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Massive thymic hemorrhage and hemothorax occurring in utero.

Gargano G, Paltrinieri AL, Gallo C, Di Pancrazio L, Roversi MF, Ferrari F - Ital J Pediatr (2015)

Bottom Line: Often it is a diagnosis of exclusion and prognosis is good.Thymic haemorrhage is an unusual condition related to high foetal and neonatal mortality.We report a case of spontaneous massive thymic haemorrhage in a newborn developing at birth acute respiratory distress associated with severe bilateral haemothorax.

View Article: PubMed Central - PubMed

Affiliation: Department of Obstetric and Pediatric, Neonatal Intensive Care Unit (NICU), Arcispedale S. Maria Nuova, Istituto Tecnologie Avanzate e Modelli Assistenziali in Oncologia-IRCCS, Viale Risorgimento n. 70, 42100, Reggio Emilia, Italy. giancarlo.gargano@asmn.re.it.

ABSTRACT

Background: Thymic enlargement is a common and physiological finding in children and neonates' X-rays, but it is usually asymptomatic. Occasionally it can cause respiratory distress. In most cases the aetiology of this expansion remains unclear and it is diagnosed as a thymic hyperplasia. True thymic hyperplasia is defined as a gland expansion, both in size and weight, while maintaining normal microscopic architecture. Often it is a diagnosis of exclusion and prognosis is good. Thymic haemorrhage is an unusual condition related to high foetal and neonatal mortality.

Case presentation: We report a case of spontaneous massive thymic haemorrhage in a newborn developing at birth acute respiratory distress associated with severe bilateral haemothorax. Thymic enlargement was evident after pleural evacuation and confirmed by radiographic, Computed Tomography (CT) images and Magnetic Resonance Imaging (MRI) sequences. The spontaneous resolution of this enlargement seen with CT scan and MRI sequences suggested a thymic haemorrhage; surgery was not necessary.

Conclusion: Thymic haemorrhage should be considered in newborn infants with pleural effusion, mediastinal space enlargement and Respiratory Distress.

No MeSH data available.


Related in: MedlinePlus

MR-sequences on day 16: thymus occupies the antero-superior mediastinum, with greatly reduced dimensions compared to the previous CT scan. Thymus appears to be homogeneous and with hyperintense signal in T1 as in T2 sequences. This aspect is suggestive of a recent bleeding. (Intera 1,5 T- Philps)
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Fig2: MR-sequences on day 16: thymus occupies the antero-superior mediastinum, with greatly reduced dimensions compared to the previous CT scan. Thymus appears to be homogeneous and with hyperintense signal in T1 as in T2 sequences. This aspect is suggestive of a recent bleeding. (Intera 1,5 T- Philps)

Mentions: In view of this finding, bloods were performed on admission, including a coagulation screening. Severe alteration of coagulation factors (PT 102 s and aPTT>120 s with normal fibrinogen and antithrombin III) and mild anaemia (Hb 10.4 g/dl, Ht 31.7 %, erythrocytes 2.82 x 106/μl, PLT 282.0 x 109/L) were found. A supplementary dose of vitamin K was given (2 mg im in total) together with fresh frozen plasma at 15 mls/kg and red packed cells transfusion at 20 mls/kg. Surgical intervention was not needed. After 24 h the coagulation normalized and so it remained subsequently. On the 2nd day, the newborn was able to breathe unassisted. The radiological control revealed a reduction of the bilateral pleural effusion and an enlargement of the superior mediastinal limbus (Fig. 1). The ultrasound disclosed an enlarged thymus in the antero-superior mediastinal space (6 cm of longitudinal diameter, 3 cm of antero-posterior diameter) with irregular limits and non-homogeneous structure. The chest CT, performed on day four of life, confirmed the presence of an enlarged thymus, mainly developed in the left paramedian zone. The trachea appeared to be dislocated to the right. In non-contrast CT- sequences, the thymus appeared with hyperdensity areas, as from a recent bleeding. The mass still looked non-homogeneous after the contrast enhancement. After nearly 10 days, a chest MRI was performed (Fig. 2). It revealed a thymus of very reduced dimension, with a homogeneous structure and hyperintense signal in both T1 and T2 sequences, compatible with the consequences of a subacute haemorrhage. Signal hyperintensity in T2w moreover than in T1w sequences is due to extracellular methemoglobin concentration caused by erythrocytes lysis, which occurs after about one week of acute bleeding and gradually becomes more intense.Fig. 1


Massive thymic hemorrhage and hemothorax occurring in utero.

Gargano G, Paltrinieri AL, Gallo C, Di Pancrazio L, Roversi MF, Ferrari F - Ital J Pediatr (2015)

MR-sequences on day 16: thymus occupies the antero-superior mediastinum, with greatly reduced dimensions compared to the previous CT scan. Thymus appears to be homogeneous and with hyperintense signal in T1 as in T2 sequences. This aspect is suggestive of a recent bleeding. (Intera 1,5 T- Philps)
© Copyright Policy - OpenAccess
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4644340&req=5

Fig2: MR-sequences on day 16: thymus occupies the antero-superior mediastinum, with greatly reduced dimensions compared to the previous CT scan. Thymus appears to be homogeneous and with hyperintense signal in T1 as in T2 sequences. This aspect is suggestive of a recent bleeding. (Intera 1,5 T- Philps)
Mentions: In view of this finding, bloods were performed on admission, including a coagulation screening. Severe alteration of coagulation factors (PT 102 s and aPTT>120 s with normal fibrinogen and antithrombin III) and mild anaemia (Hb 10.4 g/dl, Ht 31.7 %, erythrocytes 2.82 x 106/μl, PLT 282.0 x 109/L) were found. A supplementary dose of vitamin K was given (2 mg im in total) together with fresh frozen plasma at 15 mls/kg and red packed cells transfusion at 20 mls/kg. Surgical intervention was not needed. After 24 h the coagulation normalized and so it remained subsequently. On the 2nd day, the newborn was able to breathe unassisted. The radiological control revealed a reduction of the bilateral pleural effusion and an enlargement of the superior mediastinal limbus (Fig. 1). The ultrasound disclosed an enlarged thymus in the antero-superior mediastinal space (6 cm of longitudinal diameter, 3 cm of antero-posterior diameter) with irregular limits and non-homogeneous structure. The chest CT, performed on day four of life, confirmed the presence of an enlarged thymus, mainly developed in the left paramedian zone. The trachea appeared to be dislocated to the right. In non-contrast CT- sequences, the thymus appeared with hyperdensity areas, as from a recent bleeding. The mass still looked non-homogeneous after the contrast enhancement. After nearly 10 days, a chest MRI was performed (Fig. 2). It revealed a thymus of very reduced dimension, with a homogeneous structure and hyperintense signal in both T1 and T2 sequences, compatible with the consequences of a subacute haemorrhage. Signal hyperintensity in T2w moreover than in T1w sequences is due to extracellular methemoglobin concentration caused by erythrocytes lysis, which occurs after about one week of acute bleeding and gradually becomes more intense.Fig. 1

Bottom Line: Often it is a diagnosis of exclusion and prognosis is good.Thymic haemorrhage is an unusual condition related to high foetal and neonatal mortality.We report a case of spontaneous massive thymic haemorrhage in a newborn developing at birth acute respiratory distress associated with severe bilateral haemothorax.

View Article: PubMed Central - PubMed

Affiliation: Department of Obstetric and Pediatric, Neonatal Intensive Care Unit (NICU), Arcispedale S. Maria Nuova, Istituto Tecnologie Avanzate e Modelli Assistenziali in Oncologia-IRCCS, Viale Risorgimento n. 70, 42100, Reggio Emilia, Italy. giancarlo.gargano@asmn.re.it.

ABSTRACT

Background: Thymic enlargement is a common and physiological finding in children and neonates' X-rays, but it is usually asymptomatic. Occasionally it can cause respiratory distress. In most cases the aetiology of this expansion remains unclear and it is diagnosed as a thymic hyperplasia. True thymic hyperplasia is defined as a gland expansion, both in size and weight, while maintaining normal microscopic architecture. Often it is a diagnosis of exclusion and prognosis is good. Thymic haemorrhage is an unusual condition related to high foetal and neonatal mortality.

Case presentation: We report a case of spontaneous massive thymic haemorrhage in a newborn developing at birth acute respiratory distress associated with severe bilateral haemothorax. Thymic enlargement was evident after pleural evacuation and confirmed by radiographic, Computed Tomography (CT) images and Magnetic Resonance Imaging (MRI) sequences. The spontaneous resolution of this enlargement seen with CT scan and MRI sequences suggested a thymic haemorrhage; surgery was not necessary.

Conclusion: Thymic haemorrhage should be considered in newborn infants with pleural effusion, mediastinal space enlargement and Respiratory Distress.

No MeSH data available.


Related in: MedlinePlus