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Pearce J, Hadcocks L, Mansour S, van Zanten M, Jeffery S, Gordon K, Ostergaard P, Mortimer P, Macallan DC. Profound and selective lymphopaenia in primary lymphatic anomaly patients demonstrates the significance of lymphatic-lymphocyte interactions. Front Immunol 2023; 14:1279077. [PMID: 38022535 PMCID: PMC10656747 DOI: 10.3389/fimmu.2023.1279077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 10/09/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction The lymphatic system has a pivotal role in immune homeostasis. To better understand this, we investigated the impact of Primary Lymphatic Anomalies (PLA) on lymphocyte numbers and phenotype. Methods The study comprised (i) a retrospective cohort: 177 PLA subjects from the National Primary Lymphatic Anomaly Register with clinical and laboratory data, and (ii) a prospective cohort: 28 patients with PLA and 20 healthy controls. Patients were subdivided using established phenotypic diagnostic categories and grouped into simplex (localised tissue involvement only) and systemic (involvement of central lymphatics). Further grouping variables included genital involvement and the likelihood of co-existent intestinal lymphangiectasia. Haematology laboratory parameters were analysed in both cohorts. In the prospective cohort, prospective blood samples were analysed by flow cytometry for markers of proliferation, differentiation, activation, skin-homing, and for regulatory (CD4+Foxp3+) T cells (Treg). Results In patients with PLA, lymphopaenia was frequent (22% of subjects), affected primarily the CD4+ T cell subset, and was more severe in subjects with systemic versus simplex patterns of disease (36% vs 9% for lymphopaenia; 70% vs 33% for CD4+ cells). B cells, NK cells and monocytes were better conserved (except in GATA2 deficiency characterised by monocytopaenia). Genital oedema and likelihood of concomitant intestinal lymphangiectasia independently predicted CD4+ T cell depletion. Analysing CD4+ and CD8+ T cells by differentiation markers revealed disproportionate depletion of naïve cells, with a skewing towards a more differentiated effector profile. Systemic PLA conditions were associated with: increased expression of Ki67, indicative of recent cell division, in naïve CD4+, but not CD8+ T cells; increased levels of activation in CD4+, but not CD8+ T cells; and an increased proportion of Treg. Skin-homing marker (CCR10, CLA and CCR4) expression was reduced in some patients with simplex phenotypes. Discussion Patients with PLA who have dysfunctional lymphatics have a selective reduction in circulating lymphocytes which preferentially depletes naïve CD4+ T cells. The presence of systemic disease, genital oedema, and intestinal lymphangiectasia independently predict CD4 lymphopaenia. The association of this depletion with immune activation and increased circulating Tregs suggests lymphatic-lymphocyte interactions and local inflammatory changes are pivotal in driving immunopathology.
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Affiliation(s)
- Julian Pearce
- Lymphovascular Research Unit, Molecular and Clinical Sciences Research Institute, St George’s, University of London, London, United Kingdom
- Dermatology and Lymphovascular Medicine, St George’s University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Linda Hadcocks
- Institute for Infection and Immunity, St George’s, University of London, London, United Kingdom
| | - Sahar Mansour
- Lymphovascular Research Unit, Molecular and Clinical Sciences Research Institute, St George’s, University of London, London, United Kingdom
- Dermatology and Lymphovascular Medicine, St George’s University Hospitals NHS Foundation Trust, London, United Kingdom
- South West Thames Regional Centre for Genomics, St George’s University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Malou van Zanten
- Lymphovascular Research Unit, Molecular and Clinical Sciences Research Institute, St George’s, University of London, London, United Kingdom
| | - Steve Jeffery
- Lymphovascular Research Unit, Molecular and Clinical Sciences Research Institute, St George’s, University of London, London, United Kingdom
| | - Kristiana Gordon
- Dermatology and Lymphovascular Medicine, St George’s University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Pia Ostergaard
- Lymphovascular Research Unit, Molecular and Clinical Sciences Research Institute, St George’s, University of London, London, United Kingdom
| | - Peter Mortimer
- Lymphovascular Research Unit, Molecular and Clinical Sciences Research Institute, St George’s, University of London, London, United Kingdom
- Dermatology and Lymphovascular Medicine, St George’s University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Derek C. Macallan
- Institute for Infection and Immunity, St George’s, University of London, London, United Kingdom
- Infection and Immunity Clinical Academic Group, St George’s University Hospitals NHS Foundation Trust, London, United Kingdom
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Lin L, Liu K, Liu H, Xin J, Sun Y, Xia S, Shen W, Wu J. Small intestinal mucosal abnormalities using video capsule endoscopy in intestinal lymphangiectasia. Orphanet J Rare Dis 2023; 18:308. [PMID: 37784188 PMCID: PMC10544442 DOI: 10.1186/s13023-023-02914-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 09/07/2023] [Indexed: 10/04/2023] Open
Abstract
BACKGROUND Intestinal lymphangiectasia (IL) is a rare protein-losing enteropathy caused by disorders of the intestinal lymphatics. There are only a few case reports and case series concerning the VCE (video capsule endoscopy) findings of IL. This work aimed to evaluate the VCE characteristics of small intestinal mucosal abnormalities in patients with IL, and to investigate the relationship between clinical and VCE characteristics. METHODS Consecutive patients with IL who underwent VCE were enrolled in this retrospective study. The cases were classified into the white villi group and non-white villi group according to mucosal abnormalities detected by VCE. Clinical and endoscopic characteristics were investigated and analyzed. RESULTS A total of 98 patients with IL with a median onset age of 26.3 ± 19.2 years were included. VCE revealed the following small intestinal lesions: (i) white villi type (57/98, 58.2%), i.e.: white-tipped or granular villi, white nodular villi or plaques; (ii) non-white villi type (41/98, 41.8%), i.e.: diffused low and round villi; (iii) complications (46/98, 46.9%), i.e.: bleeding, ulcers, protruding or vesicular-shaped lesions, stenosis and lymphatic leakage. A total of 58.2% (57) and 41.8% (41) of the cases were classified into the white villi and non-white villi groups respectively. The percentage of chylothorax in the white villi group was significantly lower than that in the non-white villi group (12/57 vs. 19/41, p = 0.008). In VCE, there were no significant differences in the involved segments and total detected rate of complications between the white villi and non-white villi groups (p > 0.05), while the detected rate of lymphatic leakage in the white villi group was significantly higher than that in the non-white villi group (31.6% vs. 12.2%, p = 0.026). CONCLUSIONS Our study evaluated the entire small intestinal mucosal abnormalities of IL by VCE, especially endoscopic complications. IL has specific VCE abnormalities in addition to classical endoscopic findings.
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Affiliation(s)
- Lin Lin
- Department of Gastroenterology, Beijing Shijitan Hospital, Capital Medical University, Haidian District, Beijing, China
| | - Kuiliang Liu
- Department of Gastroenterology, Beijing Shijitan Hospital, Capital Medical University, Haidian District, Beijing, China
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Hong Liu
- Department of Gastroenterology, Beijing Shijitan Hospital, Capital Medical University, Haidian District, Beijing, China
| | - Jianfeng Xin
- Department of Lymphatic Surgery, Beijing Shijitan Hospital, Capital Medical University, Haidian District, Beijing, China
- Clinical Center for Lymphatic Disorders, Capital Medical University, Beijing, China
| | - Yuguang Sun
- Department of Lymphatic Surgery, Beijing Shijitan Hospital, Capital Medical University, Haidian District, Beijing, China
- Clinical Center for Lymphatic Disorders, Capital Medical University, Beijing, China
| | - Song Xia
- Department of Lymphatic Surgery, Beijing Shijitan Hospital, Capital Medical University, Haidian District, Beijing, China
- Clinical Center for Lymphatic Disorders, Capital Medical University, Beijing, China
| | - Wenbin Shen
- Department of Lymphatic Surgery, Beijing Shijitan Hospital, Capital Medical University, Haidian District, Beijing, China.
- Clinical Center for Lymphatic Disorders, Capital Medical University, Beijing, China.
| | - Jing Wu
- Department of Gastroenterology, Beijing Shijitan Hospital, Capital Medical University, Haidian District, Beijing, China.
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, Beijing, China.
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Canine Intestinal Lymphangiectasia Concomitant with Renal Cell Carcinoma. ACTA VET-BEOGRAD 2021. [DOI: 10.2478/acve-2021-0030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
The etiology of dilation of lymphatic vessels, termed as intestinal lymphangiectasia, remains unknown. In most cases, it occurs secondary to other pathologic conditions such as gastrointestinal neoplasms. However, only a few cases of canine intestinal lymphangiectasia concurrent with non-gastrointestinal neoplasms have been reported so far. Moreover, the correlation between intestinal lymphangiectasia and non-gastrointestinal neoplasms has not been discussed in any other literature. In this study, we report a rare case of intestinal lymphangiectasia concomitant with renal cell carcinoma in an 11 year old female mixed Maltese, suggesting that non-gastrointestinal neoplasms could be associated with the development of intestinal lymphangiectasia. On gross observation, the small intestine was irregularly swollen presenting an accordion like shape. Microscopic examination revealed prominent dilatation of the lymphatic vessels, especially, within the submucosa and muscularis layer. The lacteals within the villi were dilated and presented “club-shaped” tips. The carcinoma might trigger intestinal lymphangiectasia by compressing the main lymphatic vessels or the cisterna chyli, subsequently increasing the pressure of the lymphatic vessels in the gastrointestinal tract. Moreover, metastasis of the carcinoma to the gastrointestinal tract could induce intestinal lymphangiectasia. Thus, the occurrence of intestinal lymphangiectasia must be considered when an abdominal neoplasm is located around major lymphatic vessels.
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Huber R, Semmler G, Mayr A, Offner F, Datz C. Primary intestinal lymphangiectasia in an adult patient: A case report and review of literature. World J Gastroenterol 2020; 26:7707-7718. [PMID: 33505146 PMCID: PMC7789053 DOI: 10.3748/wjg.v26.i48.7707] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 11/29/2020] [Accepted: 12/06/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Primary intestinal lymphangiectasia (PIL), first described in 1961, is a rare disorder of unknown etiology resulting in protein-losing enteropathy. The disease is characterized by dilatation and leakage of intestinal lymph vessels leading to hypoalbuminemia, hypogammaglobulinemia, and lymphopenia. Since the severity and location of lymph vessels being affected can vary considerably, the range of associated symptoms is wide from mild lower-limb edema to generalized edema, abdominal and/or pleural effusion, and recurrent diarrhea, among others. Although usually developing in early childhood, we present the case of a 34-year-old woman with PIL. Moreover, we performed a literature review systematically assessing clinical presentation, and provide a practical approach to facilitate diagnosis and therapy of PIL in adults.
CASE SUMMARY Our patient presented with unspecific symptoms of abdominal discomfort, fatigue, nausea, and recurrent edema of the lower limbs. Interestingly, a striking collinearity of clinical symptoms with female hormone status was evident. Additionally, polyglobulia, hypoalbuminemia, hypogammaglobulinemia, and transient lymphocytopenia were evident. Due to suspicion of a bone marrow disease, an extensive diagnostic investigation was carried out excluding secondary causes of polyglobulinemia and hypoalbuminemia. The diagnosis of primary intestinal lymphangiectasia was established after 22 wk by histological analysis of biopsy samples obtained via enteroscopy. Consecutively, the patient was put on a high-protein and low-fat diet with medium-chain triglycerides supplementation leading to significant improvement of clinical symptoms until 2 years of follow-up.
CONCLUSION PIL can be the reason for cryptogenic hypoalbuminemia, hypogammaglobulinemia, and lymphopenia in adulthood. Due to difficulty in correct diagnosis, treatment initiation is often delayed despite being effective and well-tolerated. This leads to a significant disease burden in affected patients. PIL is increasingly been recognized in adults since the majority of case reports were published within the last 10 years, pointing towards an underestimation of the true prevalence. The association with female hormone status warrants further investigation.
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Affiliation(s)
- Rudolf Huber
- Department of Internal Medicine, General Hospital Oberndorf, Teaching Hospital of the Paracelsus Medical University Salzburg, Oberndorf 5110, Austria
| | - Georg Semmler
- Department of Internal Medicine, General Hospital Oberndorf, Teaching Hospital of the Paracelsus Medical University Salzburg, Oberndorf 5110, Austria
| | - Alexander Mayr
- Department of Internal Medicine, General Hospital Oberndorf, Teaching Hospital of the Paracelsus Medical University Salzburg, Oberndorf 5110, Austria
| | - Felix Offner
- Department of Pathology, General Hospital Feldkirch, Feldkirch 6800, Austria
| | - Christian Datz
- Department of Internal Medicine, General Hospital Oberndorf, Teaching Hospital of the Paracelsus Medical University Salzburg, Oberndorf 5110, Austria
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Lopez RN, Day AS. Primary intestinal lymphangiectasia in children: A review. J Paediatr Child Health 2020; 56:1719-1723. [PMID: 32463559 DOI: 10.1111/jpc.14837] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 02/15/2020] [Accepted: 02/17/2020] [Indexed: 02/06/2023]
Abstract
Primary intestinal lymphangiectasia is an uncommon condition that usually presents early in childhood. This incurable condition is consequent to underlying lymphatic abnormalities that lead to loss of lymphatic contents into the intestinal lumen. This article outlines an approach to the assessment of children presenting with characteristic features and consideration of other conditions that could lead to enteric protein loss. An overview of the management of primary intestinal lymphangiectasia is outlined.
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Affiliation(s)
- Robert N Lopez
- Department of Gastroenterology, Hepatology and Liver Transplantation, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Andrew S Day
- Department of Paediatrics, University of Otago, Christchurch, New Zealand.,Department of Paediatrics, Christchurch Hospital, Christchurch, New Zealand
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Cunningham JM, Nepal S, Truesdale AE. Primary intestinal lymphangiectasia diagnosed by video capsule endoscopy in a patient with immunodeficiency presenting with Morganella morganii bacteraemia. BMJ Case Rep 2020; 13:13/9/e235898. [PMID: 32928820 DOI: 10.1136/bcr-2020-235898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 24-year-old woman with a medical history of chronic lower extremity oedema, abdominal pain, diarrhoea and recurrent pulmonary infections presented with sepsis from right lower extremity cellulitis. Blood cultures grew Morganella morganii Laboratory evaluation revealed lymphopaenia, hypogammaglobulinaemia, a low CD4+ T-cell count and nutritional deficiencies resulting from protein-losing enteropathy (PLE). CT showed small bowel wall thickening in the jejunum and ileum. Primary intestinal lymphangiectasia (PIL) was the likely diagnosis that explained her PLE and immunodeficiencies. Video capsule endoscopy is an important diagnostic tool for distal small bowel pathology and confirmed patchy areas of lymphangiectasia of the jejunum and ileum. Secondary causes of lymphangiectasia were ruled out. Clinically significant immunodeficiency from PIL has not been frequently documented, and this case adds to the literature of rare infections associated with PIL. Treatment with intravenous antibiotics resolved her septicaemia, while dietary modifications improved her oedema, abdominal pain and diarrhoea.
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Affiliation(s)
- John M Cunningham
- Internal Medicine, Denver Health and Hospital Authority, Denver, Colorado, USA .,Internal Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Sansrita Nepal
- Internal Medicine, Denver Health and Hospital Authority, Denver, Colorado, USA.,Internal Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Aimee E Truesdale
- Division of Gastroenterology and Hepatology, Denver Health and Hospital Authority, Denver, Colorado, USA.,Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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Gastrointestinal Cryptococcosis Associated with Intestinal Lymphangiectasia. Case Rep Med 2020; 2020:7870154. [PMID: 32373179 PMCID: PMC7191395 DOI: 10.1155/2020/7870154] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 01/19/2020] [Accepted: 03/07/2020] [Indexed: 12/28/2022] Open
Abstract
Intestinal lymphangiectasia is a pathological dilation of enteric lymphatic vessels resulting in lymph leakage to the intestinal lumen. This chronic lymph leakage leads to a state of immunosuppression secondary to the loss of humoral and cellular components of the immune system and represents a potential risk factor for opportunistic infections. We report a case of protein-losing enteropathy in a seemingly immunocompetent patient. An intestinal histopathological study revealed the unusual association of lymphangiectasia and intestinal cryptococcosis. Although cryptococcal infection is common in immunocompromised patients, intestinal involvement is rarely reported. We found no reports on the association of intestinal cryptococcosis in patients with lymphangiectasia. This case report is the first to describe intestinal cryptococcosis associated with intestinal lymphangiectasia.
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Cappell MS, Edhi A, Amin M. Case report of primary intestinal lymphangiectasia diagnosed in an octogenarian by ileal intubation and by push enteroscopy after missed diagnosis by standard colonoscopy and EGD. Medicine (Baltimore) 2018; 97:e9649. [PMID: 29505002 PMCID: PMC5779771 DOI: 10.1097/md.0000000000009649] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
RATIONALE Primary intestinal lymphangiectasia (PIL) is a rare, presumably congenital lesion that is usually diagnosed in patients < 3 years old, is rarely first diagnosed in adulthood, and when first diagnosed in adulthood typically presents with symptoms for many years. Although PIL is often identified by endoscopic abnormalities, it must be emphasized that the jejunoileum/distal duodenum must be intubated for diagnosis because the lesions are present in these regions. This work demonstrates that 1)-PIL can occur in an octogenarian; 2)-shows that the characteristic endoscopic findings are not found at colonoscopy without terminal ileal intubation; and 3)-may be missed at standard EGD without distal duodenal intubation. DIAGNOSES A patient initially presented at age 83 with symptoms of watery diarrhea, abdominal distention, 5-Kg-weight-gain, and weakness for one month, and had typical clinical findings of PIL including chylous ascites, pleural effusions, bilateral pitting leg edema, hypoalbuminemia, borderline lymphopenia, hypovitaminosis-D, and hypocalcemia. Protein-losing-enteropathy was demonstrated by positive stool tests for alpha-1-antitrypsin. Standard colonoscopy revealed no significant lesions, but terminal ileal intubation during colonoscopy demonstrated creamy-white, punctate, mucosal lesions in terminal ileum, characteristic of lymphangiectasia. EGD with intubation to mid-descending duodenum revealed no significant lesions, but subsequent enteroscopy demonstrated lesions in distal duodenum/proximal jejunum similar to those in terminal ileum characteristic of lymphangiectasia. Histopathologic analysis of lesions of terminal ileum/distal duodenum demonstrated dilated mucosal vessels, confirmed as lymphatic vessels by immunohistochemistry. PIL was diagnosed after excluding secondary causes of intestinal lymphangiectasia. INTERVENTIONS/OUTCOMES Patient placed on standard PIL diet: oral supplements of medium-chain triglycerides, a high protein diet, supplements of fat-soluble vitamins, and avoiding long-chain fatty acids, with marked clinical improvement. LESSONS This work shows that: 1)-standard EGD and colonoscopy may miss characteristic lesions of PIL, 2)-enteroscopy or terminal ileal intubation at colonoscopy may be required for the diagnosis because lesions are typically located in distal duodenum/jejunoileum; and 3)-PIL can first present in the very elderly even with symptoms of short duration.
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Affiliation(s)
- Mitchell S. Cappell
- Division of Gastroenterology & Hepatology, Department of Medicine, William Beaumont Hospital
- Division of Gastroenterology & Hepatology, Department of Medicine, Oakland University William Beaumont School of Medicine
| | - Ahmed Edhi
- Division of Gastroenterology & Hepatology, Department of Medicine, William Beaumont Hospital
| | - Mitual Amin
- Department of Pathology, William Beaumont Hospital
- Department of Pathology, Oakland University William Beaumont School of Medicine, Royal Oak, MI, USA
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