blue rubber bleb nevus syndrome: promising response to ... · blue rubber bleb nevus syndrome:...

INDIAN PEDIATRICS 53 VOLUME 54__JANUARY 15, 2017

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Blue Rubber Bleb Nevus Syndrome: Promising Response To SirolimusCANAN AKYUZ, HILAL SUSAM-SEN AND BURCA AYDINFrom Department of Pediatric Oncology, Hacettepe University, Cancer Institute, 06100 Ankara-Turkey.

Background: Blue rubber bleb nevus syndrome is a rare disease involving venousmalformations. Case characteristics: We present a 6-year-old female with the syndrome,and consumptive coagulopathy.Intervention/Outcome: After management with sirolimus,symptoms resolved. Message: Sirolimus may be a valuable option for reducing bleedingcomplications and cosmetic sequelae for the patients with this syndrome.

Keywords: Hemangioma, Treatment, Vascular malformations.

Correspondence to:Dr Burca Aydin,Department of Pediatric Oncology,Hacettepe University, Cancer Institute,06100 [email protected]: January 07, 2016;Initial review: March 07, 2016;Accepted: November 11, 2016.

Blue rubber bleb nevus syndrome is arare disease characterized by venousmalformations on the skin, soft tissue andvisceral organs, predominantly gastro-

intestinal (GI) tract [1]. Skin lesions are multiple softvascular lesions, which may be papular, nodular orpedunculated, and red or deep blue in color [2]. Medicaltreatment with steroids, interferon and octreotide hasbeen reported with some success but in most reportedpatients lesions regrow [3].

Sirolimus is an inhibitor of mammalian target ofrapamycin (mTOR) and has been recently used forvascular anomalies with considerable success [4,5]. Wereport a patient with this syndrome who was unresponsiveto steroids and interferon, and was treated successfullywith sirolimus.

CASE REPORT

A 6-year-old female was admitted to our hospital withmultiple skin lesions and anemia. The lesions appeared atthe age of six months and increased in size and number.Oral steroids were given at a dose of 1 mg/kg/day for fewmonths and sclerotherapy was performed for her largestand painful lesion in the left cervical region without anysuccess. At the age of five she had GI bleeding andcolonoscopy showed multiple vascular ectasias andvenous malformations. She had been transfused manytimes in previous year. On admission, she was pale withwidespread small variable-sized bluish papules and largevascular masses on the face, mouth, trunk, arms, legs andfingers were noted (Fig. 1a). She had pain in her left knee

where the largest vascular lesion was located. Blood testsrevealed hemoglobin 6.1g/dL, white blood cell count8100/mm³, platelets count 77,000/mm³, unconjugatedbilirubin 1.6 mg/dL, fibrinogen 104 mg/dL, and D-dimer>40mg/dL. Acanthocytes and schistocytes were noted onperepheral blood smear. The patient was diagnosed asBlue rubber bleb nevus syndrome with typical clinicalfindings with microangiopathic hemolytic anemia andactive consumptive coagulopathy. She also had mild GIbleeding shown with microscopic blood from rectum andfresh frozen plasma and packed red cell transfusions weregiven. At the end of 11th day, due to no response tomedical treatment for anemia and consumptivecoagulopathy, sirolimus was started orally at a dose of 1,6mg/m2/day. Serum sirolimus level was measured weeklyand dose adjusted to maintain the therapeutic levelbetween 5-12 ng/mL. Sirolimus level was stabilised at thedose of 2mg/m2/day, but during follow-up daily dose hadto be adjusted occasionally. The outcome was assessed bymonitoring the reduction in size and color of the lesions.Improvement was noted at day 7, as the size and numbersof lesions were decreased and hematologic findingsdramatically improved over days and achieved normal(Fig. 1b). On the 15th day of sirolimus, supportivemedications were stopped, her pain resolved and shestarted walking. The drug was well tolerated and no sideeffects were seen. She was treated with sirolimus for 17months. Cutaneous lesions continued to regress duringtherapy, and no further GI bleeding or anemia wasobserved. She has been now off-therapy for 4 monthswithout any microscopic blood in stool and normalhemaglobin levels. Her cutaneous lesions are stable andhave not progressed since cessation of treatment.

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INDIAN PEDIATRICS 54 VOLUME 54__JANUARY 15, 2017

AKYUZ, et al. BLUE RUBBER BLEB NEVUS SYNDROME

DISCUSSION

Blue rubber blub nevus syndrome is heterogeneous inphenotypic expression. The skin lesions arise at birth orearly infancy mostly in limbs, trunk and face and varyfrom bluish black macules or papules to large venousmalformations. The size and number of skin lesions tendto increase with age. Visceral lesions can be seen in anysites in the body, but small intestine is the most commonlyinvolved organ. The lesions are fragile and bleed easily.Occult iron deficiency anemia or massive hemorrhagecan occur. Bleeding occasionally cause plateletentrapment and consumptive coagulopathy, as in ourpatient. Cutaneous lesions usually do not requiretreatment, unless they cause cosmetic or functionalproblems. The treatment of GI lesions depends on theintensity of bleeding. Occult bleeding and anemia mightonly need iron supplementation. Massive GI bleeding isthe most serious complication of vascular lesions [2,6].

No curative therapy is available for Blue rubber blebnevus syndrome. Medical treatment including steroids,propranolol and interferon alpha had been reported withvariable effect [3]. In almost all cases, lesions regrew totheir pretreatment sizes after the treatment was stopped[3]. Our patient demonstrated no response to steroids andinterferon previously, however, after sirolimus, wasstarted Hb level stabilized, GI bleeding decreased, andconsumptive coagulopathy resolved. No side effectincluding hyperlipidemia, mucositis, diarrhea,

neutropenia, headache, peripheral edema or respiratorydistress were observed [4].

Sirolimus has been increasingly used for vascular andlymphatic anomalies and kaposiform hemangioendo-thelioma [3-5]. Hammill, et al. [4] reported 6 cases ofvenous and lymphatic malformations successfully treatedwith Sirolimus. We previously reported another patientwith giant lymphatic malformation in tongue showingnear-total regression after sirolimus [7]. Sirolimus has notyet been demonstrated in clinical trial but is a promisingnew therapy for a condition not previously medicallymanaged well. Sirolimus should be considered as first-line treatment for treating GI and cutaneous vascularmalformations in Blue rubber bleb nevus syndrome.

Contributors: CA: contributed the planning treatment andfollow-ups of the patient, reviewed and revised the manuscript,and approved the final manuscript as submitted; HS: contributedthe follow-ups of the patient, drafted the initial manuscript, andapproved the final manuscript; BA: contributed the planningtreatment and follow-ups of the patient, reviewed and revised themanuscript, and approved the final manuscript as submitted.Funding: None; Competing interest: None stated.

REFERENCES

1. Bean WB. Vascular Spiders and Related Lesions of theSkin. Springfield, IL: Charles C Thomas. 1958:178-85.

2. McKusick VA. Blue rubber bleb nevus (Bean syndrome).In: McKusick VA, ed. Mendelian Inheritance in Man. 11thed. Baltimore: John Hopkins University Press; 1994: 212-3.

3. Yuksekkaya H, Ozbek O, Keser M, Toy H. Blue rubber blebnevus syndrome: successful treatment with sirolimus.Pediatrics. 2012;129:e1080-4.

4. Hammill AM, Wentzel M, Gupta A, Nelson S, LuckyA, Elluru R, et al. Sirolimus for the treatment ofcomplicated vascular anomalies in children. Pediatr BloodCancer. 2011;57:1018-24.

5. Blatt J, Stavas J, Moats-Staats B, Woosley J, Morrell DS.Treatment of childhood kaposiform hemangio-endothelioma with sirolimus. Pediatr Blood Cancer.2010;55:1396-8.

6. Nahm WK, Moise S, Eichenfield LF, Paller AS, NathansonL, Malicki DM, et al. Venous malformations in blue rubberbleb nevus syndrome: variable onset of presentation. J AmAcad Dermatol. 2004;50:101-6.

7. Akyüz C, Ataº E, Varan A. Treatment of a tonguelymphangioma with sirolimus after failure of surgicalresection and propranolol. Pediatr Blood Cancer.2014;61:931-2.

(a) (b)

FIG. 1 Vascular mass on left knee (a); regression of the vascularmass; after eight week of sirolimus treatment (b).




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