatic hemangioma was assessed via image evaluation. Although it did not alter, blood flow to the hepatic hemangioma decreased and thrombocytopenia was also suppressed. We performed hepatic lateral segmentectomy, radical operation for duodenal atresia. The pathological diagnosis of the removed tumor was infantile hemangioma.

CONCLUSION

We report everolimus may be useful when PSL and propranolol are ineffective.

Successful treatment of a patient with Kasabach-Merritt syndrome and multiple giant hepatic hemangiomas

Kasabach–Merritt syndrome (KMS) is a rare complication of hemangioma. KMS mostly occurs in the pediatric population with typical clinical manifestations, including thrombocytopenia, consumptive coagulation, and purpura. However, the pathogenesis of KMS is still unclear and the KMS therapy is controversial. We report here a case of KMS and multiple, giant, hepatic hemangiomas in a 34-year-old female patient who was successfully treated in our hospital. Glucocorticoid along with supportive treatments was administrated immediately to reverse fatal disseminated intravascular coagulation and acute hemolysis. After the acute phase, glucocorticoid was tapered slowly and sirolimus was added to treat the hemangiomas. In conclusion, the risk factors of gestation, interventional treatment, and autoimmune disturbance might contribute to the pathogenesis of KMS. Additionally, treatment with glucocorticoid and sirolimus is effective in KMS and multiple giant hepatic hemangiomas.

Massive liver haemangioma causing Kasabach-Merritt syndrome in an adult

Liver haemangiomas are common, but their size very rarely exceeds 40cm. Most people with liver haemangiomas are asymptomatic, and diagnosis is usually made incidentally during imaging for other complaints. When a liver haemangioma is symptomatic or produces complications, surgical intervention may be warranted. Kasabach-Merritt syndrome is an uncommon complication reported in certain rare vascular tumours in children, with only a few cases reported in adults. The syndrome describes a consumptive coagulopathy initiated within a vascular tumour, mainly tufted angiomas and kaposiform haemangioendotheliomas and, less commonly, giant haemangiomas. The process can extend beyond the tumour and become disseminated in certain cases due to trauma or surgery. The definitive treatment for giant liver haemangiomas can include arterial embolisation, surgical excision, hepatectomy or even liver transplantation. We report the case of a 32-year-old woman with a 42 × 32 × 27cm (18,870ml) liver haemangioma associated with Kasabach-Merritt syndrome. The diagnosis was challenging, even with proper imaging, owing to the rarity of the condition. It was achieved with an exploratory laparotomy with biopsy.

A case of an elderly female with diffuse hepatic hemangiomatosis complicated with multiple organic dysfunction and Kasabach-Merritt syndrome

Since diffuse hepatic hemangiomatosis (DHH) is an extremely rare disease especially in adults, the etiology and natural course of adult-onset DHH has not been well understood. We report a case of DHH complicated with multiple organic dysfunction and Kasabach-Merritt syndrome (KMS) in an 83-year-old female. She presented with mild abdominal distension and laboratory findings revealed thrombocytopenia and abnormal coagulation, indicating disseminated intravascular coagulation (DIC). Enhanced computed tomography revealed diffuse, hypodense hepatic nodules with delayed enhancement involving the whole liver, and multiple hypodense splenic legions. To obtain a definitive diagnosis, laparoscopic-guided biopsy was performed. Histological findings revealed irregularly dilated non-anastomotic vascular spaces, which were lined with flat endothelial cells without cellular atypia. We diagnosed this as DHH complicated with splenic lesions and KMS. Although the patient was treated with symptomatic treatment, such as anti-coagulation therapy, hemangiomatous lesions, especially in the spleen, progressed rapidly, leading to worsening of DIC. Finally, the patient died of multiple organ failure at 12 months after diagnosis. A postmortem examination demonstrated diffuse hemangiomatosis of not only the liver and spleen, but also the adrenal glands and bone marrow. Despite no malignant histologically, DHH can be fatal if it progresses rapidly within a short period of time.

Propranolol in the preoperative treatment of Kasabach-Merritt syndrome: a case report

Background

Kasabach–Merritt syndrome represents the association of hemangioma with thrombocytopenia and consumptive coagulopathy. We present a case of Kasabach–Merritt syndrome treatment with orally administered propranolol.

Case presentation

A 4.5-month-old caucasian female infant with congenital giant hemangioma in the posterior region of her neck presented to our Institute for Childhood Diseases where she underwent clinical, laboratory, and radiological investigations. A low blood platelet count indicated the use of corticosteroids and blood components as first-line therapy. The lack of therapeutic response induced the introduction of orally administered propranolol as additive therapy. A 3-week treatment led to a reduction in the size of hemangioma and a rise in platelet count which enabled surgical treatment and definite healing.

Conclusion

Orally administered propranolol as monotherapy or in combination with other therapeutic modalities may play a key role in the treatment of Kasabach–Merritt syndrome.

A tufted angioma

Tufted angioma (TA) is a rare, benign, cutaneous angiomatous proliferation. It is more common in children, usually presenting as red-purple painful plaques on the trunk. We describe here a TA observed at nine months of age, appearing initially over the retroauricular area, gradually extending to involve skin of neck and trunk by two years of age. This case of a large TA (7 × 12 cm) in an Indian male child is reported here due to its rare presentation.

Kasabach-Merritt Syndrome Associated With a Large Cavernous Splenic Hemangioma Treated With Splenectomy: A Surgeon's Introspection of an Uncommon, Little Read, and Yet Complex Problem-Review Article

Cavernous hemangiomas of the spleen are small benign lesions found incidentally, majority of times while patients are being investigated for some other disease and patients remain asymptomatic otherwise for this condition. The natural history of cavernous hemangiomas of spleen is slow, symptoms or complications, when present, occur late, they are rarely large and can manifest as a palpable non-tender mass in the left upper quadrant. A very rare syndrome is associated with this condition called Kasabach-Merritt syndrome (KMS), which is defined as diffuse cavernous hemangioma of the spleen alongwith anemia, thrombocytopenia, and coagulopathy. Perioperative diagnosis can be confirmed by imaging study which can be CT, MRI, or ultrasound. Splenectomy is considered the treatment of choice for such patients with symptoms. To our knowledge, a very few cases have been reported so far. The purpose of writing this review article is the reporting of this rare case and to provide some experience related to the management of this condition in a patient with KMS.

Kasabach-Merritt syndrome with large cutaneous vascular tumors

A case series of four patients who presented with large surface vascular tumors and low platelet count and their management is reported. Medical management was done with steroids, propranolol and vincristine in different combinations. The final response was excellent without surgery.