Letter: Bilateral eventration of the diaphragm in a neonate with congenital cytomegalic inclusion disease

Congenital CMV associated with diaphragm dysfunction: a rare cause of tachypnoea

A late preterm infant with intrauterine growth restriction developed respiratory distress, tachypnoea and hypoxia after birth, requiring supplemental oxygen. Chest radiographs demonstrated persistent elevation of the right hemidiaphragm. Chest ultrasound initially demonstrated symmetrical bilateral diaphragm motion, but subsequent ultrasounds showed asymmetrical excursion with weaker movement of the right hemidiaphragm. Placental pathology demonstrated chronic infectious villitis secondary to cytomegalovirus (CMV), and subsequent CMV testing on the infant was positive. The infant was microcephalic and head imaging revealed intracranial calcifications, consistent with congenital CMV infection.CMV is the most common congenital infection and has a wide array of clinical manifestations. This report highlights the rarely described association between congenital CMV infection and respiratory distress due to underlying diaphragm dysfunction. In neonates with respiratory distress and features of congenital CMV infection, clinicians should have a high index of suspicion for diaphragm dysfunction.

Fetal Diaphragmatic Eventration: A Case Report

BACKGROUND

Congenital diaphragmatic eventration (CDE) is a rare congenital malformation that is well described in the pediatric literature. In contrast to congenital diaphragmatic hernia (CDH), there is no physical defect in the diaphragm with CDE. Prenatal differentiation of the two pathologies represents a diagnostic and prognostic challenge.

CASE

A 26-year-old nulliparous woman was evaluated for a fetal thoracic mass. At 22 weeks, detailed morphology ultrasound revealed a multi-cystic structure in the left side of the thorax. Differential diagnosis included cystic congenital adenomatoid pulmonary malformation and CDH. Left diaphragmatic eventration was added to the differential diagnosis when serial ultrasound at 36 weeks showed the left hemidiaphragm as a thin membrane bulging into the fetal chest with the left kidney in a higher position underneath. The male infant was delivered vaginally at 37³ weeks. CT imaging at 2 days of life showed findings consistent with left diaphragmatic eventration with protrusion of small bowel loops and the left kidney underneath. The infant was successfully extubated 3 days later and remained on nasal cannula until discharge on day 17 of life. At 6 months, the infant required operative repair owing to increasing shortness of breath.

CONCLUSION

CDE is a rare and difficult diagnosis to consider prenatally. Probable associated features may aid diagnosis. Additional, larger case series are needed to improve prenatal differentiation of this condition.

Diaphragmatic paralysis: Evaluation in infants with congenital Zika syndrome

BACKGROUND

Paralysis of the diaphragm in newborn infants can lead to recurrent infections and life-threatening respiratory insufficiency. The clinical diagnosis of unilateral diaphragmatic paralysis has been reported in infants with laboratory evidence of congenital Zika virus infection and/or the congenital Zika syndrome (CZS) phenotype but no evaluation of phrenic nerve function has been described. All reported infants have had accompanying arthrogryposis. High infant mortality is reported.

METHODS

The causal mechanism of congenital diaphragmatic paralysis was evaluated in three infants with arthrogryposis as a manifestation of CZS (two of the three infants had laboratory evidence of ZIKV infection shortly after birth; the remaining infant had negative serology for ZIKV when first tested at 7 months of age). Electromyography and phrenic nerve compound muscle action potential (CMAP) were performed in all infants with diaphragmatic paralysis demonstrated on imaging studies.

RESULTS

All infants had evidence of moderate chronic involvement of peripheral motor neurons. Phrenic nerve CMAP was reduced on the side of the diaphragmatic paralysis in two infants and reduced bilaterally in the remaining infant who had primarily anterior involvement of the diaphragm. All three infants had multiple medical complications and one infant died at 18 months of age.

CONCLUSION

Evaluation of three infants with CZS and diaphragmatic paralysis demonstrated phrenic nerve dysfunction. In these and other affected infants, arthrogryposis appears to be a constant co-occurring condition and health problems are significant; both conditions are likely due to involvement of the peripheral nervous system in some infants with CZS.

Diaphragm dysfunction with congenital cytomegalovirus infection

Congenital cytomegalovirus infection can cause a wide variety of symptoms. We report three infants with congenital cytomegalovirus infection presenting with respiratory insufficiency associated with persistent diaphragmatic dysfunction. Congenital cytomegalovirus infection should be considered in the differential diagnosis of neonatal diaphragmatic dysfunction.

Bilateral eventration of the diaphragm with malrotation and unilateral renal agenesis

Bilateral eventration of the diaphragm associated with malrotation of gut and unilateral renal agenesis is a very rare entity. The authors treated a seven mth old male child who presented to them with respiratory distress and gastrointestinal problem. The child was anemic and was in type II respiratory failure. His X-ray chest showed bilateral eventration of diaphragm and ultrasonography abdomen was consistent with left renal agenesis which was confirmed by radionuclide scan. Bilateral plication of the diaphragm done with correction of malrotation which was diagnosed peroperatively. The association of these three anomalies are rare and to be kept in mind whenever treating a patient with bilateral eventration of the diaphragm.

Right-sided diaphragmatic eventration: a rare cause of non-immune hydrops fetalis

We report 2 cases of non-immune hydrops fetalis (NIHF) in which autopsy findings revealed an association with right-sided congenital diaphragmatic eventration (CDE). Both patients born at 30 weeks of gestation presented with severe generalized skin oedema, pleural effusions and ascites. They both died shortly after birth of cardiorespiratory insufficiency due to lung hypoplasia and low output heart failure. The right thoracic cavity was filled with the membranous but intact right diaphragm covering the herniated visceral organs including parts of the liver, small bowel and colon surrounded by voluminous ascites. In similar fashion to the situation seen in congenital diaphragmatic hernia (CDH), the displaced visceral organs led to impaired lung growth resulting in important lung hypoplasia and obstructed venous return. Extravascular liquid accumulation was probably further aggravated by hypoproteinaemia secondary to liver dysfunction resulting from the venous congestion and cardiac failure. In summary, CDE is a rare condition resulting from impaired ingrowth of muscle fibres into the diaphragm during the first trimester. Prenatal differentiation of CDE from CDH is a real challenge. The association of CDE and NIHF has not been previously described.

The place of neuronal migration abnormalities in child neurology

With the development of modern imaging techniques, disturbances of neuronal migration appear to be a major cause of epilepsy, mental retardation and chronic neurological disability in childhood. Sixty-nine cases are presented, including 46 of diffuse migration abnormalities and 23 of localized dysplasia. Patients with diffuse migration disorders presented with mental retardation, gross motor impairment and severe seizure disorders whereas in those with focal anomalies, epilepsy was the chief complaint. Magnetic resonance imaging, although usually diagnostic of migration disorders often does not allow definition of the pathologic type. Some EEG patterns, such as high amplitude fast rhythms or the theta-delta pattern are highly suggestive. Most cases of abnormal migration are sporadic and probably acquired. Some are due to chromosomal anomalies, especially of chromosome 17p where a gene for lissencephaly has been mapped. Familial cases occur with both recessive and possibly dominant inheritance. Epilepsy due to migration abnormalities is often intractable. Resection of dysplastic cortex may be effective for localized disease and callosotomy has been proposed for diffuse anomalies.

Dystrophic myopathy of the diaphragm in a neonate with severe respiratory failure during infectious episodes

In this study a boy is described who showed slight postnatal asphyxia related to isolated dystrophic diaphragmatic musculature. Development was complicated by several periods of bronchopneumonia necessitating artificial respiration each time.

Congenital bilateral eventration of the diaphragm in a pair of male twins

We present a case of congenital bilateral eventration of the diaphragm in a pair of male twins. The case is associated with severe pulmonary hypoplasia. Both infants died in the neonatal period. An exposure to Thiotepa in the first trimester of the pregnancy is a possible etiologic factor.

Bilateral congenital eventration of the diaphragms: successful surgical management

Bilateral congenital eventration of the diaphragms is a relatively rare occurrence, associated with an almost uniform mortality. We recently have had experience with three patients who underwent successful treatment of this anomaly. Each patient presented as a newborn with severe respiratory insufficiency. One had had a sibling who died shortly after birth with a congenital diaphragmatic hernia. One infant had associated respiratory distress syndrome. PA and lateral chest roentgenograms demonstrated the anomaly in each patient. In two, the use of ultrasound clearly demonstrated the presence of attenuated diaphragms and paradoxical motion. Each infant underwent transabdominal bilateral diaphragmatic plication, reinforced with transversus abdominis muscle, within the first 2 weeks of life. Two infants showed prompt improvement in arterial blood gases and were extubated following the operation. The infant with respiratory distress syndrome required a tracheostomy for continued mechanical ventilation. This infant developed a recurrent eventration of the left diaphragm 6 months after the initial operation and has undergone a secondary plication with clinical improvement. Unlike unilateral eventration, bilateral eventration of the diaphragms is associated with persistent and significant respiratory symptoms. Surgical plication should be performed urgently in all of these patients, before chronic pulmonary changes occur.

The presumptive diagnosis of primary cytomegalovirus infection in early pregnancy by means of a radioimmunoassay for specific-IgM antibodies

During a 30 month investigation 3633 women were studied when the booked for antenatal care. Complement fixing antibodies against cytomegalovirus (CMV) were detected in 2078 (57 per cent) of the women and these sera were further tested for the presence of specific IgM antibodies by means of a solid-phase radioimmunoassay. Since specific IgM antibodies have previously been shown to persist for up to four months after primary CMV infection, their presence in a booking serum sample (mean gestation 15 weeks) was taken as presumptive evidence of a first trimester primary CMV infection. From theoretical considerations, 11.6 positive CMV-IgM reactions were predicted in these women and 11 were observed. A highly significant (p less than 0.001) excess of fetal death was seen in the infected women since three pregnancies ended in missed abortion (15 weeks), intrauterine death (29 weeks) and spontaneous abortion (24 weeks) whilst the remaining 8 women gave birth to apparently normal babies. Cord sera were available from 5 of the surviving babies and only one contained specific IgM antibodies, showing that transplacental spread of the maternal infections had not occurred in 4 of the 5 survivors.