Neonatal pulmonary arteriovenous malformation in hereditary haemorrhagic telangiectasia

Asymptomatic pulmonary arteriovenous malformations in children with hereditary hemorrhagic telangiectasia

BACKGROUND

Children with Hereditary Hemorrhagic Telangiectasia (HHT) may have pulmonary arteriovenous malformations (AVMs), which can lead to symptoms of shortness of breath, exercise intolerance, clubbing, cyanosis and hemoptysis. However, some patients with pulmonary AVMs may be asymptomatic, placing them at risk for complications such as stroke or brain abscess if they are not identified and treated. This study examines the incidence of signs and symptoms associated with pulmonary AVMs in children with HHT known to have pulmonary AVMs.

METHOD

Sixty-one children with HHT and documented pulmonary AVMs were questioned for any symptoms possibly associated with their pulmonary AVMs, prior to embolization.

RESULTS

The results show that the majority of these children were asymptomatic (56%), and their AVMs were discovered by routine screening. Those who did experience symptoms most often complained of shortness of breath and exercise intolerance, although there was a tendency to blame other conditions, such as asthma or deconditioning (being out of shape), for these symptoms. Migraine headaches were common in those with pulmonary AVMs, regardless of whether they were symptomatic or not (17 of 61 children, 28%), although they were more common in those who were symptomatic (10 of 27, 37%) versus those who were asymptomatic (7 of 34, 21%).

CONCLUSION

Children with HHT and pulmonary AVMs are often asymptomatic. Routine screening for the presence of AVMs should be performed regardless of symptomatology.

Pulmonary Arteriovenous Malformation Causing Systemic Hypoxemia in Early Infancy

Pulmonary arteriovenous malformation (AVM) is not routinely appreciated during the standard echocardiogram to assess for structural abnormalities or pulmonary hypertension. The distal pulmonary AVM is suspected only if an injection of agitated saline is performed and late entry of particles is appreciated in the left heart structures. A large or complex pulmonary AVM can result in significant right-to-left shunting and consequential systemic hypoxemia in the presence or absence of pulmonary hypertension. For direct visualization of the pulmonary AVM, computerized tomography (CT) scan is the procedure of choice. Here, we present two young infants with systemic hypoxemia who underwent standard medical management including mechanical ventilation and one patient was placed on extracorporeal membrane oxygenation (ECMO) before the diagnosis of pulmonary AVM was established. Subsequently, both patients have done well into mid-term follow-up after being treated successfully using transcatheter occlusion techniques in the cardiac catheterization laboratory during early infancy. We aim to emphasize the importance of a high index of suspicion for pulmonary AVM in infants with refractory systemic hypoxemia of unclear etiology.

Surgical treatment of congenital pulmonary arteriovenous fistula in children

Congenital pulmonary arteriovenous fistulas are rare vascular malformations in which an abnormal connection develops between an artery and a vein in the lung. We report the case of a 5-year-old boy with a history of cyanosis since birth and cough for 2 days. Physical examination revealed cyanosis of oral mucosa and extremities, digital clubbing, and 82% O(2) saturation on room air. Chest radiograph showed a nodule in left lower lobe; echocardiogram was normal, but chest computed tomography showed 2 nodules in left lower lobe. Arteriography showed 2 large arteriovenous fistulas in left lower lobe. Patient underwent left lower lobectomy, and surgical outcome was excellent. At hospital discharge, mucosal color was normal and O(2) saturation was 96% on room air. Congenital pulmonary arteriovenous fistulas should be suspected in children with cyanosis but no cardiac malformations. Symptomatic congenital pulmonary arteriovenous fistulas should be treated with embolization when fistulas are small and multiple, or with lung resection when they are large and localized.

Long-term follow-up in 12 children with pulmonary arteriovenous malformations: confirmation of hereditary hemorrhagic telangiectasia in all cases

OBJECTIVE

To assess whether pulmonary arteriovenous malformation (PAVM) is associated with hereditary hemorrhagic telangiectasia (HHT).

STUDY DESIGN

This study was a review of 12 children (sex ratio = 1) including family history, mutation analysis, and long-term follow-up.

RESULTS

Five children were under age 3 years when PAVM was diagnosed. Presentations included pulmonary symptoms (n = 8), cerebral abscess (n = 2), and transient ischemic attack (TIA) (n = 1); 1 patient was asymptomatic. Nine of the 12 children (75%) had a family history of PAVM. The diagnosis of HHT was confirmed in all cases. A mutation in ENG was found in 9 of the 10 children available for testing. No mutation in ACVRL1 was found. During long-term follow-up (mean, 16 years), the following complications occurred: TIA (n = 2), hemoptysis (n = 2), and cerebral abscess (n = 2). Nine children experienced recurrence of PAVM. The children with no recurrence were those without a family history of PAVM.

CONCLUSIONS

The diagnosis of HHT should be considered in a child with an apparently isolated PAVM. Because serious complications may occur at any age, we recommend screening for PAVM and long-term follow-up in children from families with HHT, especially those with an ENG mutation.

Early neurologic complications of pulmonary arteriovenous malformation in a newborn: an indication for surgical resection

A case report of a neonate with pulmonary arteriovenous malformation is described. The anomaly was prenatally diagnosed, and family history was positive for Rendu-Osler-Weber syndrome. Because neurologic symptoms developed during the second week of life, surgical resection was deemed the best curative option to avoid further embolic events and reoccurrence of the lesion. Previous reports detailing coil embolization therapy for pulmonary arteriovenous malformation are discussed.

Surgical treatment of pulmonary arteriovenous malformation: report of two cases and review of the literature

Pulmonary arteriovenous malformations (PAVMs) are rare anomalies. The degree of right-to-left shunting, which can lead to cyanosis and paradoxical embolism causing neurological complications, determines the prognosis. We report two cases of PAVM and review the literature. A 45-year-old woman with clinical signs and symptoms of PAVM was examined using several different scanning techniques, which showed a large PAVM in the lower lobe of her right lung. A lobectomy was performed, which revealed a 5 cm diameter PAVM with one feeding artery and multiple veins. Intravenous angiography of a 7-year-old girl with symptoms of fatigue and acro-cyanosis confirmed the presence of a large PAVM in her right lower lobe. The PAVM had two major arteries arising from the aorta, which were ligated during a lobectomy. Both patients recovered well following surgery. Although PAVMs are rare, their neurological and haemodynamic consequences may be fatal. Interventional treatment techniques, including surgery, are usually curative.

Telangiectasia hemorrágica hereditaria

Hereditary Hemorrhagic Telangiectasia (HHT) or Rendu-Osler-Weber disease is a genetic disorder with a dominant autosomic transmission. Its prevalence is estimated in one in 5-8,000 individuals. Two different mutations have been described involving endoglin and ALK-1 genes, resulting in HHT type 1 and 2 respectively. It is characterized by the occurrence of spontaneous and recurrent episodes of epistaxis, telangiectasias and the presence of visceral arteriovenous malformations (mainly affecting lungs, liver, brain and digestive tract) which are responsible for the clinical manifestations and constitute a basic point in the diagnostic criteria of Curaçao. The aim of this article is to review the pathogenesis, clinical aspects, screening procedures to disclose the visceral involvement and the therapeutic options of this rare disease.