Intrahepatic Dynamic Contrast-Enhanced Magnetic Resonance Lymphangiography: Potential Imaging Signature for Protein-Losing Enteropathy in Congenital Heart Disease

Background

Protein‐losing enteropathy (PLE) is a significant cause of morbidity and mortality in congenital heart disease patients with single ventricle physiology. Intrahepatic dynamic contrast‐enhanced magnetic resonance lymphangiography (IH‐DCMRL) is a novel diagnostic technique that may be useful in characterizing pathologic abdominal lymphatic flow in the congenital heart disease population and in diagnosing PLE. The objective of this study was to characterize differences in IH‐DCMRL findings in patients with single ventricle congenital heart disease with and without PLE.

Methods and Results

This was a single‐center retrospective study of IH‐DCMRL findings and clinical data in 41 consecutive patients, 20 with PLE and 21 without PLE, with single ventricle physiology referred for lymphatic evaluation. There were 3 distinct duodenal imaging patterns by IH‐DCMRL: (1) enhancement of the duodenal wall with leakage into the lumen, (2) enhancement of the duodenal wall without leakage into the lumen, and (3) no duodenal involvement. Patients with PLE were more likely to have duodenal involvement on IH‐DCMRL than patients without PLE (P<0.001).

Conclusions

IH‐DCMRL findings of lymphatic enhancement of the duodenal wall and leakage of lymph into the duodenal lumen are associated with PLE. IH‐DCMRL is a useful new modality for characterizing pathologic abdominal lymphatic flow in PLE and might be useful as a risk‐assessment tool for PLE in at‐risk patients.

Acute onset collagenous colitis associated with protein-losing enteropathy

Collagenous colitis is a cause of chronic diarrhea. We report an atypical case of collagenous colitis, presenting with an acute onset, and associated with protein‐losing enteropathy. An 82‐year‐old woman was admitted with a 1 week history of nausea, appetite loss, and diarrhea. Serum albumin level was low. Protein leakage from the small intestine was found by a Technetium‐99m human serum albumin scintigraphy. We diagnosed the patient with collagenous colitis from pathology findings of multiple biopsies taken from the colon. This case implies that collagenous colitis should be considered in acute watery diarrhea, and that it can cause protein‐losing enteropathy.

Diagnostic dilemma in diagnosing rare cause of protein losing enteropathy: Waldmann's disease

Waldmann's disease, or primary intestinal lymphangiectasia, is an unusual cause of protein-losing enteropathy primarily characterized by lymphopenia, hypoalbuminemia, and hypogammaglobulinemia. However, variable clinical presentations result dilemmas in diagnosis and effective management. We present a toddler diagnosed with Waldmann's disease managed with a high-protein diet and medium-chain triglyceride supplementation.

Fat ring sign and tumoral pseudocapsule sign in idiopathic mesenteric panniculitis complicated by protein-losing enteropathy

A 66-year-old man complained of lower limb edema was diagnosed with mesenteric panniculitis because of fat ring sign and tumoral pseudocapsule sign on contrast-enhanced CT. Patient had edema due to protein-losing enteropathy associated with mesenteric panniculitis.

Waldmann's disease: Primary intestinal lymphangiectasia diagnosed by 99mTc-labeled albumin macroaggregate scintigraphy-A case report in an adult patient

Key Clinical Message

Rare yet significant, this case sheds light on the uncommon presentation of Waldmann's disease in adults, showcasing the diagnostic challenges it poses. A multidisciplinary approach, integrating clinical, endoscopic, histological, and radiological evaluations, is crucial for accurate diagnosis and management. Further research is needed to deepen our understanding of this complex disorder.

Abstract

Waldmann's disease, or primary intestinal lymphangiectasia, is a rare disorder characterized by protein-losing enteropathy due to dilation and leakage of intestinal lymphatic vessels. Although typically diagnosed in early childhood, we present a case of a 55-year-old male with a complex medical history. The patient's history included intestinal obstruction, multidrug-resistant pulmonary tuberculosis, and primary antiphospholipid syndrome. He presented with a 2-year history of chronic diarrhea, weight loss, and lower limb edema. Endoscopic and histological examination revealed scattered white spots in the duodenum and terminal ileum, indicative of intestinal lymphangiectasia. Nuclear medicine studies confirmed abnormal protein loss. The rarity of Waldmann's disease in adulthood and its association with other significant medical conditions pose diagnostic challenges. The distinct endoscopic and histological findings, coupled with scintigraphy results, contribute to a comprehensive understanding of this complex case. Differential diagnoses and management considerations are discussed. This case highlights the atypical presentation of Waldmann's disease in adulthood, emphasizing the importance of a multidisciplinary approach for accurate diagnosis and management. Further research is warranted to enhance our understanding of this uncommon disorder and its potential implications for patients with complex medical histories.

Pre-clinical enteropathy in healthy soft-coated wheaten terriers

BACKGROUND

Soft-coated wheaten terriers (SCWTs) have a predisposition to the development of protein-losing enteropathy (PLE). Early recognition of disease may improve morbidity and mortality in these and other at-risk dogs. Preclinical inflammatory bowel disease (IBD), characterized by increased intestinal permeability, immune dysregulation and inflammation, and changes to the gut microbial composition, or biochemical evidence of disease many years before development of clinical signs, has been proposed for people at risk for IBD.

HYPOTHESIS/OBJECTIVES

Determine if changes in fecal metabolites and intestinal permeability could be identified in SCWTs before development of clinical signs. We hypothesized that, in contrast to healthy non-SCWT dogs, healthy SCWT would have changes similar to those of dogs with PLE.

ANIMALS

Twelve healthy SCWTs, 10 healthy non-SCWTs, and 8 PLE dogs.

METHODS

Prospective study. Fecal calprotectin, targeted metabolites and unconjugated bile acids, intestinal permeability testing, and video capsule endoscopy were evaluated. Single-factor analysis of variance (ANOVA) was performed to evaluate fecal metabolites and bile acids for group differences. A repeated-measures mixed model ANOVA was performed for blood lactulose:galactose area under the curve (AUC).

RESULTS

Significant differences among groups were found for several fecal fatty acids and sterols. Healthy non-SCWT dogs, but not healthy SCWTs, were found to have significantly lower AUCs than PLE dogs (P = .04).

CONCLUSIONS

Healthy SCWT dogs had changes in several biomarkers used to identify preclinical IBD in humans.

Protein-losing enteropathy as the first presentation of systemic lupus erythematosus: A case report from Sudan

Key Clinical Message

In low- and middle-income countries, protein-losing enteropathy is a diagnosis of exclusion. SLE should be on the list of differential diagnoses of protein-losing enteropathy, especially if the patient had a long history of GI symptoms and ascites.

Abstract

Protein-losing enteropathy can rarely be the initial presentation of systemic lupus erythematosus (SLE). Protein-losing enteropathy is a diagnosis of exclusion in low- and middle-income countries. Protein-losing enteropathy in SLE should be in the list of differential diagnosis of unexplained ascites, especially if patient had long history of gastrointestinal symptoms. We present a case of 33 years old male with long standing gastrointestinal symptoms and diarrhea attributed previously to irritable bowel syndrome. Presented with progressive abdominal distension, and diagnosed with ascites. Workup for him showed leucopenia, thrombocytopenia, hypoalbumenemia, elevated inflammatory markers (ESR 30, CRP 6.6), high cholesterol level (306 mg/dL), normal renal profile and normal urine analysis. Ascitic tab pale yellow with SAAG 0.9 and positive for adenosine deaminase (66 u/L) sugesstive for tuberculous peritonitis although quantitative PCR and geneXpert for MBT was negative. Antituberculous treatment was started and his condition deteriorated, immediately antituberculous was withdrawal. Further tests revealed positive serology for ANA (1:320 speckled pattern) with positive anti-RNP/Sm, positive anti-Sm antibodies. Complements level were normal. He started immunosuppressive therapy (prednisolone 10 mg/day, hydroxychloroquine 400 mg/day, azathioprine 100 mg/day). In addition, his condition is improved Diagnosis was made as SLE with Protein-losing enteropathy based on hypoalbumenemia (with exclusion of renal loss of protein), ascites, hypercholesrtolemia and exclusions of other mimics as explained later. As well as positive response to immunosuppressive medications. Our patient diagnosed clinically as SLE with protein-losing enteropathy. Protein-losing enteropathy in SLE is challenging in diagnosis because of its rarity as well as limitations in its diagnostic tests.

Ascites in infantile onset type II Sialidosis

Sialidosis is a rare autosomal-recessive lysosomal storage disease due to mutations in the NEU1 gene leading to a deficit of alpha-n-acetyl neuraminidase and causing aberrant accumulation of sialylated glycoproteins/peptides and oligosaccharides in the lysosomes of various organs and tissues. Type II sialidosis (dysmorphic form) is classified into three subgroups based on the age of onset and the clinical severity: Congenital or neonatal, infantile (onset 0-12 months) and juvenile form (onset 13 months-20 years). We report the case of a 3-year-old boy with sialidosis type II infantile form, who developed a voluminous ascites. To the best of our knowledge, ascites is not described in the infantile form but in the congenital form of the disease. Ascites seems to be of a multifactorial origin regarding our investigations: on the one hand, portal hypertension and on the other hypoalbuminemia maintained by proteinuria secondary to nephrosialidosis. Loss of plasma proteins in the gastrointestinal tract (protein-losing enteropathy) should also be considered in the case of portal hypertension and damages of the reticuloendothelial system.