Physiological Stimulation of the Synthesis of Preelastic Fibers in the Dermis of a Patient with Fibrosis

Objective. The aim of the present study was to report the physiological stimulation of the synthesis of preelastic fibers in the dermis of a patient with fibrosis. Design. A clinical study was conducted involving the analysis of histological changes in preelastic fibers following treatment for stage II primary lymphedema for the clinical reversal of lymphedema and fibrosis. Setting. University Hospital of the São Jose do Rio Preto of School of Medicine in 2020. Participant was a 67-year-old male patient with late-onset primary lymphedema diagnosed 12 years earlier. Intervention is the lymphatic stimulation using the Godoy method adapted to the treatment of fibrosis. Main outcomes and measures are biopsies before and after treatment. Ten randomly selected histological fields were evaluated using the multipoint morphometric method. The values with this method are relative and expressed as percentages. Statistical analysis was performed with the t-test, considering a 95% significance level. Results. A visible, significant difference in the percentage of preelastic fibers was found between the preintervention and postintervention slides, which were confirmed by the microscopic evaluation and quantification (4.95 ± 0.64% and 14.70 ± 1.06%, respectively). Conclusion. The physiological stimulation of the lymphatic system using a specific method resulted in the clinical reduction of fibrosis, the return of the elasticity of the skin, and the stimulation of the synthesis of preelastic fibers.

Stimulation of Synthesis and Lysis of Extracellular Matrix Proteins in Fibrosis Associated with Lymphedema

Background: Fibrotic diseases pose a problem for overall health due to their chronic, progressive nature; the lack of a cure; and the fact that such conditions are largely refractory to current medical and surgical treatment practices. Objective: The aim of the present study was to report the physiological stimulation of synthesis and lysis of extracellular matrix proteins during the treatment of primary lymphedema. Material and Methods: A clinical trial was conducted involving the analysis of changes in type I and III collagen fibers and elastic fibers as well as the thickness of the epidermis and dermis in 10 histological fields. Samples were taken from the skin before and after intensive treatment using the Godoy Method® and adapted to the treatment of fibrosis in a patient with a clinical diagnosis of lower limb lymphedema. Slides were stained with orcein, hematoxylin and eosin, picrosirius red, and Gomori’s reticulin stains. Weibel’s multipoint method was used for the morphometric evaluation. The data were compared using the t-test with a 95% confidence interval. Results: Significant changes were detected in all aspects of interest (thickness of the epidermis and dermis, type I and III collagen fibers, and elastic fibers). Conclusion: The present findings demonstrate the physiological stimulation of synthesis and lysis of the main components of an extracellular matrix, such as type I and III collagen fibers and elastic fibers, as well as a reduction in the thickness of the epidermis and dermis in cases of fibrosis through adequate stimulation of the lymphatic system.

ABNORMAL LYMPHATIC PHENOTYPE IN A CRISPR MOUSE MODEL OF THE HUMAN LYMPHEDEMA-CAUSING CONNEXIN47 R260C POINT MUTATION

Connexin proteins form gap junctions controlling exchange of ions and small molecules between cells and play an important role in movement of lymph within lymphatic vessels. Connexin47 (CX47) is highly expressed in lymphatic endothelial cells and CX47 missense mutations, i.e., R260C, cosegregate with primary lymphedema in humans. However, studies utilizing CX47 knockout mice have failed to demonstrate any lymphatic anomalies. To unravel the lymphatic consequences of expressing a mutant CX47 protein, we used CRISPR technology to create a mouse carrying a Cx47 missense mutation (Cx47R259C) equivalent to the human CX47R260C missense mutation associated with human primary lymphedema. Intradermal Evans Blue dye injection identified a 2-fold increase in regional lymph nodes in homozygous Cx47R259C mice compared to wildtype, particularly in the jugular region (4.8 ± 0.4 and 2.0 ± 0.0, respectively, p<0.01). Associated lymphatic channels were increased in Cx47R259C mice and mesenteric lymph reflux occurred in homozygous Cx47R259C mice but not in wildtype. Contractility of superficial cervical lymphatics, assessed by pressure myography, was reduced in homozygous Cx47R259C mice compared to wildtype. In conclusion, our data are the first to demonstrate a role for the Cx47 protein in lymphatic anatomy and function. This phenotype is similar to that found with other valve deficient mouse mutants, e.g., in Foxc2. Of significance, this study is the first to use CRISPR technology to develop a pre-clinical model of primary lymphedema and demonstrates the importance of distinguishing between lack of and presence of mutant protein when developing clinically relevant animal models for translation of pre-clinical findings.

Lymphaticovenous Anastomosis for Age-Related Lymphedema

Introduction: Primary lymphedema is usually caused by intrinsic disruption or genetic damage to the lymphatics but may also be the result of age-related deterioration of the lymphatics. The aims of this study were to determine the characteristics of age-related lymphedema and to assess the effectiveness of lymphaticovenous anastomosis (LVA) in its treatment. Methods: Eighty-six patients with primary lymphedema affecting 150 lower limbs were divided into three groups according to whether the age of onset was younger than 35 years, 35–64 years, or 65 years or older. Indocyanine green (ICG) lymphography was performed, followed by LVA surgery. ICG lymphography images were visually classified according to whether the pattern was linear, low enhancement (LE), distal dermal backflow (dDB), or extended dermal backflow (eDB). The lower extremity lymphedema (LEL) index score was calculated before and after LVA. Lymphatic vessel diameter and detection rates were also recorded. Results: In the ≥65 group, the lymphedema was bilateral in 54 patients and unilateral in 1 patient. There was statistically significant deterioration in the LEL index score with progression from the linear, LE, dDB through to the eDB pattern in the ≥65 group. The lymphatic vessel diameter was significantly greater in the ≥65 group. The rate of improvement was highest in the ≥65 group. Conclusion: Age-related lymphedema was bilateral and deterioration started distally. The lymphatic vessels in patients with age-related lymphedema tended to be ectatic, which is advantageous for LVA and may increase the improvement rate.

Molecular Analysis of The First Reported Hereditary Lymphedema-Distichiasis Case in Bangladesh

BackgroundLymphedema–distichiasis syndrome (LD, OMIM 153400) is a hereditary primary lymphedema with autosomal dominant nature of inheritance and variable expression. LD is characterized by late childhood or pubertal onset of lower limb lymphedema and an aberrant second row of eyelashes (distichiasis) arising from the meibomian glands. Underlying molecular causes include mutations in the FOXC2 gene, which codes for a forkhead transcription factor involved in the development of the lymphatic and vascular system. ResultsIn this study, we report the first case of LD from Bangladesh with classical lymphedema–distichiasis syndrome who carries an eight-base-pair deletion in the FOXC2 -gene. ClinVar accession code for this deletion is RCV000007679.3. Although most other mutations of this gene are unique among different families, literature survey indicates this 8 bp deletion has been reported multiples times in independent studies for families from different geographical regions. ConclusionFOXC2 protein is 501 amino acid long. This deletion of 8 bp (ACGCCGCC) causes frameshift of codons after amino acid number 304. The frameshift creates an altered truncated protein with 154 newly amino acids after codon 304. We assume that these changes in the protein may affect its function contributing to the disease manifestations. Further research may confirm these assumptions.

Parkes Weber Syndrome with Lymphedema Caused by a Somatic KRAS Variant

Parkes Weber syndrome is a vascular malformation overgrowth condition typically involving the legs. Its main features are diffuse arteriovenous fistulas and enlargement of the limb. The condition has been associated with pathogenic germline variants in RASA1 and EPHB4. We report two individuals with Parkes Weber syndrome of the leg and primary lymphedema containing a somatic KRAS variant (NM_004985.5:c.35G>A; p.Gly12Asp). KRAS variants, which cause somatic intracranial and extracranial arteriovenous malformations, also result in Parkes Weber syndrome with lymphatic malformations.

Giant fibroepithelial polyp of vulva with fibroid uterus with primary lymphedema (Meige disease/lymphedema praecox): a rare case report

Fibroepithelial polyps or FSPs develop in the reproductive years of young to middle-aged women. They primarily affect the vagina, and their occurrence in the vulva is less common. Giant FSP are very rare. We present a case of a patient with giant FSP of the vulva with unilateral lymphedema. A forty year old patient presented with history of mild, dull, aching, continuous pain in lower abdomen. After her first delivery, she had developed pruritis over vulva followed by appearance of a growth. A non-tender, mobile warty growth was found on the examination of vulva, and it involved the mons pubis, clitoris and left labia minora and major. Dermatological consultation made a preliminary diagnosis of nevoid growth vulva. Operative findings from exploratory laparotomy confirmed that uterus had enlarged to 28 weeks size. The diagnosis of fibroepithelial polyp was confirmed by histopathological examination. A common pathogenetic background of lymphedematous FSPs is persistent lymph stasis, along with consequent injury of microcirculation and stromal hyperplasia. The role of hormonal factors in the development of these lesions in also supported by the Estrogen and progesterone receptor positivity. The association of FSPs with unilateral lymphedema, as in our patient, is very rare. This case provides some evidence that chronic lymph stasis can lead to microcirculation injury which further lead to stromal hyperplasia.