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Fricke K, Övermo Tydén K, Bergman G, Hedström E. The Nutmeg Lung Pattern in a Fetus with Hypoplastic Left Heart Syndrome and Turner Syndrome. Pediatr Cardiol 2025:10.1007/s00246-025-03873-x. [PMID: 40287864 DOI: 10.1007/s00246-025-03873-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2025] [Accepted: 04/17/2025] [Indexed: 04/29/2025]
Abstract
The "nutmeg lung pattern" on fetal magnetic resonance imaging (MRI) indicates pulmonary lymphangiectasia. This is associated with adverse outcomes, particularly in fetuses with congenital heart defects and impaired pulmonary venous return. Whereas lymphedema is common in fetuses with Turner syndrome, pulmonary lymphangiectasia is not. A 26-year-old woman presented with a fetus with hypoplastic left heart syndrome (HLHS) without restrictive atrial septum (RAS). The family declined amniocentesis, yet non-invasive prenatal testing showed an increased risk for Turner syndrome. The patient underwent a fetal MRI as part of a blinded research protocol. Postnatal echocardiogram confirmed the fetal echocardiographic findings without evidence of RAS. Norwood stage I palliation was performed at two days of age. Significant neonatal respiratory morbidity including pneumonia, diaphragmatic and vocal cord pareses and chylothorax occurred. Subsequent review of fetal MRI revealed a prominent thoracic duct and mild pulmonary lymphangiectasia. Turner syndrome was confirmed by genetic testing. After one month, the patient was discharged to her home hospital with respiratory support, which was discontinued a few weeks later. Respiratory problems continued, but the vocal cord paresis resolved over time. This is a unique case of a fetus with HLHS/non-RAS with mild fetal pulmonary lymphangiectasia, and significant neonatal respiratory morbidity, probably in part due to Turner syndrome. The infant survived the neonatal period and underwent uneventful Glenn surgery. The patient's tolerance to the total cavopulmonary connection (TCPC) procedure is yet to be seen. An MRI lymphography should precede it to assess residual lymphatic abnormalities and serve as baseline for post-TCPC changes.
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Affiliation(s)
- Katrin Fricke
- Pediatric Cardiology, Pediatric Heart Center, Skåne University Hospital, Lund, Sweden.
- Pediatrics, Department of Clinical Sciences Lund, Lund University, Lund, Sweden.
| | - Katarina Övermo Tydén
- Department of Pediatric Cardiology, Karolinska University Hospital, Stockholm, Sweden
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Gunnar Bergman
- Department of Pediatric Cardiology, Karolinska University Hospital, Stockholm, Sweden
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Erik Hedström
- Clinical Physiology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Clinical Physiology, Skåne University Hospital, Lund, Sweden
- Diagnostic Radiology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Radiology, Skåne University Hospital, Lund, Sweden
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LaFontaine R, Lyle ANJ, Upadhyay K. Respiratory Distress in a 3-Week-Old Late Preterm Male Neonate. Neoreviews 2024; 25:e220-e223. [PMID: 38556489 DOI: 10.1542/neo.25-3-e220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Affiliation(s)
- Rachel LaFontaine
- Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA
| | - Allison N J Lyle
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA
| | - Kirti Upadhyay
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA
- Neonatal Intensive Care Unit (NICU) at UW Medical Center-Montlake, Seattle Children's Hospital, University of Washington, Seattle, WA
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3
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LaFontaine R, Lyle ANJ, Upadhyay K. Respiratory Distress in a 3-Week-Old Late Preterm Male Neonate. Neoreviews 2024; 25:e220-e223. [PMID: 38556498 DOI: 10.1542/neo.25-4-e220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Affiliation(s)
- Rachel LaFontaine
- Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA
| | - Allison N J Lyle
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA
| | - Kirti Upadhyay
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA
- Neonatal Intensive Care Unit (NICU) at UW Medical Center-Montlake, Seattle Children's Hospital, University of Washington, Seattle, WA
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Abdulkarim A, Shaji S, Elfituri M, Gunsaulus M, Zafar MA, Zaidi AN, Pass RH, Feingold B, Kurland G, Kreutzer J, Ghassemzadeh R, Goldstein B, West S, Alsaied T. Pulmonary Complications in Patients With Fontan Circulation: JACC Review Topic of the Week. J Am Coll Cardiol 2023; 81:2434-2444. [PMID: 37344046 DOI: 10.1016/j.jacc.2023.04.036] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 04/03/2023] [Accepted: 04/10/2023] [Indexed: 06/23/2023]
Abstract
The Fontan operation has resulted in significant improvement in survival of patients with single ventricle physiology. As a result, there is a growing population of individuals with Fontan physiology reaching adolescence and adulthood. Despite the improved survival, there are long-term morbidities associated with the Fontan operation. Pulmonary complications are common and may contribute to both circulatory and pulmonary insufficiency, leading ultimately to Fontan failure. These complications include restrictive lung disease, sleep abnormalities, plastic bronchitis, and cyanosis. Cyanosis post-Fontan procedure can be attributed to multiple causes including systemic to pulmonary venous collateral channels and pulmonary arteriovenous malformations. This review presents the unique cardiopulmonary interactions in the Fontan circulation. Understanding the cardiopulmonary interactions along with improved recognition and treatment of pulmonary abnormalities may improve the long-term outcomes in this growing patient population. Interventions focused on improving pulmonary function including inspiratory muscle training and endurance training have shown a promising effect post-Fontan procedure.
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Affiliation(s)
- Ali Abdulkarim
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Shawn Shaji
- Heart Institute, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA; Division of Pediatric Cardiology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Mahmud Elfituri
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Megan Gunsaulus
- Heart Institute, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA; Division of Pediatric Cardiology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Muhammad A Zafar
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Ali N Zaidi
- Mount Sinai Heart, Mount Sinai Kravis Children's Heart Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Robert H Pass
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, Division of Pediatric Cardiology and Mount Sinai Kravis Children's Heart Center, New York, New York, USA
| | - Brian Feingold
- Heart Institute, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA; Division of Pediatric Cardiology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Geoffrey Kurland
- University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA; Division of Pediatric Pulmonology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jacqueline Kreutzer
- Heart Institute, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA; Division of Pediatric Cardiology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Rod Ghassemzadeh
- University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Department of Critical Care, Pittsburgh, Pennsylvania, USA
| | - Bryan Goldstein
- Heart Institute, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA; Division of Pediatric Cardiology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Shawn West
- Heart Institute, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA; Division of Pediatric Cardiology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Tarek Alsaied
- Heart Institute, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA; Division of Pediatric Cardiology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
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Moza R, Winder M, Adamson GT, Ou Z, Presson AP, Vijayarajah S, Goldstein SA, Bailly DK. Prediction Model with External Validation for Early Detection of Postoperative Pediatric Chylothorax. Pediatr Cardiol 2023:10.1007/s00246-022-03034-4. [PMID: 36754886 DOI: 10.1007/s00246-022-03034-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 10/14/2022] [Indexed: 02/10/2023]
Abstract
Earlier diagnosis of chylothorax following pediatric cardiac surgery is associated with decreased duration of chylothorax. Pleural fluid testing is used to diagnosis chylothorax which may delay detection in patients who are not enterally fed at time of chylothorax onset. Our aim was to develop and externally validate a prediction model to detect chylothorax earlier than pleural fluid testing in pediatric patients following cardiac surgery. A multivariable logistic regression model was developed to detect chylothorax using a stepwise approach. The model was developed using data from patients < 18 years following cardiac surgery from Primary Children's Hospital, a tertiary-care academic center, between 2017 and 2020. External validation used a contemporary cohort (n = 171) from Lucille Packard Children's Hospital. A total of 763 encounters (735 patients) were analyzed, of which 72 had chylothorax. The final variables selected were chest tube output (CTO) the day after sternal closure (dichotomized at 15.6 mL/kg/day, and as a continuous variable) and delayed sternal closure. The highest odds of chylothorax were associated with CTO on post-sternal closure day 1 > 15.6 mL/kg/day (odds ratio 11.3, 95% CI 6,3, 21.3). The c-statistic for the internal and external validation datasets using the dichotomized CTO variable were 0.78 (95% CI 0.73, 0.82) and 0.84 (95% CI, 0.78, 0.9) and performance improved when using CTO as a continuous variable (OR 0.84, CI: 95% CI 0.80, 0.87). Using the models described, chylothorax after pediatric cardiac surgery may be detected earlier and without reliance on enteral feeds.
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Affiliation(s)
- Rohin Moza
- Division of Pediatric Critical Care, University of Utah/Primary Children's Hospital, 295 Chipeta Way, Salt Lake City, UT, 84108, USA.
| | - Melissa Winder
- Division of Pediatric Critical Care, University of Utah/Primary Children's Hospital, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
| | - Gregory T Adamson
- Department of Pediatric Cardiology, Stanford University/Lucile Packard Children's Hospital, 725 Welch Road, Palo Alto, CA, 94304, USA
| | - Zhining Ou
- Division of Epidemiology, Department of Internal Medicine, University of Utah, 295 Chipeta Way, Salt Lake City, UT, 84132, USA
| | - Angela P Presson
- Division of Epidemiology, Department of Internal Medicine, University of Utah, 295 Chipeta Way, Salt Lake City, UT, 84132, USA
| | - Senthuran Vijayarajah
- Section of Pediatric Critical Care, University of Oklahoma Health Sciences Center, 1200 Everett Dr, Oklahoma City, OK, 73104, USA
| | - Stephanie A Goldstein
- Division of Pediatric Critical Care, University of Utah/Primary Children's Hospital, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
| | - David K Bailly
- Division of Pediatric Critical Care, University of Utah/Primary Children's Hospital, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
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Bhattacharya D, Gopalakrishnan A, Sasikumar D, Ayyappan A, Kurup HKN, Menon S, Krishnamoorthy KM. Recurrent pericardial effusion in a boy: A clue to underlying pericardial and pulmonary lymphangiectasia. Ann Pediatr Cardiol 2022; 15:412-414. [PMID: 36935824 PMCID: PMC10015394 DOI: 10.4103/apc.apc_212_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 01/27/2022] [Accepted: 03/23/2022] [Indexed: 01/07/2023] Open
Abstract
Pulmonary lymphangiectasia is a rare congenital malformation of lymphatic vessels. We report the case of a 5-year-old boy with recurrent pericardial effusion which was diagnosed to be due to pericardial and pulmonary lymphangiectasia.
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Affiliation(s)
- Deepanjan Bhattacharya
- Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Arun Gopalakrishnan
- Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Deepa Sasikumar
- Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Anoop Ayyappan
- Department of Radiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Harikrishnan KN Kurup
- Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Sabarinath Menon
- Department of Cardiothoracic and Vascular Surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Kavasseri M Krishnamoorthy
- Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
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Peri-operative myocardial performance in infants with Down syndrome undergoing CHD repair. Cardiol Young 2022; 32:960-968. [PMID: 34462021 DOI: 10.1017/s1047951121003449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND We aimed to characterise the impact of Down syndrome on myocardial performance and loading conditions in infants with Down syndrome and CHD over the peri-operative period by comparing them with infants matched for cardiac lesion with a normal microarray. METHODS Left ventricular global longitudinal strain, right ventricular free wall longitudinal strain, left ventricular end-systolic wall stress, and right ventricular systolic pressure were measured in the two groups over the peri-operative period. RESULTS Fifty-five infants had a diagnosis of Down syndrome and these were compared with 29 control infants. Left ventricular global longitudinal strain decreased in both groups post-operatively with the Down syndrome group demonstrating some recovery pre-discharge (18 ± 3 versus 16 ± 3 %, p = 0.01). Right ventricular longitudinal strain significantly decreased in both groups post-operatively with the control group demonstrating better recovery by hospital discharge (14 ± 4 versus 18 ± 6 %, p < 0.01). End-systolic wall stress was lower and right ventricular systolic pressure was higher in the Down syndrome group throughout the study period (all p < 0.05). Down syndrome was an independent predictor of the duration of ventilation, post-operative use of inotropes, and intensive care stay. Right ventricular longitudinal strain was an independent predictor of duration of intensive care stay. CONCLUSION This study demonstrates the difference between the two groups in relation to left and right ventricular function, particularly prior to discharge, and outlines the additional impact a diagnosis of Down syndrome has on myocardial performance during the peri-operative period.
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Nunes GDC, Grenier K, Kron CM, Kitzler T, Helou JE, Rosenblatt DS, Olivier F. Pulmonary lymphangiectasia in myotubular myopathy: a novel unrecognized association? Neuromuscul Disord 2022; 32:512-515. [DOI: 10.1016/j.nmd.2022.04.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 04/27/2022] [Accepted: 04/29/2022] [Indexed: 01/21/2023]
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Masood F, Bhattaram R, Rosenblatt MI, Kazlauskas A, Chang JH, Azar DT. Lymphatic Vessel Regression and Its Therapeutic Applications: Learning From Principles of Blood Vessel Regression. Front Physiol 2022; 13:846936. [PMID: 35392370 PMCID: PMC8980686 DOI: 10.3389/fphys.2022.846936] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 02/25/2022] [Indexed: 02/03/2023] Open
Abstract
Aberrant lymphatic system function has been increasingly implicated in pathologies such as lymphedema, organ transplant rejection, cardiovascular disease, obesity, and neurodegenerative diseases including Alzheimer's disease and Parkinson's disease. While some pathologies are exacerbated by lymphatic vessel regression and dysfunction, induced lymphatic regression could be therapeutically beneficial in others. Despite its importance, our understanding of lymphatic vessel regression is far behind that of blood vessel regression. Herein, we review the current understanding of blood vessel regression to identify several hallmarks of this phenomenon that can be extended to further our understanding of lymphatic vessel regression. We also summarize current research on lymphatic vessel regression and an array of research tools and models that can be utilized to advance this field. Additionally, we discuss the roles of lymphatic vessel regression and dysfunction in select pathologies, highlighting how an improved understanding of lymphatic vessel regression may yield therapeutic insights for these disease states.
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Zakharchenko L, EL-Khuffash A, Hurley T, Kelly L, Melo A, Padden M, Franklin O, Molloy EJ. Infants with Down syndrome and congenital heart disease have altered peri-operative immune responses. Pediatr Res 2022; 92:1716-1723. [PMID: 35352006 PMCID: PMC9771806 DOI: 10.1038/s41390-022-02000-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 12/03/2021] [Accepted: 02/15/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Infants with Down syndrome (DS) have an altered immune response. We aimed to characterise the inflammatory response in infants with DS and congenital heart disease (CHD) peri-operatively in comparison to infants with CHD and a normal chromosomal complement, and to healthy infants pre-operatively. METHODS Infants with DS/CHD, infants without DS but with CHD (CHD only) and healthy infants were prospectively recruited and serial serum cytokines evaluated peri-operatively using multiplex ELISA: tumour necrosis factor (TNF)-α and TNF-β; interferon (IFN)-γ, interleukin (IL)-1α, IL-2, IL-6, IL-8, IL-18, IL-1β, IL-10, and IL-1ra; vascular endothelial growth factor (VEGF); granulocyte macrophage colony-stimulating factor (GM-CSF); and erythropoietin (EPO). RESULTS Ninety-four infants were recruited including age-matched controls (n = 10), DS/CHD (n = 55), and CHD only (n = 29). Children with DS/CHD had significantly lower concentrations of several cytokines (IL-10, IL-6, IL-8, IL-1β, VEGF) in the pre- and post-operatively vs CHD only and controls. EPO and GM-CSF were significantly higher in DS/CHD (p value <0.05). CONCLUSIONS Children with DS/CHD had significantly lower concentrations of several cytokines compared to controls or children with CHD only. EPO and GM-CSF were significantly higher in children with DS/CHD. The assessment of the immune response may be suitable for the predictable clinical outcomes in these children. IMPACT This study demonstrated that children with Down syndrome (DS) and congenital heart disease (CHD) have significant alterations in pro-inflammatory and anti-inflammatory immune responses peri-operatively. These changes may contribute to adverse clinical outcomes, including sepsis, chylothorax, and autoimmunity. They may impact the pathogenesis and outcome post-operatively and long term in this population. Children with DS and CHD have significantly lower cytokine concentrations, increased EPO and GM-CSF, and decreased VEGF pre- and post-operatively. Assessing their inflammatory state peri-operatively may facilitate the development of a predictive model that can inform tailored management of these infants using novel therapies including immunomodulation.
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Affiliation(s)
- Lyudmyla Zakharchenko
- grid.417322.10000 0004 0516 3853Paediatric Cardiology, Children’s Health Ireland at Crumlin & Tallaght, Dublin, Ireland ,grid.452722.4National Children’s Research Centre, Crumlin, Dublin, Ireland
| | - Afif EL-Khuffash
- grid.452722.4National Children’s Research Centre, Crumlin, Dublin, Ireland ,grid.416068.d0000 0004 0617 7587Department of Neonatology, Rotunda Hospital, Dublin, Ireland ,grid.4912.e0000 0004 0488 7120Department of Paediatrics, Royal College of Surgeons in Ireland, Dublin, Ireland ,grid.8217.c0000 0004 1936 9705Paediatrics, Trinity College, The University of Dublin, Trinity Research in Childhood Centre (TRiCC) & Trinity Translational Medicine Institute (TTMI), Dublin, Ireland
| | - Tim Hurley
- grid.8217.c0000 0004 1936 9705Paediatrics, Trinity College, The University of Dublin, Trinity Research in Childhood Centre (TRiCC) & Trinity Translational Medicine Institute (TTMI), Dublin, Ireland
| | - Lynne Kelly
- grid.8217.c0000 0004 1936 9705Paediatrics, Trinity College, The University of Dublin, Trinity Research in Childhood Centre (TRiCC) & Trinity Translational Medicine Institute (TTMI), Dublin, Ireland
| | - Ashanti Melo
- grid.8217.c0000 0004 1936 9705Paediatrics, Trinity College, The University of Dublin, Trinity Research in Childhood Centre (TRiCC) & Trinity Translational Medicine Institute (TTMI), Dublin, Ireland
| | - Maureen Padden
- grid.452722.4National Children’s Research Centre, Crumlin, Dublin, Ireland
| | - Orla Franklin
- grid.417322.10000 0004 0516 3853Paediatric Cardiology, Children’s Health Ireland at Crumlin & Tallaght, Dublin, Ireland ,grid.452722.4National Children’s Research Centre, Crumlin, Dublin, Ireland ,grid.8217.c0000 0004 1936 9705Paediatrics, Trinity College, The University of Dublin, Trinity Research in Childhood Centre (TRiCC) & Trinity Translational Medicine Institute (TTMI), Dublin, Ireland ,grid.411886.20000 0004 0488 4333Paediatrics, Coombe Women and Infants University Hospital, Dublin, Ireland
| | - Eleanor J. Molloy
- grid.452722.4National Children’s Research Centre, Crumlin, Dublin, Ireland ,grid.4912.e0000 0004 0488 7120Department of Paediatrics, Royal College of Surgeons in Ireland, Dublin, Ireland ,grid.8217.c0000 0004 1936 9705Paediatrics, Trinity College, The University of Dublin, Trinity Research in Childhood Centre (TRiCC) & Trinity Translational Medicine Institute (TTMI), Dublin, Ireland ,grid.411886.20000 0004 0488 4333Paediatrics, Coombe Women and Infants University Hospital, Dublin, Ireland ,grid.417322.10000 0004 0516 3853Neonatology, Children’s Health Ireland at Crumlin & Tallaght, Dublin, Ireland
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Barrera CA, Johnson AM, Rychik J, Biko DM, Degenhardt K, Moldenhauer JS, Victoria T. Prognostic value of the nutmeg lung pattern/lymphangiectasia on fetal magnetic resonance imaging. Pediatr Radiol 2021; 51:1809-1817. [PMID: 33856503 DOI: 10.1007/s00247-021-05061-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 02/10/2021] [Accepted: 03/16/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND A nutmeg lung pattern on magnetic resonance imaging (MRI) is an imaging finding associated with pulmonary lymphangiectasia. However, the prognostic value of the nutmeg lung pattern is unknown. OBJECTIVE To evaluate the clinical associations of nutmeg lung indicating lymphangiectasia on fetal lung MRI and its relationship with early mortality in fetuses with primary and secondary lymphangiectasia. MATERIALS AND METHODS We retrospectively identified all pregnant patients with a fetal MRI performed for indication of evaluating for pulmonary lymphangiectasia from 2006 to 2019. Two readers evaluated the fetal MRIs and interobserver agreement was calculated. Multivariable logistic regression models were performed to estimate the association of the echocardiographic findings and the presence of nutmeg lung. Kaplan-Meier and Cox regression analyses were performed to evaluate association with mortality in the first 30 days of life. Survival analysis was defined as mortality or orthotopic heart transplant at 30 days of age. P<0.05 was considered significant. RESULTS Our sample included 53 fetuses. Forty-seven (89%) had congenital heart disease (CHD) and 6 (11%) were diagnosed postnatally with primary lymphangiectasia. Interobserver agreement was 0.83. Pulmonary vein congestion on echocardiography was the strongest predictor of nutmeg lung (odds ratio [OR]=12.0, P=0.002). Ten fetuses reached the outcome of heart transplantation (n=1) or death (n=9) within the first 30 days of life. In fetuses with CHD, survival of those with nutmeg lung was significantly lower than in those without (P<0.001). Nutmeg lung was an independent risk factor for 30-day mortality (hazard ratio [HR]: 6.1, P=0.01). CONCLUSION Nutmeg lung pattern on fetal MRI is an independent risk factor associated with 30-day mortality in fetuses with CHD.
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Affiliation(s)
- Christian A Barrera
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.
| | - Ann M Johnson
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jack Rychik
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - David M Biko
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Karl Degenhardt
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Julie S Moldenhauer
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Teresa Victoria
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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12
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Gardner K, Sumner J, Lu M, Moschovis P, Sagar P, O'Sullivan B, Nelson BA. Recurrent hypoxemia: When crackles crack the case. Pediatr Pulmonol 2021; 56:2355-2361. [PMID: 33844459 PMCID: PMC9851803 DOI: 10.1002/ppul.25419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 04/05/2021] [Accepted: 04/07/2021] [Indexed: 01/21/2023]
Affiliation(s)
- Kelly Gardner
- Department of Pediatric Pulmonology, Massachusetts General Hospital for Children, Harvard Medical School, Boston, Massachusetts, USA
| | - Jeffrey Sumner
- Department of Pediatric Pulmonology, Massachusetts General Hospital for Children, Harvard Medical School, Boston, Massachusetts, USA
| | - Mengdi Lu
- Department of Pediatric Pulmonology, Massachusetts General Hospital for Children, Harvard Medical School, Boston, Massachusetts, USA
| | - Peter Moschovis
- Department of Pediatric Pulmonology, Massachusetts General Hospital for Children, Harvard Medical School, Boston, Massachusetts, USA
| | - Pallavi Sagar
- Department of Pediatric Radiology, Massachusetts General Hospital for Children, Harvard Medical School, Boston, Massachusetts, USA
| | - Brian O'Sullivan
- Department of Pediatric Pulmonology, Dartmouth-Hitchcock Medical Center, Geisel School of Medicine, Hanover, New Hampshire, USA
| | - Benjamin A Nelson
- Department of Pediatric Pulmonology, Massachusetts General Hospital for Children, Harvard Medical School, Boston, Massachusetts, USA
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Barrera CA, Victoria T, Escobar FA, Krishnamurthy G, Smith CL, Moldenhauer JS, Biko DM. Imaging of fetal lymphangiectasias: prenatal and postnatal imaging findings. Pediatr Radiol 2020; 50:1872-1880. [PMID: 33252755 DOI: 10.1007/s00247-020-04673-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 02/25/2020] [Accepted: 03/31/2020] [Indexed: 12/22/2022]
Abstract
Lymphangiectasias are lymphatic malformations characterized by the abnormal dilation and morphology of the lymphatic channels. The classification and treatment of these disorders can be challenging given the limited amount of literature available in children. Various imaging modalities are used to confirm suspected diagnosis, plan the most appropriate treatment, and estimate a prognosis. Prenatal evaluation is performed using both prenatal US imaging and fetal MRI. These modalities are paramount for appropriate parental counseling and planning of perinatal care. During the neonatal period, chest US imaging is a useful modality to evaluate pulmonary lymphangiectasia because other modalities such as conventional radiography and CT display nonspecific findings. Finally, the recent breakthroughs in lymphatic imaging with MRI have allowed us to better classify lymphatic disorders. Dynamic contrast-enhanced lymphangiography, conventional lymphangiography and percutaneous lymphatic procedures offer static and dynamic evaluation of the central conducting lymphatics in children, with excellent spatial resolution and the possibility to provide treatment. The purpose of this review is to discuss the normal and abnormal development of the fetal lymphatic system and how to best depict it by imaging during the prenatal and postnatal life.
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Affiliation(s)
- Christian A Barrera
- Department of Radiology, Children's Hospital of Philadelphia,, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.
| | - Teresa Victoria
- Department of Radiology, Children's Hospital of Philadelphia,, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
| | - Fernando A Escobar
- Department of Radiology, Section of Interventional Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ganesh Krishnamurthy
- Department of Radiology, Section of Interventional Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Christopher L Smith
- Division of Cardiology, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Julie S Moldenhauer
- Center for Fetal Diagnosis and Treatment,, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Surgery, Perelman School of Medicine,, University of Pennsylvania, Philadelphia, PA, USA
| | - David M Biko
- Department of Radiology, Children's Hospital of Philadelphia,, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
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14
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Abstract
Purpose of Review Lymphatic disorders have received an increasing amount of attention over the last decade. Sparked primarily by improved imaging modalities and the dawn of lymphatic interventions, understanding, diagnostics, and treatment of lymphatic complications have undergone considerable improvements. Thus, the current review aims to summarize understanding, diagnostics, and treatment of lymphatic complications in individuals with congenital heart disease. Recent Findings The altered hemodynamics of individuals with congenital heart disease has been found to profoundly affect morphology and function of the lymphatic system, rendering this population especially prone to the development of lymphatic complications such as chylous and serous effusions, protein-losing enteropathy and plastic bronchitis. Summary Although improved, a full understanding of the pathophysiology and targeted treatment for lymphatic complications is still wanting. Future research into pharmacological improvement of lymphatic function and continued implementation of lymphatic imaging and interventions may improve knowledge, treatment options, and outcome for affected individuals.
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15
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Basti C, Mareri A, Maranella E, Di Fabio S. Congenital pulmonary lymphangiectasia in an extremely low birth weight: a case report. CASE REPORTS IN PERINATAL MEDICINE 2020. [DOI: 10.1515/crpm-2020-0003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
Objectives
Congenital pulmonary lymphangiectasia (CPL) is a rare but fatal disorder of the lung.
Case presentation
We describe the case of an extremely low birth weight (ELBW) infant who presented with severe respiratory distress and recurrent bilateral pneumothorax. He died on day 17. The post-mortem examination of the lungs showed numerous cystic spaces, ranging from 1 to 2 mm in size, in the visceral pleura, in the thickened interlobular septum and hilum. A diagnosis of primary CPL was made.
Conclusions
We intend to underline that CPL, albeit rare, must be one of the differential diagnoses in infants with severe neonatal respiratory distress not responding to intensive care. Chronic interstitial lung diseases are a challenging diagnostic clinical problem, which requires a multidisciplinary approach. Histological lung examination may be useful to demonstrate the presence of CPL.
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Affiliation(s)
- Claudia Basti
- Neonatology and Neonatal Intensive Care Unit , San Salvatore Hospital , L’Aquila , Italy
| | - Arianna Mareri
- Neonatology and Neonatal Intensive Care Unit , San Salvatore Hospital , L’Aquila , Italy
| | - Eugenia Maranella
- Neonatology and Neonatal Intensive Care Unit , San Salvatore Hospital , L’Aquila , Italy
| | - Sandra Di Fabio
- Neonatology and Neonatal Intensive Care Unit , San Salvatore Hospital , L’Aquila , Italy
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16
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Abstract
Interstitial (diffuse) lung diseases in infants and children comprise a rare heterogeneous group of parenchymal lung disorders, with clinical syndromes characterized by dyspnea, tachypnea, crackles, and hypoxemia. They arise from a wide spectrum of developmental, genetic, inflammatory, infectious, and reactive disorders. In the past, there has been a paucity of information and limited understanding regarding their pathogenesis, natural history, imaging findings, and histopathologic features, which often resulted in enormous diagnostic challenges and confusion. In recent years, there has been a substantial improvement in the understanding of interstitial lung disease in pediatric patients due to the development of a structured classification system based on the etiology of the lung disease, established pathologic criteria for consistent diagnosis, and the improvement of thoracoscopic techniques for lung biopsy. Imaging plays an important role in evaluating interstitial lung diseases in infants and children by confirming and characterizing the disorder, generating differential diagnoses, and providing localization for lung biopsy for pathological diagnosis. In this chapter, the authors present the epidemiology, challenges, and uncertainties of diagnosis and amplify a recently developed classification system for interstitial lung disease in infants and children with clinical, imaging, and pathological correlation.
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Affiliation(s)
- Robert H. Cleveland
- Department of Radiology, Harvard Medical School Boston Children’s Hospital, Boston, MA USA
| | - Edward Y. Lee
- Department of Radiology, Harvard Medical School Boston Children’s Hospital, Boston, MA USA
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17
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Shaikh R, Biko DM, Lee EY. MR Imaging Evaluation of Pediatric Lymphatics:: Overview of Techniques and Imaging Findings. Magn Reson Imaging Clin N Am 2019; 27:373-385. [PMID: 30910103 DOI: 10.1016/j.mric.2019.01.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Recent advances in understanding lymphatic disorders have significantly improved noninvasive imaging of the lymphatic circulation, especially in pediatric patients. The ability to obtain high-quality MR imaging using 3-dimensional reconstruction has transformed the display of the lymph vessels and substantially enhanced the ability to diagnose various pediatric lymphatic disorders. Real-time dynamic imaging adds functional information to the assessment. MR imaging is increasingly used, not only to assess but also as a follow-up after lymphatic disorder treatment. This article discusses up-to-date imaging techniques and clinical applications of dynamic magnetic resonance lymphangiography for assessing central conducting lymphatic anomalies.
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Affiliation(s)
- Raja Shaikh
- Division of Interventional Radiology, Department of Radiology, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA.
| | - David M Biko
- Department of Radiology, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Edward Y Lee
- Division of Thoracic Imaging, Department of Radiology, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
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18
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Matsuoka K, Ueda M, Miyamoto Y. Pulmonary lymphangiectasis presenting as solitary pulmonary coin lesion. Indian J Thorac Cardiovasc Surg 2019; 35:81-84. [PMID: 33060978 DOI: 10.1007/s12055-018-0722-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 07/13/2018] [Accepted: 07/17/2018] [Indexed: 11/25/2022] Open
Abstract
Pulmonary lymphangiectasis is a rare anomaly of infancy characterized by dilatation of pulmonary lymphatic vessels. It is considered to occur exclusively in young children and neonates, and pulmonary lymphangiectasis in asymptomatic adults is rare. Moreover, because chest radiography usually demonstrated the generalized congestive pattern of increased pulmonary vascularity or a reticulonodular pattern, it is extremely unusual for pulmonary lymphangiectasis to be demonstrated as a solitary nodular lesion. There were only two case reports of lymphangiectasis that developed as a nodular shadow in asymptomatic adults in English and Japanese literature. Here, we describe two cases of pulmonary lymphangiectasis that were demonstrated as solitary coin lesions in asymptomatic adults without any extrapulmonary manifestations. An 84-year-old male and a 48-year-old male were found to have a gradually increasing round pulmonary nodule. Chest computed tomography (CT) demonstrated a smooth round nodule on the lung surface, and video-assisted thoracoscopic wedge resection was performed. The nodule was a thin-walled cyst containing yellowish liquid. Histological examination of the resected lung demonstrated lymphangiectasis in the subpleural and interlobular connective tissue and no abnormal cell proliferation. Therefore, we considered that the pulmonary nodule had been formed as a result of local fluid collection in pulmonary lymphangiectasis.
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Affiliation(s)
- Katsunari Matsuoka
- Department of Thoracic Surgery, National Hospital Organization Himeji Medical Center, Honmachi 68, Himeji City, Hyogo 670-8520 Japan
| | - Mitsuhiro Ueda
- Department of Thoracic Surgery, National Hospital Organization Himeji Medical Center, Honmachi 68, Himeji City, Hyogo 670-8520 Japan
| | - Yoshihiro Miyamoto
- Department of Thoracic Surgery, National Hospital Organization Himeji Medical Center, Honmachi 68, Himeji City, Hyogo 670-8520 Japan
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19
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Abstract
OBJECTIVE Lung disease is a common indication for neonates to require medical attention, and neonatal chest radiographs are among the most common studies interpreted by pediatric radiologists. Radiographic features of many neonatal lung disorders overlap, and it may be difficult to differentiate among conditions. CONCLUSION This review presents an up-to-date practical approach to the radiologic diagnosis of neonatal lung disorders, with a focus on pattern recognition and consideration of clinical history, patient age, and symptoms.
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20
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Diagnosis of secondary pulmonary lymphangiectasia in congenital heart disease: a novel role for chest ultrasound and prognostic implications. Pediatr Radiol 2017. [PMID: 28631156 DOI: 10.1007/s00247-017-3892-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Secondary pulmonary lymphangiectasia is a complication of congenital heart disease that results from chronic pulmonary venous obstruction. OBJECTIVES We aimed to evaluate the performance of chest ultrasound (US) in diagnosing secondary pulmonary lymphangiectasia and to review the clinical course of children with secondary pulmonary lymphangiectasia. MATERIALS AND METHODS Chest US was performed on 26 children with hypoplastic left heart syndrome, total anomalous pulmonary venous connection or cor triatriatum in a prospective observational study. Thirteen children had pulmonary venous obstruction (62% male; median age: 17 days old, range: 1-430 days old) and 13 children did not have obstruction (62% male; median age: 72 days old, range: 4-333 days old). US features of secondary pulmonary lymphangiectasia were documented and diagnostic performance was determined. Clinical course of patients with secondary pulmonary lymphangiectasia was reviewed. RESULTS Eleven of 13 (84.6%) patients in the obstructed group had a clinical and/or biopsy diagnosis of secondary pulmonary lymphangiectasia. Statistically significant chest US criteria for diagnosis were presence of irregular lung surface (likelihood ratio [LR] 6.8, 95% confidence interval [CI] 1.9-25.1), subpleural cystic appearing structures (LR 3.6, 95% CI 1.2-10.7), and combination of subpleural cystic appearing structures and surface irregularity together (LR 10.9, 95% CI 1.6-75.0). Seven of 11 (63.6%) patients with secondary pulmonary lymphangiectasia died during follow-up, the majority due to cardiopulmonary failure or complications. CONCLUSION Chest US is an accurate and reproducible bedside method for diagnosing secondary pulmonary lymphangiectasia in patients with pulmonary venous obstruction. These patients may have worse prognoses.
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21
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Cystic Lung Disease in Down Syndrome: A Case Report and Literature Review. Case Rep Pediatr 2016; 2016:4048501. [PMID: 27781131 PMCID: PMC5066005 DOI: 10.1155/2016/4048501] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Accepted: 09/15/2016] [Indexed: 11/17/2022] Open
Abstract
Subpleural lung cysts (SPC) are seen in children with Down syndrome (DS). The incidence and the long term course of these lesions are not known. It is important for pediatricians and pediatric radiologists to be aware of these lung lesions since the DS patients' longevity has increased and they have greater frequency to encounter the clinicians. Autopsy and the radiology series have shown that these lesions are often found in association with congenital heart disease, particularly the endocardial cushion defect and prematurity.
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22
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Abstract
The thoracic lymphatic disorders are a heterogeneous group of uncommon conditions that are associated with thoracic masses, interstitial pulmonary infiltrates, and chylous complications. Accurate diagnosis of the thoracic lymphatic disorders has important implications for the newest approaches to management, including embolization and treatment with antilymphangiogenic drugs. New imaging techniques to characterize lymphatic flow, such as dynamic contrast-enhanced magnetic resonance lymphangiogram, are redefining approaches to disease classification and therapy.
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Affiliation(s)
- Maxim Itkin
- Interventional Radiology, Hospital of the University of Pennsylvania, Penn Medicine, 1 Silverstein, 3400 Spruce Street, Philadelphia, PA 19104, USA.
| | - Francis X McCormack
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Cincinnati, MSB 6165, 231 Albert Sabin Way, Cincinnati, OH 45267-0564, USA
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23
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Lee H, Al-Wahab H, Ambat MT. Pulmonary Shadow on Prenatal Sonogram. Clin Pediatr (Phila) 2016; 55:785-8. [PMID: 26346656 DOI: 10.1177/0009922815604599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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24
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Ferreira CR, Sibre V, Schultz R, de Melo AMAGP, Ibidi SM, Torre JD. Congenital generalized lymphangiectasia: a rare developmental disorder for non-immune fetal hydrops. AUTOPSY AND CASE REPORTS 2016; 5:27-33. [PMID: 26894043 PMCID: PMC4757917 DOI: 10.4322/acr.2015.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 11/17/2015] [Indexed: 11/23/2022] Open
Abstract
Firstly described by Rudolf Virchow in the 19th century, congenital generalized lymphangiectasia is a rare entity characterized by dilation of lymphatic vessels, and was recently classified in primary or secondary lymphangiectasia. Generalized forms may be diagnosed during pre-natal follow-up with ultrasound examination, and, depending on its severity, the newborn outcome is very poor. The authors report the case of a female newborn with a previous diagnosis of fetal hydropsy who was born after a full-term gestation with respiratory failure due to bilateral voluminous pleural effusion and ascites. Physical examination also disclosed syndromic facies. Despite all efforts of the intensive supportive care, the patient died after 24 days of life. The autopsy findings were consistent with the diagnosis of congenital pulmonary lymphangiectasia. The authors call attention to this rare diagnosis in patients with cavitary effusion and respiratory insufficiency at birth.
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Affiliation(s)
- Cristiane Rúbia Ferreira
- Anatomy Pathology Service - Hospital Universitário - University of São Paulo, São Paulo/SP - Brazil
| | - Verônica Sibre
- Department of Pathology - Hospital das Clínicas - University of São Paulo, São Paulo/SP - Brazil
| | - Regina Schultz
- Department of Pathology - Faculty of Medicine - University of São Paulo, São Paulo/SP - Brazil.; Anatomy Pathology Service - Instituto do Cancer de São Paulo, São Paulo/SP - Brazil
| | | | - Silvia Maria Ibidi
- Pediatrics Division - Hospital Universitário - University of São Paulo, São Paulo/SP - Brazil
| | - Jackeline Della Torre
- Pediatrics Department - Faculty of Medicine - University of São Paulo, São Paulo/SP - Brazil
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25
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Panchabhai TS, Bandyopadhyay D, Yadav R, Arrossi AV, Mehta AC, Faress JA. A 42-Year-Old Woman With Abnormal Chest CT Scan and Chylous Ascites. Chest 2016; 149:e25-8. [PMID: 26757302 DOI: 10.1016/j.chest.2015.10.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
A 42-year-old white woman presented to the pulmonary clinic for evaluation of abnormal chest imaging. Twenty years prior to presentation, she was noted to have an abnormal chest radiograph during a routine preemployment evaluation. A subsequent bronchoscopy was nondiagnostic. She was followed up with annual imaging, which demonstrated little or no progression of her disease. She remained symptom free throughout this period. A year before her visit to the pulmonary clinic, she developed abdominal discomfort and was found to have ascites. Subsequently, she underwent three paracenteses with analysis revealing chylous fluid. She was a nonsmoker without a history of exposures or travel.
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Affiliation(s)
- Tanmay S Panchabhai
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ
| | | | - Ruchi Yadav
- Department of Thoracic Radiology, Imaging Institute, Cleveland Clinic, Cleveland OH
| | - Andrea V Arrossi
- Department of Pulmonary Pathology, Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland OH
| | - Atul C Mehta
- Department of Pulmonary Medicine, Respiratory Institute, Cleveland Clinic, Cleveland OH
| | - Jihane A Faress
- Department of Pulmonary and Critical Care Medicine, Case Western Reserve University, Louis Stokes Cleveland Department of Veterans Affair Medical Center, Cleveland OH.
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26
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Pediatric lymphangiectasia: an imaging spectrum. Pediatr Radiol 2015; 45:562-9. [PMID: 25301383 DOI: 10.1007/s00247-014-3191-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Revised: 08/20/2014] [Accepted: 09/17/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Lymphangiectasia is a rarely encountered lymphatic dysplasia characterized by lymphatic dilation without proliferation. Although it can occur anywhere, the most common locations are the central conducting lymphatics and the pulmonary and intestinal lymphatic networks. Recent advances in lymphatic interventions have resulted in an increased reliance on imaging to characterize patterns of disease. OBJECTIVE To describe the patient populations, underlying conditions, and imaging features of lymphangiectasia encountered at a tertiary pediatric institution over a 10-year period and correlate these with pathology and patient outcomes. MATERIALS AND METHODS We retrospectively reviewed the pathology database from 2002 to 2012 to identify patients with pathologically or surgically proven lymphangiectasia who had undergone cross-sectional imaging. Medical records were reviewed for patient demographics, underlying conditions, treatment and outcome. RESULTS Thirteen children were identified, ranging in age from 1 month to 16 years. Five had pulmonary lymphangiectasia, four intestinal and four diffuse involvement. Pulmonary imaging findings include diffuse or segmental interlobular septal thickening, pleural effusions and dilated mediastinal lymphatics. Intestinal imaging findings include focal or diffuse bowel wall thickening with central lymphatic dilation. Diffuse involvement included dilation of the central lymphatics and involvement of more than one organ system. Children with infantile presentation and diffuse pulmonary, intestinal or diffuse lymphatic abnormalities had a high mortality rate. Children with later presentations and segmental involvement demonstrated clinical improvement with occasional regression of disease. Three children with dilated central lymphatics on imaging underwent successful lymphatic duct ligation procedures with improved clinical course. CONCLUSION Lymphangiectasia is a complex disorder with a spectrum of presentations, imaging appearances, treatments and outcomes. Cross-sectional imaging techniques distinguish segmental involvement of a single system (pulmonary or intestinal) from diffuse disease and may show dilated central conducting lymphatics, which may benefit from interventions such as ligation or occlusion.
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27
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Reiterer F, Grossauer K, Pfleger A, Häusler M, Resch B, Eber E, Popper H, Urlesberger B. Severe primary pulmonary lymphangiectasis in a premature infant: management and follow up to early childhood. Pediatr Int 2015; 57:166-9. [PMID: 25711257 DOI: 10.1111/ped.12416] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Revised: 04/16/2014] [Accepted: 05/09/2014] [Indexed: 11/27/2022]
Abstract
Primary pulmonary lymphangiectasis (PPL) is a rare congenital developmental abnormality of the lung with a generally poor prognosis. Only a limited number of patients with neonatal-onset PPL have been reported to survive. We present the case of a male preterm infant (gestational age 34 weeks 6 days) with histologically confirmed PPL, complicated by hydrops fetalis, bilateral hydrothorax (treated in utero with pleuro-amniotic shunts), and immediate respiratory distress at birth. He survived after extensive neonatal intensive care therapy and was discharged home at the age of 7 months. At last follow up he was 3 years 7 months old, still requiring assisted ventilation via tracheostomy, having recurrent episodes of wheezing and had mild global developmental delay. This case demonstrates that survival beyond the neonatal period is possible even with severe PPL but long-term morbidity may be relevant, and multidisciplinary management and close follow up are essential.
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28
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Reiterer F, Grossauer K, Morris N, Uhrig S, Resch B. Congenital pulmonary lymphangiectasis. Paediatr Respir Rev 2014; 15:275-80. [PMID: 24997116 DOI: 10.1016/j.prrv.2014.05.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Accepted: 05/09/2014] [Indexed: 12/31/2022]
Abstract
Congenital pulmonary lymphangiectasis (CPL) is a rare vascular malformation causing dilated lymph vessels and disturbed drainage of lymph fluid. Based on the pathogenesis and clinical phenotype it can be classified as primary or secondary CPL. Associated genetic syndromes with or without lymphedema, familial occurrence and gene mutations have been described. In utero, it may present as non-immune hydrops with pleural effusions. At birth neonates may have respiratory failure due to chylothorax and pulmonary hypoplasia, causing very high short term mortality rates. Other cases may become symptomatic any time later in childhood or even during adult life. CPL is usually diagnosed based on the combination of clinical signs, imaging and histological findings. Open-lung biopsy is considered the gold standard for the diagnosis of CPL. Treatment is primarily supportive featuring aggressive mechanical ventilation and the management of problems associated with congenital chylothorax including chest-drainage, medium-chain triglycerides (MCT) diet, and octreotide.
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Affiliation(s)
- Friedrich Reiterer
- Division of Neonatology, Department of Paediatrics, Medical University of Graz, Austria.
| | - Karin Grossauer
- Division of Neonatology, Department of Paediatrics, Medical University of Graz, Austria
| | - Nicholas Morris
- Division of Neonatology, Department of Paediatrics, Medical University of Graz, Austria
| | - Sabine Uhrig
- Institute of Human Genetics, Medical University of Graz, Austria
| | - Bernhard Resch
- Division of Neonatology, Department of Paediatrics, Medical University of Graz, Austria; Research Unit for Neonatal Infectious Diseases and Epidemiology, Medical University of Graz, Austria
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29
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Gray M, Kovatis KZ, Stuart T, Enlow E, Itkin M, Keller MS, French HM. Treatment of congenital pulmonary lymphangiectasia using ethiodized oil lymphangiography. J Perinatol 2014; 34:720-2. [PMID: 25179384 DOI: 10.1038/jp.2014.71] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2013] [Revised: 03/04/2014] [Accepted: 03/18/2014] [Indexed: 11/09/2022]
Abstract
Historically, congenital pulmonary lymphangiectasia (CPL) has had poor treatment outcomes despite aggressive therapy. There are recent reports of ethiodized oil (Lipiodol) lymphangiography successfully treating lymphatic leakage in adults. In this report, we describe two infants with CPL complicated by chylothoraces successfully treated by instillation of ethiodized oil into the lymphatic system. Congenital atresia of the thoracic duct was demonstrated on the lymphangiogram in both patients before treatment. Both patients have shown good short-term outcomes without supplemental oxygen or fat restricted diets at 9 months of age. Ethiodized oil lymphangiography represents a new treatment modality for some patients with CPL.
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Affiliation(s)
- M Gray
- Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - K Z Kovatis
- Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - T Stuart
- Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - E Enlow
- Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - M Itkin
- Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - M S Keller
- Division of Interventional Radiology, Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - H M French
- Division of Neonatology, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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30
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Toru HS, Sanhal CY, Yilmaz GT, Ozbudak IH, Mendilcioglu I, Ozbilim G. Rare congenital pulmonary malformation with diagnostic challenging: congenital pulmonary lymphangiectasia, report of four autopsy cases and review of literature. J Matern Fetal Neonatal Med 2014; 28:1457-60. [PMID: 25142108 DOI: 10.3109/14767058.2014.956719] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Congenital pulmonary lymphangiectasia (CPL) is a rare congenital disorder that typically presents with intractable respiratory failure in the first few days of life. There is an association non-immun hydrops and CPL. In this study we reviewed four CPL cases between January 2006 and January 2014 among 684 fetal-pediatric autopsies. All cases were in the second trimester. In light microscopy there were marked dilatated channels in the subpleural -peribronchial-subseptal region of the lungs. The channels were lined with flattened cells which were expressing CD 31 and D2-40, negative for CD34. Although pulmonary interstitial emphysema (PIE) was considered an important differential diagnosis, a giant cell reaction surrounding the interstitial cystic lesions, a histological hallmark of PIE. CPL is characterized by dilatation of the pulmonary lymphatic vessels and occurs as a congenital anomaly. Noonan classified it into three groups. Primary developmental defect of pulmonary lymphatics is group 3. Group 3 is called also as CPL; normal regression of the connective tissue elements fails to occur after the 16th week of fetal life, associated with an aggressive clinical course, poor prognosis. In fetal autopsy examination CPL should be recognized if there is a fetus with pleural effusion, non-immune hydrops. There is no clinical evidence for CPL.
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Affiliation(s)
- Havva Serap Toru
- a Department of Pathology , School of Medicine, Akdeniz University , Antalya , Turkey and
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31
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Hwang JH, Kim JH, Hwang JJ, Kim KS, Kim SY. Pneumonectomy case in a newborn with congenital pulmonary lymphangiectasia. J Korean Med Sci 2014; 29:609-13. [PMID: 24753713 PMCID: PMC3991809 DOI: 10.3346/jkms.2014.29.4.609] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Accepted: 09/30/2013] [Indexed: 11/20/2022] Open
Abstract
Congenital pulmonary lymphangiectasia (CPL) is a rare lymphatic pulmonary abnormality. CPL with respiratory distress has a poor prognosis, and is frequently fatal in neonates. We report a case of pneumonectomy for CPL in a newborn. An infant girl, born at 39 weeks' after an uncomplicated pregnancy, exhibited respiratory distress 1 hr after birth, which necessitated intubation and aggressive ventilator care. Right pneumonectomy was performed after her symptoms worsened. Histologic examination indicated CPL. She is currently 12 months old and developing normally. Pneumonectomy can be considered for treating respiratory symptoms for improving chances of survival in cases with unilateral CPL.
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Affiliation(s)
- Joon Ho Hwang
- Department of Pediatrics, Eulji University College of Medicine, Daejeon, Korea
| | - Joo Heon Kim
- Department of Thorasic and Cardiovascular Surgery, Eulji University College of Medicine, Daejeon, Korea
| | - Jung Ju Hwang
- Department of Pathology, Eulji University College of Medicine, Daejeon, Korea
| | - Kyu Soon Kim
- Department of Radiology, Eulji University College of Medicine, Daejeon, Korea
| | - Seung Yeon Kim
- Department of Pediatrics, Eulji University College of Medicine, Daejeon, Korea
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Yao LC, Testini C, Tvorogov D, Anisimov A, Vargas SO, Baluk P, Pytowski B, Claesson-Welsh L, Alitalo K, McDonald DM. Pulmonary lymphangiectasia resulting from vascular endothelial growth factor-C overexpression during a critical period. Circ Res 2014; 114:806-22. [PMID: 24429550 DOI: 10.1161/circresaha.114.303119] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
RATIONALE Lymphatic vessels in the respiratory tract normally mature into a functional network during the neonatal period, but under some pathological conditions they can grow as enlarged, dilated sacs that result in the potentially lethal condition of pulmonary lymphangiectasia. OBJECTIVE We sought to determine whether overexpression of the lymphangiogenic growth factor (vascular endothelial growth factor-C [VEGF-C]) can promote lymphatic growth and maturation in the respiratory tract. Unexpectedly, perinatal overexpression of VEGF-C in the respiratory epithelium led to a condition resembling human pulmonary lymphangiectasia, a life-threatening disorder of the newborn characterized by respiratory distress and the presence of widely dilated lymphatics. METHODS AND RESULTS Administration of doxycycline to Clara cell secretory protein-reverse tetracycline-controlled transactivator/tetracycline operator-VEGF-C double-transgenic mice during a critical period from embryonic day 15.5 to postnatal day 14 was accompanied by respiratory distress, chylothorax, pulmonary lymphangiectasia, and high mortality. Enlarged sac-like lymphatics were abundant near major airways, pulmonary vessels, and visceral pleura. Side-by-side comparison revealed morphological features similar to pulmonary lymphangiectasia in humans. The condition was milder in mice given doxycycline after age postnatal day 14 and did not develop after postnatal day 35. Mechanistic studies revealed that VEGF recptor (VEGFR)-3 alone drove lymphatic growth in adult mice, but both VEGFR-2 and VEGFR-3 were required for the development of lymphangiectasia in neonates. VEGFR-2/VEGFR-3 heterodimers were more abundant in the dilated lymphatics, consistent with the involvement of both receptors. Despite the dependence of lymphangiectasia on VEGFR-2 and VEGFR-3, the condition was not reversed by blocking both receptors together or by withdrawing VEGF-C. CONCLUSIONS The findings indicate that VEGF-C overexpression can induce pulmonary lymphangiectasia during a critical period in perinatal development.
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Affiliation(s)
- Li-Chin Yao
- From the Department of Anatomy, Cardiovascular Research Institute, Comprehensive Cancer Center, University of California, San Francisco (L.-C.Y., P.B., D.M.M.); Department of Immunology, Genetics, and Pathology, Rudbeck Laboratory, Uppsala University, Uppsala, Sweden (C.T., L.C.-W.); Wihuri Research Institute and Translational Cancer Biology Program, Biomedicum Helsinki and University of Helsinki, Helsinki, Finland (D.T., A.A., K.A.); Department of Pathology, Boston Children's Hospital, Harvard University, MA (S.O.V.), and Department of Cell Biology, ImClone Systems, Eli Lilly and Company, New York (B.P.)
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Diffuse Lung Disease. PEDIATRIC CHEST IMAGING 2014. [PMCID: PMC7120093 DOI: 10.1007/174_2014_1021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Diffuse lung disease (DLD) comprises a diverse group of disorders characterized by widespread pulmonary parenchymal pathology and impaired gas exchange. While many of these disorders are categorized under the rubric of interstitial lung disease (ILD), some of these disorders involve the airspaces or peripheral airways in addition to, or rather than, the interstitium. Some of these disorders are present primarily in infancy or early childhood, while others that are prevalent in adulthood rarely occur in childhood. This chapter will review the classification of pediatric DLD and the characteristic imaging findings of specific disorders to facilitate accurate diagnosis and guide appropriate treatment of children with these disorders.
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Singh P, Ahmed F. Congenital pulmonary lymphangiectasis resulting in pleural effusions managed by thoracoamniotic shunting. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2013. [DOI: 10.1016/j.epsc.2013.05.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Ruggeri G, Destro F, Maffi M, Gregori G, Lima M. A Rare Case of Chylothorax due to Pulmonary Lymphangiectasia in a 7-Year-Old Boy. European J Pediatr Surg Rep 2013; 1:18-20. [PMID: 25755942 PMCID: PMC4336100 DOI: 10.1055/s-0033-1337111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2012] [Accepted: 11/26/2012] [Indexed: 11/04/2022] Open
Abstract
Pulmonary lymphangiectasia (PL) is a rare condition characterized by dilatation of the lymphatic vessels. Post-neonatal PL is usually associated with pleural effusion and should therefore be suspected in the presence of chylothorax. We describe a post-neonatal manifestation of PL in a 7-year-old boy presenting chylothorax. Radiological examinations included thorax X-ray, ultrasound, and computed tomography scans. After the failure of conservative management (maintenance of the chest tube, total parenteral nutrition, administration of somatostatin synthetic analogues) we performed a thoracoscopic massive ligation of the thoracic duct's collateral along with a lung biopsy. Histology was compatible with type 1 congenital pulmonary lymphangectasia. One month after surgery a thoracoscopic pleurodesis was required for persistent chylothorax. The boy is now doing well 1 year after surgery.
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Affiliation(s)
- Giovanni Ruggeri
- Department of Pediatric Surgery, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Francesca Destro
- Department of Pediatric Surgery, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Michela Maffi
- Department of Pediatric Surgery, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Giulio Gregori
- Department of Pediatric Surgery, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Mario Lima
- Department of Pediatric Surgery, S. Orsola-Malpighi Hospital, Bologna, Italy
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Congenital pulmonary lymphangiectasia: an unusual presentation of nonimmune hydrops in a preterm infant. Adv Neonatal Care 2012; 12:166-71. [PMID: 22668688 DOI: 10.1097/anc.0b013e3182569c61] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Congenital pulmonary lymphangiectasia (CPL) is a rare developmental disorder of the lung. CPL can present antenatally as nonimmune hydrops with pleural effusions, which are frequently associated with polyhydraminos. CPL presents in the neonatal period with severe respiratory distress and can be complicated by chylothorax. Diagnosis is difficult, as radiographic findings are nonspecific. Lung biopsy is indicated in some severe cases to diagnose CPL. The majority of infants with this condition rarely survive the neonatal period and are often diagnosed at autopsy. The final diagnosis is confirmed histologically by lung biopsy or at postmortem. We report a rare case of CPL in a preterm female infant presenting with severe nonimmune Hydrops fetalis who survived the neonatal period, and report clinical follow-up to early childhood.
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Nouri-Merchaoui S, Mahdhaoui N, Yacoubi MT, Seboui H. [Congenital pulmonary lymphangiectasis: an unusual cause of respiratory distress in neonates]. Arch Pediatr 2012; 19:408-12. [PMID: 22381667 DOI: 10.1016/j.arcped.2012.01.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2011] [Revised: 09/30/2011] [Accepted: 01/16/2012] [Indexed: 11/25/2022]
Abstract
Congenital pulmonary lymphangiectasis (CPL) is a rare condition in neonates characterized by abnormal dilatation of the lymphatics draining the interstitial and subpleural spaces of the lungs. Diagnosis is difficult in the neonatal period because respiratory features and radiological findings are not specific of the disease. Definitive diagnosis of CPL can be made only by pathologic examinations. We report a case of a male near-term neonate presenting with severe respiratory distress at birth. The initial chest X-ray showed frosted glass-like infiltrates with air bronchogram suggesting a maternofetal infection or respiratory distress syndrome. The infant required mechanical ventilation and chest tube insertion for right then bilateral pneumothorax. The child died 15 days later in spite of optimal high-frequency ventilation, bilateral pneumothorax drainage, and hemodynamic support. Autopsy revealed features consistent with the diagnosis of CPL. Although CPL is very rare, we should be aware that it is a possible cause of severe unexplained respiratory distress in neonates.
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Lesser DJ, Young LR, Hagood JS. Rare Childhood Lung Disorders. KENDIG & CHERNICKÂS DISORDERS OF THE RESPIRATORY TRACT IN CHILDREN 2012:877-885. [DOI: 10.1016/b978-1-4377-1984-0.00060-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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Lee EY, Cleveland RH, Langston C. Interstitial Lung Disease in Infants and Children: New Classification System with Emphasis on Clinical, Imaging, and Pathological Correlation. IMAGING IN PEDIATRIC PULMONOLOGY 2011. [PMCID: PMC7120961 DOI: 10.1007/978-1-4419-5872-3_8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 03/26/2023]
Abstract
Interstitial lung diseases in infants and children comprise a rare heterogeneous group of parenchymal lung disorders, with clinical syndromes characterized by dyspnea, tachypnea, crackles, and hypoxemia. They arise from a wide spectrum of developmental, genetic, inflammatory, infectious, and reactive disorders. In the past, there has been a paucity of information and limited understanding regarding their pathogenesis, natural history, imaging findings, and histopathologic features, which often resulted in enormous diagnostic challenges and confusion. In recent years, there has been a substantial improvement in the understanding of interstitial lung disease in the pediatric patient, due to the development of a structured classification system based on etiology of the lung disease, established pathologic criteria for consistent diagnosis, and improvement of thoracoscopic techniques for lung biopsy. Imaging plays an important role in evaluating interstitial lung diseases in infants and children by confirming and characterizing the disorder, generating differential diagnoses, and providing localization for lung biopsy for pathological diagnosis. In this chapter, the authors present epidemiology, challenges and uncertainties of diagnosis, and amplify a recently developed classification system for interstitial lung disease in infants and children with clinical, imaging, and pathological correlation.
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Children with genetic disorders undergoing open-heart surgery: are they at increased risk for postoperative complications? Pediatr Crit Care Med 2011; 12:539-44. [PMID: 21057364 DOI: 10.1097/pcc.0b013e3181fe4085] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Children with congenital heart disease and genetic disorders may be at increased risk for postoperative mortality and morbidity compared with children with congenital heart disease alone. The aim of the present study was to determine differences in postcardiopulmonary bypass outcome between these two groups. DESIGN Prospective cohort study. SETTING Tertiary university children's hospital. PATIENTS We enrolled 211 infants (<1 yr) who underwent bypass surgery for congenital heart disease. Data on perioperative course were compared between infants with and without genetic disorders. Univariate analysis was followed by regression analysis to control for confounders. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We enrolled 148 infants without and 63 infants with a genetic disorder. The majority of infants with genetic disorders had trisomy 21 (n = 32), six had microdeletion 22q11, and 25 had other genetic disorders. There was no significant difference in mortality between infants with and without genetic disorders. An underlying genetic disorder was an independent risk factor for renal insufficiency (p = .003) and reintubation (p = .02). Trisomy 21 was an independent risk factor for chylothorax (p = .01) and sepsis (p = .05). The length of hospital stay was longer in infants with genetic disorders other than trisomy 21 compared with infants with trisomy 21 (p = .009). CONCLUSIONS Infants with congenital heart disease and genetic disorders are not at increased risk for postoperative mortality. However, a genetic disorder is a risk factor for reintubation and renal insufficiency, whereas infants with trisomy 21 have a higher risk of chylothorax and sepsis. Intensive care providers need to be aware of these differences in morbidity to improve management decisions and parental counseling.
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Guillerman RP. Imaging of Childhood Interstitial Lung Disease. PEDIATRIC ALLERGY IMMUNOLOGY AND PULMONOLOGY 2010; 23:43-68. [PMID: 22332031 DOI: 10.1089/ped.2010.0010] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2010] [Accepted: 03/22/2010] [Indexed: 01/15/2023]
Abstract
The aphorism that children are not little adults certainly applies for the imaging of interstitial lung disease. Acquiring motion-free images of fine pulmonary structures at desired lung volumes is much more difficult in children than in adults. Several forms of interstitial lung disease are unique to children, and some forms of interstitial lung disease encountered in adults rarely, if ever, occur in children. Meticulous attention to imaging technique and specialized knowledge are required to properly perform and interpret chest imaging studies obtained for the evaluation of childhood interstitial lung disease (chILD). This review will address technique recommendations for imaging chILD, the salient imaging findings in various forms of chILD, and the efficacy of imaging in the diagnosis and management of chILD.
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Affiliation(s)
- R Paul Guillerman
- Department of Radiology, Baylor College of Medicine, Singleton Department of Diagnostic Imaging, Texas Children's Hospital , Houston, Texas
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43
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Deterding RR. Infants and Young Children with Children's Interstitial Lung Disease. PEDIATRIC ALLERGY IMMUNOLOGY AND PULMONOLOGY 2010; 23:25-31. [PMID: 22332029 DOI: 10.1089/ped.2010.0011] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2010] [Accepted: 03/24/2010] [Indexed: 11/12/2022]
Abstract
Though interstitial lung disease (ILD) can occur at any age in children, disorders more common in infancy and young children have received increased attention as an important group that is disproportionally affected, linked to lung development and lung injury, and represents disorders not seen in adult ILD. Identifying those children with potential children's ILD (chILD) and establishing a specific chILD diagnosis has evolved and is critical for pediatric pulmonologists, neonatologists, radiologists, and pathologists to recognize. Specific disorders more common in infancy include diffuse developmental disorders, growth abnormalities, pulmonary interstitial glycogenosis, neuroendocrine cell hyperplasia of infancy, and surfactant mutation dysfunction mutations. The presentation, evaluation, treatment, and clinical course are discussed for each of these specific disorders and other categories less common in infants and young children are briefly mentioned. Resources for physicians and families are also reviewed.
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Abstract
OBJECTIVE This review will focus on radiographic description of lymphangiomas, lymphangiohemangiomas, pulmonary lymphangiomatosis, lymphangiectasis, lymphangioleiomyomatosis, lymphatic dysplasia, and traumatic lymphatic injury. CONCLUSION Diseases of the thoracic lymphatic system have a wide variety of unique radiographic manifestations, all of which can be explained by the underlying pathophysiology and relationship to the normal distribution of lymphatics in the chest.
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45
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Cabrera AG, Dyamenahalli U, Gossett J, Prodhan P, Morrow WR, Imamura M, Jaquiss RD, Bhutta AT. Preoperative lymphopenia is a predictor of postoperative adverse outcomes in children with congenital heart disease. J Thorac Cardiovasc Surg 2009; 138:1172-9. [DOI: 10.1016/j.jtcvs.2009.06.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2008] [Revised: 04/03/2009] [Accepted: 06/14/2009] [Indexed: 12/01/2022]
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Mettauer N, Agrawal S, Pierce C, Ashworth M, Petros A. Outcome of children with pulmonary lymphangiectasis. Pediatr Pulmonol 2009; 44:351-7. [PMID: 19330773 DOI: 10.1002/ppul.21008] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Pulmonary lymphangiectasis (PL) is a very rare developmental defect of the lungs, which has previously been reported to have a very poor prognosis. However, recent reports have suggested improved outcomes, possibly as a result of advances in neonatal and pediatric intensive care medicine. We performed a retrospective study on the outcome of children with PL between 1990 and 2008 referred to our tertiary center. Seven patients with histologically proven PL were identified over the 18-year period. Six patients presented in the neonatal period and one patient at 7 months of age, all of them requiring intensive care treatment. Three neonatal patients required extracorporeal membrane oxygenation (ECMO). Six of the seven patients did not survive including all those who received ECMO. Two of the six non-survivors died of other causes than their underlying disease. The only survivor had an antenatal diagnosis of hydrops and required in utero chest drain insertion. Postnatally he was managed with maximal medical treatment for bilateral pleural effusions and persistent pulmonary hypertension. A 7-month follow-up showed this infant to be doing well. In conclusion overall the prognosis of congenital PL remains poor. The one survivor demonstrates that this condition is survivable with aggressive intervention and as current evidence suggests gradual improvement of symptoms may occur over time, and that maximal medical treatment remains warranted.
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Affiliation(s)
- Nicole Mettauer
- Paediatric Intensive Care Unit, Great Ormond Street Hospital for Children NHS Trust, London WC1N 3JH, United Kingdom.
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Abstract
Structural upper and lower airway disorders and parenchymal disorders are uncommon in pediatric practice, but many pediatricians will encounter them and be responsible for the ongoing care of these patients. Pediatricians need to be cognizant of these diagnoses because, even though management of these disorders generally lacks an evidence base, existing principles of good care surrounding accurate diagnosis, classifications of severity, judicious use of investigations, medication, and surgical approaches are essential to good outcomes.
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Kamada N, Mitani Y, Kihira K, Iwao A, Sinoki T, Ikeyama Y, Sawada H, Deguchi T, Takabayashi S, Shimpo H, Komada Y. Images in cardiovascular medicine. Fatal pulmonary lymphangiectasia manifesting after repeated surgeries for intractable chylopericardium and chylothorax in a 20-month-old girl. Circulation 2008; 117:1894-6. [PMID: 18391124 DOI: 10.1161/circulationaha.107.728113] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Naoki Kamada
- Department of Pediatrics, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie Prefecture, 514-8507, Japan
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Abstract
The lymphatic circulation appears to be a vital component in lung biology in health and in disease. Animal models have established the role of the lymphatic circulation in neoplastic and inflammatory diseases of the lung, such as asthma and cancer, and allowed for the understanding of the molecular controls of lymphangiogenesis in normal lung development. Understanding the role of lymphatics in human lung disease appears likely to contribute to the understanding of the pathogenesis of disease and the development of novel therapeutic targets.
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Affiliation(s)
- Souheil El-Chemaly
- Translational Medicine Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bldg. 10, Rm 6D03, MSC 1590, Bethesda, MD 20892-1590, USA
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Abstract
Difficulty breathing is a common presenting complaint for infants in the emergency department (ED). Periodic breathing, respiratory or systemic infection, and congenital heart disease are common diagnoses in this age group. We report the case of a male neonate presenting to the ED on multiple occasions with respiratory distress and recurrent pleural effusions of unique origin. Unlike adult pleural effusions, pediatric effusions are most commonly exudative and of infectious origin. In neonates, acquired chylothorax secondary to surgery or trauma is the most common cause of symptomatic pleural effusions. Congenital chylothorax is a rare entity that has not been presented in the emergency medicine literature. This case illustrates the extremely rare ED presentation of congenital chylothorax and outlines an approach to pediatric pleural effusions.
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