Diagnosis of neonatal hemochromatosis with MR imaging and duplex Doppler sonography

French retrospective multicentric study of neonatal hemochromatosis: importance of autopsy and autoimmune maternal manifestations

Neonatal hemochromatosis is a rare disease that causes fetal loss and neonatal death in the 1st weeks of life and is one of the most common causes of liver failure in the neonate. The diagnosis is mostly made retrospectively, based on histopathologic features of severe liver fibrosis associated with hepatic and extrahepatic siderosis. Several etiologies may underlie this phenotype, including a recently hypothesized gestational alloimmune disease. Fifty-one cases of liver failure with intrahepatic siderosis in fetuses and neonates were analyzed retrospectively. Maternal and infant data were collected from hospitalization and autopsy reports. All available slides were reviewed independently by 3 pathologists. Immunologic studies were performed on maternal sera collected immediately after delivery. The diagnosis of neonatal haemochromatosis was retained in 33 cases, including 1 case with Down syndrome and 1 case with myofibromas. Liver siderosis was inversely proportional to fibrosis progression. In fetuses, iron storage was more frequent in the thyroid than in the pancreas. Perls staining in labial salivary glands was positive in 1 of 5 cases. Abnormal low signal intensity by magnetic resonance imaging was detected in the pancreas in 2 of 7 cases. Renal tubular dysgenesis was observed in 7 of 23 autopsy cases. Chronic villitis was seen in 7 of 15 placentas. Half of the mothers presented with an autoimmune background and/or autoantibodies in their sera. Our work highlights the importance of autopsy in cases of neonatal hemochromatosis and marshals additional data in support of the hypothesis that neonatal hemochromatosis could reflect maternal immune system dysregulation.

MR imaging of the abdomen and pelvis in infants, children, and adolescents

Recent developments in magnetic resonance (MR) imaging have profoundly changed the investigation of abdominal and pelvic disease in pediatrics. Motion reduction techniques, such periodically rotated overlapping parallel lines with enhanced reconstruction, or PROPELLER, have resulted in reliable imaging with quiet breathing. Faster imaging sequences minimize artifact and allow for more efficient studies. Diffusion-weighted imaging has become increasingly important in the evaluation of neoplastic disease, depicting disease with increased cellularity and helping to differentiate benign from malignant masses. MR enterography helps visualize intra- and extraluminal bowel pathologic conditions. MR cholangiopancreatography can depict congenital and acquired causes of pancreatic and biliary abnormalities. MR urography is an effective technique for a one-stop-shop evaluation of structural urinary tract abnormality and renal function. Three-dimensional acquisitions allow volumetric display of structures from multiple angles. Specialized techniques allow quantification of iron and fat in the viscera in children with hemolytic anemia and obesity, respectively. This article covers current techniques and strategies to perform and optimize MR imaging of the abdomen and pelvis in infants, children, and adolescents and describes important practical applications.

Neonatal hemochromatosis and patent ductus venosus: clinical course and diagnostic pitfalls

BACKGROUND

Neonatal hemochromatosis is a rare metabolic disorder characterized by excessive iron deposition within the liver leading to hepatic failure and portal hypertension.

OBJECTIVE

We describe the clinical course and imaging findings in three infants with neonatal hemochromatosis associated with patent ductus venosus. We paid special attention to the diagnostic challenges encountered in these patients in order to emphasize some of the potential diagnostic pitfalls.

MATERIALS AND METHODS

We conducted a comprehensive search of our radiology database of the last 10 years (1999-2008) for the keywords "neonatal hemochromatosis." Medical records and imaging studies of various modalities were reviewed.

RESULTS

Three neonates were found to have neonatal hemochromatosis; all of them were associated with patent ductus venosus. Two of these patients were referred to our tertiary center for embolization of an inaccurately diagnosed hepatic vascular malformation. Two patients underwent successful liver transplantation and one died shortly after referral.

CONCLUSION

The awareness and inclusion of neonatal hemochromatosis in the differential diagnosis of newborns with liver failure and patent ductus venosus has critical treatment implications.

Neonatal haemochromatosis associated with gastroschisis

We describe, to our knowledge, the first case of progressive neonatal liver failure due to neonatal haemochromatosis (NH) occurring in an infant with a gastroschisis and review the literature regarding these two conditions. A 1,665 g male infant with antenatally diagnosed gastroschisis was born with a severe coagulopathy, anaemia, thrombocytopenia, hypoglycaemia and jaundice. He developed progressive liver failure, complicated by necrotising enterocolitis. Serum ferritin was elevated at 1,459 microg/L. He died on day 40 and a limited post-mortem examination confirmed significant hepatic siderosis with fibrosis and cholestasis, and siderosis of the pancreas. Although no genetic aetiology for gastroschisis has been identified, an occasional inherited tendency has been observed. There is also evidence to support an autosomal recessive inheritance in NH.

Quantitative ultrasound, magnetic resonance imaging, and histologic image analysis of hepatic iron accumulation in pigeons (Columbia livia)

Iron overload was induced by iron dextran i.v. in clinically healthy adult pigeons, Columbia livia, (n = 8). Hemosiderosis was induced in all treated birds. Two control pigeons received no iron injections. Pigeons did not show clinical signs of iron overload during the 6-wk study. Ultrasound examination of the liver in the pigeons receiving iron dextran was performed on days 0, 13, 28, and 42. No ultrasound images were collected on the control pigeons. Magnetic resonance imaging was performed on days 0, 13, 28, and 42 on all study pigeons and imaging sequences were collected in three different imaging formats: T1, T2, and gradient-recalled echo (GRE). Surgical liver biopsies were performed on pigeons receiving iron dextran on days 2, 16, and 45 (at necropsy). A single liver sample was collected at necropsy from the control birds. Histologic examination, quantitative image analysis, and tissue iron analysis by thin-layer chromatography were performed on each liver sample and compared to the imaging studies. Although hemosiderosis was confirmed histologically in each experimental pigeon, no significant change in pixel intensity of the ultrasound images was seen at any point in the study. Signal intensity, in all magnetic resonance imaging formats, significantly decreased in a linear fashion as the accumulation of iron increased.

Neonatal hemochromatosis: long-term experience with favorable outcome

OBJECTIVE

Neonatal hemochromatosis is a severe, often fatal multiorgan disorder of iron metabolism. Liver transplantation can be curative; the benefit of antioxidant treatment is discussed controversially. We summarize our experience with neonatal hemochromatosis over the past 13 years.

METHODS

A retrospective study was performed of 16 patients with acute liver failure attributable to neonatal hemochromatosis between 1992 and 2004.

RESULTS

Median age at the onset of neonatal hemochromatosis was 2 days (range: 0-21 days). Median weight at the time of diagnosis was 2900 g (range: 1520-4200 g). All patients had elevated ferritin levels (median: 4179 microg/L), and transferrin saturation (median: 99%). Fourteen patients (87.5%) showed significant hepatocyte siderosis in biopsies; 4 children had additional iron deposition in extrahepatic tissue. Four patients were diagnosed by MRI. Seven infants received liver transplants, 5 of them in combination with a preceding antioxidant treatment. Four children (25%) received antioxidants without the necessity of liver transplantation and were in good clinical condition at the time of this evaluation. Five patients (31.3%) died, 3 of them without any treatment because of initial fulminant multiorgan failure. In September 2005, 68.7% of the patients were still alive after a median follow-up of 5 years.

CONCLUSIONS

Neonatal hemochromatosis is a severe metabolic disease, but early antioxidant treatment and liver transplantation in addition to optimal medical care can improve the outcome dramatically. Children with moderate liver failure can survive without liver transplantation, but should be monitored closely for deterioration.

Neonatal hemochromatosis

Neonatal hemochromatosis is a rare gestational condition in which iron accumulates in the fetal tissues in a distribution like that seen in hereditary hemochromatosis. Extensive liver damage is the dominant clinical feature, with late fetal loss or early neonatal death. NH recurs within sibships at a rate higher than that predicted for simple Mendelian autosomal-recessive inheritance, possibly suggesting the role of a maternal factor. Immunomodulation during pregnancy at risk appears to lessen the severity of disease.

The neonatal liver part II: Assessment and diagnosis of liver dysfunction

The liver, the largest organ in the body, performs many essential functions, including the storage and filtration of blood, production of bile, regulation of plasma proteins and glucose, and biotransformation of drugs and toxins. Many neonates display signs of hepatic dysfunction such as hyperbilirubinemia, hepatomegaly, or elevated liver enzymes. Primary liver disease in neonates is rare; much of the liver dysfunction seen in the neonatal period is secondary to systemic illness such as sepsis or hypoxic injury. It is important for the clinician to have the skills and knowledge necessary to distinguish intrinsic liver disease from liver dysfunction resulting from extrahepatic causes. Early intervention to address the cause of dysfunction is critical to successful management of liver disease. This article reviews the assessment of liver function in neonates and examines the techniques used to diagnose liver dysfunction.

Hepatic failure with neonatal tissue siderosis of hemochromatotic type in an infant presenting with meconium ileus. Case report and differential diagnosis of the perinatal iron storage disorders

We report on a female preterm infant with hepatic failure and neonatal tissue siderosis of hemochromatotic type diagnosed by using both histochemistry and atomic absorption spectroscopy. The infant presented with meconium ileus, signs of rapidly progressive hepatic failure, and hyperferritinemia (7132 ng/ml). Despite surgery and intensive care the infant died 32 days after birth. Postmortem examination showed a wrinkled liver with extensive collapse of the hepatic architecture and regenerating nodules as well as hepatic and extrahepatic iron accumulation of hemochromatotic type, sparing the reticuloendothelial system. Atomic absorption spectroscopy confirmed an increase in the iron content of various organs: liver, heart, pancreas, oral salivary gland, kidney, and adrenal gland. The increase in the iron content of various organs was determined by comparing the analysis of the propositus with those of 5 gestationally age-related preterm infants who had died in the intensive care unit: 2 died of meconium aspiration syndrome, the other 3 of hyaline membrane disease, bronchopulmonary dysplasia, and immaturity, respectively. We also compared the analysis of 15 fetuses having a a condition predisposing to iron accumulation (trisomy 21, trisomy 18, cytomegalovirus, amnion infection syndrome, Rhesus- and ABO-incompatibility, congenital hemolysis, anti-phospholipid syndrome, congenital heart disease). Delta F508, the most frequent mutation seen in cystic fibrosis patients, was excluded by gene sequencing. Different noxae causing iron accumulation in the neonatal period have led to the statement that neonatal hemochromatosis may collect different etiologies, such as metabolic disorders, infections, chromosomal aberrations, and immunological disorders. In this study, we report the singular evidence of neonatal iron accumulation of hemochromatotic type in an infant presenting with meconium ileus and propose a classification of the neonatal disorders associated with iron accumulation.

MR imaging of the pediatric liver

Applications of MR imaging of the pediatric abdomen are expanding rapidly. New techniques of MR imaging, such as MRA or MRCP, are becoming commonplace. MR imaging is particularly helpful in the diagnosis and characterization of liver and biliary tree disease in children. Consistent and reproducible quality imaging is achieved with faster imaging sequences tailored to reduce motion artifacts. The lack of radiation, the ability to directly acquire multiple imaging planes, and the superior contrast resolution, particularly with the administration of gadolinium, have contributed to the acceptance of MR imaging as an invaluable tool in the pediatric age group.