Introduction :

1. Recurrent Chylous Ascites and Diamond-Blackfan Anemia in an Infant: A Case Report of Rare Hematologic and Gastrointestinal Entities Presenting Concurrently Ali Ghazi-Askar, MS, MD, Rajeev Nagpal, MD Department of Pediatrics, Advocate Christ Medical Center Hope Children’s Hospital Figure 2 (L). Triphalangeal thumb seen in Diamond-Blackfan anemia. Figure 3 (R), Bone marrow showing dearth of hematopoetic cells in pure red cell aplasia Intervention: Introduction: The use of total parenteral nutrition delivers fats intravenously directly to the blood stream in the form of fatty emulsion of phospholipids which do not utilize the incompetent lacteals for processing of fats. The use of TPN for 6 months allowed the lacteals the time they needed to mature and, being competent by 7 months of age, allowed the patient to resume regular diet and have permanent resolution of his chylous ascites. Diamond-Blackfan anemia has been classified as a gene disorder encoding a defective ribosomal protein. Studies have suggested that this impaired ribosomal biogenesis causes errors in mRNA transcription and affecting rate and start point of salient erythrocyte proteins which causes the genetically programmed anemia of Diamond-Blackfan. In addition, this faulty ribosomal functioning and error in transcription may account for the predilection patients with Diamond-Blackfan anemia have for leukemic transformation in the bone marrow. (Gazda et al). The mechanism of steroid response in Diamond-Blackfan anemia does not involve altering defective ribosome functioning, but rather increasing sensitivity to erythropoietin and thus causing a marked change of gene expression promoting erythroid differentiation (Ebert, et al., Ohene-Abuakwa, et al.). On steroids, 20% of patients go into remission, often after many years of steroids and maintain normal hemoglobin levels without further intervention, 40% of patients with Diamond-Blackfan anemia remain transfusion independent on continuous steroid treatment, the remaining 40% to respond or become irresponsive to steroids and need chronic transfusion therapy (Lipton, et al). In regards to chylous ascites, patient was started on hyperalimentation for 2 weeks after initial diagnosis; during which time patient continued to gain weight. Repeat abdominal ultrasound showed decrease in ascites. On day 29 of life, patient started on Portagen formula for its high MCT content (contains 87% Medium Chain Triglycerides as fat constituent). Over four weeks on Portagen, patient had increased abdominal distention with ultrasound confirming increased ascites. Paracentesis revealed clear and non chylous fluid with triglyceride level of 91 mg/dL. Patient remained stable on Portagen following second paracentesis and until 3 months of age. Repeat upper GI was performed at 3 months of age and read as likely malrotation. Laparotomy was scheduled with liver biopsy. During laparotomy, patient found not to have malrotation. However, his liver was notated to be enlarged and pathologic examination revealed chronic hepatitis with mild periportal fibrosis. All investigations came back negative for infiltrative and hepatic storage disorders including alpha-1 antitrypsin deficiency, hemochromatosis, Wilson’s disease and autoimmune hepatitis which could cause liver fibrosis in our patient. Examination of pertinent laboratory studies showed bilirubin, PT/INR, and albumin, all proteins of liver function, to be in normal range with AST and ALT, enzymes indicative of liver damage, being only slightly elevated at 67 U/L and 84 U/L, respectively.   Considering liver biopsy findings with lab results, it was concluded that the hepatic findings of open biopsy were due to extended hyperalimentation the patient had been on. Consequently, AST and ALT normalized by four months of age when patient had been weaned off hyperalimentation . At four months of age, as Portagen intake increased, the patient’s abdominal distention worsened which prompted another paracentesis. Analysis of 700 cc of milky yellow tinged fluid revealed a triglyceride level of 533mg/dL. In light of recurrent chylous ascites, patient was placed back on daily hyperalimentation . At 7 months of age, after 6 months of total hyperalimentation use, all total parenteral nutrition was discontinued. Patient did well on Portagen until 11 months of age with no re-accumulation of fluid confirmed via abdominal ultrasound. Patient began liberalization of fat intake and started 2% milk by 1 year of age and continued on pediatric general diet with no re-accumulation of abdominal free fluid for the last 10 years. In regards to intervention for anemia, patient was placed on erythrocyte colony stimulating factor which caused a favorable increase in hemoglobin concentration. After definitive diagnosis of Diamond-Blackfan anemia via increased erythrocyte adenosine deaminase activity, patient was placed on steroid therapy. Patients has been having regular follow up with a pediatric hematologist with multiple surveillance bone marrow biopsies since initial diagnosis. All bone marrow aspirates to date show no evidence of malignant transformation. Initially, patient had 7 years of favorable response to steroids with gradual lower doses still maintaining goal hemoglobin of 9 g/dl. However, over the past year our patient has become increasingly steroid resistant with increasing steroid doses needed to maintain goal hemoglobin levels. . Chylous Ascities is a rare entity characterized by the presence of chyle (a mixture of fat and lymph fluid) in the abdominal cavity. Lymphatic dysregulation leading to chylous ascites is generally attributed to trauma, obstruction, or lymphatic dysfunction. Predominantly, cases of chylous ascites seen in the first weeks to month of life are deemed to be congenital or due to immature or “leaky lymphatics.” A problem that emerges when initially working up an infant with chylous ascites is eliminating other insidious causes such as malignancy, storage disease leading to hepatitis or fibrosis, and metabolic disorders before turning to immature or hypoplastic lymphatic lacteals as the cause of this fluid build- up. Diamond-Blackfan anemia (DBA) is a congenital erythroid aplasia that usually presents as pallor with macrocytic anemia during infancy. First cited in the literature in 1938 by L.K Diamond and K.D Blackfan, (Diamond) 50% of patients with DBA have short stature and/or various physical anomalies. In the monitoring of lifelong anemia, patients with DBA patients have an increased lifetime risk of developing hematologic and solid malignancies and must be monitored for subsequent transformation. Patient Description: Our patient was born full term via normal spontaneous delivery and went home with mom on day 2 of life. Patient was noted to have mild ascites on prenatal ultrasound . However, on clinical examination after birth, his abdomen was normal and did not appear to be distended. At day 19 of life, the infant was noted to have mild to moderate abdominal distention. He had been otherwise asymptomatic and was feeding appropriately and was gaining weight. No emesis, diarrhea, or jaundice noted. On physical exam, patient was noted to have no dysmorphia; liver was palpable 1 cm below costal margin. Spleen was not enlarged. Chest x-ray was normal with no cardiomegaly. Laboratory evaluation revealed normal hemoglobin (12.8 g/dl) and platelets (394,000 per µL). Serum albumin was 3.0 g/dL and ALT was 33 U/L. Total bilirubin value was 5.5 mg/dL with a conjugated fraction of 1.8 mg/dL. Evaluation by ultrasound confirmed a large amount of echogenic ascites with no hepatoslenomegaly. In exploring an inflammatory cause for ascites, ESR was found to be normal at 1mm/hr. UA showed no evidence of proteinuria to suggest a renal pathology. As the literature has documented metabolic anomalies (Basu, et al) as a source of ascites in the neonatal period, urine amino acids and urine organic acids were sent and showed no abnormality. Obstructive processes such as volvulus or intussusception have been documented to be a cause of ascites, mostly likely due to impaired lymph drainage. (Aalami, et al) As such, upper GI with small bowel follow through was performed to rule out malrotation. The upper GI was read as questionable. CT of the abdomen and pelvis was performed and did not reveal any abdominal abnormalities. Paracentesis was performed and fluid sent for analysis. Cytologic analysis yielded no evidence of lymphoproliferative exudates. However, fluid was noted to be yellow milky in nature and analysis yielded a high level of cholesterol and triglyceride level>1000mg/dl consistent with chylous ascites. At this time, a diagnosis of chylous ascites was made. Having excluded secondary causes for ascites, we made a diagnosis of primary chylous ascites, most likely due to leaking lacteals in the peritoneal surface. Patient was treated with parenteral nutrition in hopes of bypassing the need for high functioning abdominal lymphatic lacteals and allowing time for growth and development of presumed hypoplastic or underdeveloped lacteals. Of clinical interest, during initial investigation of cause of ascites at 2 weeks of age, patient was noted to have increased pallor. CBC drawn revealed normal WBC and platelet count with hemoglobin of 6.0 g/d L with reticulocyte count of 1.9% and MCV of 99 fL. This anemia was treated with a transfusion of packed red blood cells (PRBC) to minimize risks of procedure. Throughout the first year of life patient continued to have anemia with no abnormality of myeloid cells or platelet size or number. Patient was noted to have no noted discordance of height and weight with growth along the 25th percentile for height and 10th percentile for weight throughout the first year of life. No axial or appendicular skeletal anomalies noted on physical examination. Initial bone marrow biopsy showed over decreased cellular elements and decreased number of erythroid precursor cells with no cytogenic or microscopic evidence of malignancy or neoplastic growth. At this point, patient was classified as having erythroid precursor bone marrow failure and consequent anemia of unknown etiology. Considering congenital erythrocyte deficiencies as the most likely cause for isolated red cell aplasia, comprehensive erythrocyte enzyme activity levels were evaluated as was chromosome breakage analysis that might implicate Fanconi anemia. All erythrocyte enzyme activities were within normal range except for adenosine deaminase which was significantly elevated at 3.60 (range: 0.33-0.96), thus leading to diagnosis of Diamond-Blackfan anemia Conclusions: Chylous ascites in the infant period should be examined carefully to eliminate obstruction, malignancy, storage disease leading to hepatitis or fibrosis, and metabolic disorders as potential causes. If deemed that the ascities is due to incompetent lacteals, every effort should be made to reduce the work load on lacteals by using formula high in medium chain triglycerides and using total parenteral nutrition as needed for support. A pure red cell aplasia in the first year of life should be evaluated for malignancy, autoimmune disorder, and congenital bone marrow deficiency. In light of an increased predisposition for leukemic transformation, patients with diagnosed bone marrow aplasias should have regular visits to experienced hematologists that can provide surveillance labs and bone marrow studies. References: Figure 1. Ascites demonstrated as free fluid in the peritoneal cavity. 1. L. K. Diamond, K. D. Blackfan, J. M. Baty: Erythroblastosis fetalis and its association with universal edema of the fetus, icterus gravis neonatorum, and anemia of the newborn. The Journal of Pediatrics, St. Louis, 1932, 1: 269 2. Press OW, Press NO, Kaufman SD. Evaluation and management of chylous ascites. Ann Intern Med 1982;96:358–64. 3. Strumer FC Infantile chylous ascites: review of literature and case report. Am Surg 1965; 31:281-284 4. McKendry JBJ, Lindsay WK, Gerstein MC Congenital defects of the lymphatics in infancy. Pediatrics 1957; 19:21-34 5. Smeltzer DM, Stickler GB, Fleming RE Primary lymphatic dysplasia in children: Chylothorax, chylous ascites and generalized lymphatic dysplasia. Eur J Pediatr 1986;145:286-292 6. Ball, S.E., McGuckin, C.P., Jenkins, G. & Gordon-Smith, E.C. (1996) Diamond–Blackfan anaemia in the UK analysis of 80 cases from a 20-year birth cohort. British Journal of Haematology, 94, 645 – 653 7. Ozenne V, Paradis V, Vullierme MP, et al. Liver tumours in patients with Fanconi anaemia: a report of three cases. Eur J Gastroenterol Hepatol. 2008;20:1036–1039 8. Basu, S, Chandra, P.K., Basu, S . Annals of Tropical Pediatrics: International Child Health . Volume 28, Number 3, September 2008 , pp. 235-239(5)  9. Aalami OO, Allen DB, Organ CH Jr. Chylous ascites: a collective review. Surgery 2000; 128: 761-778 10. Gazda HT, Kho AT, Sanoudou D, et al. Defective ribosomal protein gene expression alters transcription, translation, apoptosis, and oncogenic pathways in Diamond-Blackfan anemia. Stem Cells 2006; 24:2034-2044 11. Ebert BL, Lee MM, Pretz JL, et al. An RNA interference model of RPS 19 deficiency in Diamond-Blackfan anemia recapitulates defective hematopoesis and rescue by dexamethasone: identification of dexamethasone-responsive genes by microarray. Blood 2005; 105;4620-4626 12. Ohene-Abuakwa Y, Orfali KA, Marius C, Ball SE. Two-phase culture in Diamond Blackfan anemia: localization of erythroid defect. Blood 2005; 105:838-846 13. Lipton JM, Atsidaftos E, Zyskind I, Vlachos A. Improving clinical care and elucidating the pathophysiology of Diamond Blackfan anemia: an update from the Diamond Blackfan Anemia Registry. Pediatr Blood Cancer. 2006;46(5):558-64 Uniqueness of Case: Diamond-Blackfan anemia and chylous ascites are both extremely rare diagnoses. For both conditions to exist in one patient, makes this case presentation unique. Indeed, inspection of current literature showed no reported cases of chylous ascites occurring with Diamond-Blackfan anemia. Chylous ascites is an uncommon finding with a reported incidence of approximately one in 20,000 admissions at a large university-based hospital over a 20-yr period (Press). Diamond-Blackfan is a pure red cell aplasia that has an incidence of 4–5 per million live births (Ball) that has never been correlated with gastrointestinal anomalies in the literature. . Implications: Congenital abnormalities of the lymphatic channels are the main cause of chylous ascites in infancy (Smetlzer et al, McKendry et al). In about 50% of case in neonates, no known causes such as trauma, lymphatic obstruction, lymphangiomatosis or atresia of the lymphatic system can be documented. In the case of underdeveloped and immature lymphatic lacteals causing leakage of chyle into the abdominal cavity the term “leaky lymphatic” has been used in the literature (Strummer). Portagen, a formula whose fat content is composed of 87% medium chain triglycerides was used due to the ability of medium chain triglycerides to be absorbed directly across the intestinal villi and into the portal vein, minimizing the transport of lipids to the portal vein via the immature lacteals. However, the remaining 13% of triglycerides in Portagen are long chain triglycerides. These long chain triglycerides do need utilization of lacteals for processing and absorption from the intestine. Possibly it is the persistent need for lacteal use that caused a recurrence of the ascites when on Portagen alone. Methods: Acknowledgements: Literature review conducted via PubMed included search terms of “neonatal chylous ascites,” “neonatal chylous ascites AND anemia,” “chylous ascites AND Diamond-Blackfan anemia,” “liver AND bone marrow failure,” “gastrointestinal AND bone marrow failure.” Results were limited to English language publications. Dr. Ammar Hayani Dr. Sharad Salvi