Congenital Pulmonary Lymphangiectasia: A Disorder not only of Fetoneonates

Abstract

Congenital pulmonary lymphangiectasia (CPL) is a rare developmental disorder of the lung, characterized by dilation of pulmonary subpleural, interlobar, perivascular and peribronchial lymphatics. The incidence of CPL among stillborn and neonates was estimated to be <1%. The etiology of CPL is unknown. However, it has been suspected to be of a genetic background. Recent basic studies revealed that it might be caused by the FOXC2, Vegfr-3 and integrin α9β1gene mutations. A clinical diagnosis of CPL can be made much easier in full-term neonates who present with respiratory distress, pleural (especially chylous) effusions with or without generalized edema. In infancy, the diagnosis seems to be more difficult due to the nonspecific respiratory symptoms like persistent tachypnea, cough and wheeze. Lung biopsy with subsequent histological and immunohistochemical studies is the golden diagnostic method of CPL. Immunohistochemical staining for endothelial cell markers CD31, CD34 and D2-40 confirms lymphatic origin. Therapeutic strategies include supportive, nutritional, investigational, aggressively interventional and surgical regimens, most of which have shown promising outcomes. Although CPL was once regarded as a disorder of very poor prognosis in neonatal onset cases, teenager and adult patients have shown good outcomes upon long-term follow-up.Die angeborene pulmonale Lymphangiektasie (CPL) ist eine seltene Entwicklungsstörung der Lunge, die durch eine Dilatation der pulmonalen subpleuralen, interlobären, perivaskulären und peribronchialen Lymphgefäße charakterisiert ist. Die Inzidenz der CPL bei Totgeburten und Neugeborenen wird <1% geschätzt. Die Ätiologie der CPL ist unbekannt. Allerdings wird ein genetischer Hintergrund vermutet. Neuere Grundlagenstudien zeigten, dass die CPL durch FOXC2, Vegfr-3 und Integrin α9β1-Genmutationen verursacht sein könnte. Die klinische Diagnose der CPL ist sehr viel einfacher in Reifgeborenen zu stellen, die Atemnot, Pleuraergüsse (vor allem chylöse) mit und ohne generalisiertem Ödem aufweisen. In der frühen Kindheit ist die Diagnose aufgrund der unspezifischen respiratorischen Symptomatik wie persistierende Tachypnoen, Husten oder Röcheln schwerer zu stellen. Die Lungenbiopsie mit anschließenden histologischen und immunhistochemischen Untersuchungen ist der Goldstandard für die Diagnose der CPL. Die immunhistochemische Färbung der Endothelzellmarker CD31, CD34 und D2-40 bestätigt den lymphatischen Ursprung. Die Behandlungsstrategien umfassen unterstützende, alimentäre, in Erprobung befindliche, aggressiv-interventionelle und chirurgische Behandlungspläne, von denen die meisten ermutigende Ergebnisse zeigten. Obwohl die CPL einst bei Fällen mit Ausbruch im Neugeborenenalter als Erkrankung mit sehr schlechter Prognose galt, zeigen Teenager und erwachsene Patienten in der Langzeit-Nachbeobachtung gute Verläufe.

Case Report: A Relatively Mild Presentation of Unilateral Congenital Pulmonary Lymphangiectasia

“…Theories involve failed regression of large lymphatic channels which appear between 9 and 16 weeks gestation or bronchomediastinal lymphatic obstruction. Genes involved in lymphangiogenesis, such as vascular endothelial growth factors (VEGF-C, VEGF-D) and their receptors (VEGFR-2, VEGFR-3) have also been implicated (2). There is a well-known association with trisomy 21, Noonan's Syndrome and Turners Syndrome.…”

“…Treatment, therefore, is patient-specific and mostly supportive. Emerging therapies with short-term benefits include lymphatic embolization and sirolimus, a mammalian target of rapamycin (mTOR) inhibitor known to have antiangiogenic properties (2). Lobectomy or pneumonectomy may be considered in severe cases of localized disease.…”

“…Pulmonary lymphangiectasia (PL) is a rare disorder characterized by dilation of lymphatic vessels in the lung. This condition is predominantly seen in infancy and has traditionally carried a poor, and often, fatal prognosis for neonatal-onset cases (1,2). We report a case of unilateral congenital pulmonary lymphangiectasia presenting with relatively mild symptoms.…”

Congenital pulmonary lymphatic duct hypoplasia in a fetus with hydrops fetalis found at delivery: A case report

“…Previous studies reveal that a definite cause of fetal edemacan be attributed in 51%–85% of prenatal cases, among which CPL has the highest mortality rate. Thus all causes of fetal edema should be considered as CPL first before further explorations [ 3 ].…”