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===Proteus syndrome===
===Proteus syndrome===
* Congenital syndrome characterized by asymmetric overgrowth of multiple tissues in limbs, hamartomas and vascular lesions such as capillary malformations, venous malformations, lymphatic malformations. Cerebriform connective tissue nevi, a pathognomonic lesion if present alone, are helpful in diagnosing Proteus syndrome. It may affect multiple organs such as eyes, spleen, liver, thymus, intestine, and lungs, and may cause facial dysmorphia. Some benign and malignant neoplasms such as testicular papillary adenocarcinoma and mesothelioma.<ref name="pmid29166516">{{cite journal |vauthors=Rocha RCC, Estrella MPS, Amaral DMD, Barbosa AM, Abreu MAMM |title=Proteus syndrome |journal=An Bras Dermatol |volume=92 |issue=5 |pages=717–720 |date=2017 |pmid=29166516 |pmc=5674710 |doi=10.1590/abd1806-4841.20174496 |url=}}</ref><ref name="pmid28377973">{{cite journal |vauthors=El-Sobky TA, Elsayed SM, El Mikkawy DM |title=Orthopaedic manifestations of Proteus syndrome in a child with literature update |journal=Bone Rep |volume=3 |issue= |pages=104–108 |date=December 2015 |pmid=28377973 |pmc=5365241 |doi=10.1016/j.bonr.2015.09.004 |url=}}</ref><ref name="pmid24882963">{{cite journal |vauthors=Sarman ZS, Yuksel N, Sarman H, Bayramgurler D |title=Proteus syndrome: report of a case with developmental glaucoma |journal=Korean J Ophthalmol |volume=28 |issue=3 |pages=272–4 |date=June 2014 |pmid=24882963 |pmc=4038735 |doi=10.3341/kjo.2014.28.3.272 |url=}}</ref><ref name="pmid25713623">{{cite journal |vauthors=Popescu MD, Burnei G, Draghici L, Draghici I |title=Proteus Syndrome: a difficult diagnosis and management plan |journal=J Med Life |volume=7 |issue=4 |pages=563–6 |date=2014 |pmid=25713623 |pmc=4316140 |doi= |url=}}</ref>
* Congenital syndrome characterized by asymmetric overgrowth of multiple tissues in limbs, hamartomas and vascular lesions such as capillary malformations, venous malformations, lymphatic malformations. Cerebriform connective tissue nevi, a pathognomonic lesion if present alone, are helpful in diagnosing Proteus syndrome. It may affect multiple organs such as eyes, spleen, liver, thymus, intestine, and lungs, and may cause facial dysmorphia. Some benign and malignant neoplasms such as testicular papillary adenocarcinoma and mesothelioma.<ref name="pmid29166516">{{cite journal |vauthors=Rocha RCC, Estrella MPS, Amaral DMD, Barbosa AM, Abreu MAMM |title=Proteus syndrome |journal=An Bras Dermatol |volume=92 |issue=5 |pages=717–720 |date=2017 |pmid=29166516 |pmc=5674710 |doi=10.1590/abd1806-4841.20174496 |url=}}</ref><ref name="pmid28377973">{{cite journal |vauthors=El-Sobky TA, Elsayed SM, El Mikkawy DM |title=Orthopaedic manifestations of Proteus syndrome in a child with literature update |journal=Bone Rep |volume=3 |issue= |pages=104–108 |date=December 2015 |pmid=28377973 |pmc=5365241 |doi=10.1016/j.bonr.2015.09.004 |url=}}</ref><ref name="pmid24882963">{{cite journal |vauthors=Sarman ZS, Yuksel N, Sarman H, Bayramgurler D |title=Proteus syndrome: report of a case with developmental glaucoma |journal=Korean J Ophthalmol |volume=28 |issue=3 |pages=272–4 |date=June 2014 |pmid=24882963 |pmc=4038735 |doi=10.3341/kjo.2014.28.3.272 |url=}}</ref><ref name="pmid25713623">{{cite journal |vauthors=Popescu MD, Burnei G, Draghici L, Draghici I |title=Proteus Syndrome: a difficult diagnosis and management plan |journal=J Med Life |volume=7 |issue=4 |pages=563–6 |date=2014 |pmid=25713623 |pmc=4316140 |doi= |url=}}</ref>
* Clinical manifestations and findings may include hemihypertrophy, asymmetry of the limbs, scoliosis, subcutaneous tumors, soft tissues tumors such as lipoma, limb abnormalities such as macrodactyly, hyperpigmented lesions on skin, verrucous epidermal nevi, glaucoma, strabismus, nystagmus, pseudopapileudema, cardiac defects such as ARVC, healed myocardial infarctions, cardiomyopathies, cardiac lipomas, and central nervous system findings. These findings may be detected prenatally or at birth but majority of the patients present after 6 months of birth.<ref name="pmid29166516"></ref><ref name="pmid28377973"></ref><ref name="pmid25377688"></ref><ref name="pmid24882963"></ref><ref name="pmid23896365">{{cite journal |vauthors=Trivedi D, Lee SY, Brundler MA, Parulekar MV |title=Fibrous tumor of the superior oblique tendon in Proteus syndrome |journal=J AAPOS |volume=17 |issue=4 |pages=420–2 |date=August 2013 |pmid=23896365 |doi=10.1016/j.jaapos.2013.03.019 |url=}}</ref><ref name="pmid2729359">{{cite journal |vauthors=Mayatepek E, Kurczynski TW, Ruppert ES, Hennessy JR, Brinker RA, French BN |title=Expanding the phenotype of the Proteus syndrome: a severely affected patient with new findings |journal=Am. J. Med. Genet. |volume=32 |issue=3 |pages=402–6 |date=March 1989 |pmid=2729359 |doi=10.1002/ajmg.1320320327 |url=}}</ref>
* Clinical manifestations and findings may include hemihypertrophy, asymmetry of the limbs, scoliosis, subcutaneous tumors, soft tissues tumors such as lipoma, limb abnormalities such as macrodactyly, hyperpigmented lesions on skin, verrucous epidermal nevi, lung diseases, pulmonary embolism, venous thrombosis,  glaucoma, strabismus, nystagmus, pseudopapileudema, cardiac defects such as ARVC, healed myocardial infarctions, cardiomyopathies, cardiac lipomas, and central nervous system findings. These findings may be detected prenatally or at birth but majority of the patients present after 6 months of birth.<ref name="pmid29166516"></ref><ref name="pmid28377973"></ref><ref name="pmid24882963"></ref><ref name="pmid25377688"></ref><ref name="pmid23896365">{{cite journal |vauthors=Trivedi D, Lee SY, Brundler MA, Parulekar MV |title=Fibrous tumor of the superior oblique tendon in Proteus syndrome |journal=J AAPOS |volume=17 |issue=4 |pages=420–2 |date=August 2013 |pmid=23896365 |doi=10.1016/j.jaapos.2013.03.019 |url=}}</ref><ref name="pmid2729359">{{cite journal |vauthors=Mayatepek E, Kurczynski TW, Ruppert ES, Hennessy JR, Brinker RA, French BN |title=Expanding the phenotype of the Proteus syndrome: a severely affected patient with new findings |journal=Am. J. Med. Genet. |volume=32 |issue=3 |pages=402–6 |date=March 1989 |pmid=2729359 |doi=10.1002/ajmg.1320320327 |url=}}</ref>
*
* Somatic mutations in AKT1 gene that encodes proteins functioning in AKT/PI3K signaling pathway has been proposed to be the cause of this syndrome. This pathway functions in cell growth, differentiation and survival.<ref name="pmid25377688"></ref><ref name="pmid22876373">{{cite journal |vauthors=Adam MP, Ardinger HH, Pagon RA, Wallace SE, Bean LJH, Stephens K, Amemiya A, Biesecker LG, Sapp JC |title= |journal= |volume= |issue= |pages= |date= |pmid=22876373 |doi= |url=}}</ref>
* Diagnosis is based on clinical and radiological findings and must meet general and specific criteria. Management consists of clinical and psychological assistance. This may include orthopedic consultation to stop or delay bone growth, physical rehabilitation, surgical correction of deformities such as scoliosis, dermatology consultation fro skin lesions, workup and followup for vein thrombosis and pulmonary embolism (, intervention for developmental delay, and evaluation for associated neoplasms at regular intervals.<ref name="pmid29166516"></ref><ref name="pmid22876373"></ref><ref name="pmid16883308">{{cite journal |vauthors=Biesecker L |title=The challenges of Proteus syndrome: diagnosis and management |journal=Eur. J. Hum. Genet. |volume=14 |issue=11 |pages=1151–7 |date=November 2006 |pmid=16883308 |doi=10.1038/sj.ejhg.5201638 |url=}}</ref>
* To learn more, click here.


==References==
==References==

Revision as of 14:31, 5 October 2018


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Hannan Javed, M.D.[2]

Overview

Vascular Anomalies
Vascular Tumors Vascular Malformations
Benign

Locally aggressive or

Borderline

Malignant

Simple Combined° of major named vessels associated with other anomalies
Capillary malformations

Lymphatic malformations

Venous malformations

Arteriovenous malformations*

Arteriovenous fistula*

Capillary venous malformation , Capillary lymphatic malformation

Lymphatic venous malformation, Capillary lymphatic venous malformation

Capillary arteriovenous malformation

Capillary lymphatic arteriovenous malformation

others

See details See list

° defined as two or more vascular malformations found in one lesion

* high flow lesions

Classification

Classification of Vascular Malformations

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Vascular malformations
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Simple
 
 
 
 
 
 
 
Combined
 
 
 
 
 
 
 
 
 
of major named vessels
 
 
 
 
 
 
 
asscoiated with other anomalies
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Combined vascular malformations*
CM + VMCapillary-venous malformationCVM
CM + LMCapillary-lymphatic malformationCLM
CM + AVMCapillary-arteriovenous malformationCAVM
LM + VMLymphatic-venous malformationLVM
CM + LM + VMCapillary-lymphatic-venous malformationCLVM
CM + LM + AVMCapillary-lymphatic-arteriovenous malformationCLVM
CM + VM + AVMCapillary-venous-arteriovenous malformationCVAVM
CM + LM + VM + AVMCapillary-lymphatic-venous-arteriovenous malformationCLVAVM
 
 
 
 
 
 
 
 
 
Anomalies of major named vessels
(also known as "channel type" or "truncal" vascular malformations)
 
 
 
 
 
 
 
Vascular malformations associated with other anomalies
Klippel-Trenaunay syndromeCM + VM +/-LM + limb overgrowth
Parke's Weber syndromeCM + AVF + limb overgrowth
Servelle-Martorell syndromeLimb VM + bone undergrowth
Sturge-Weber syndromeFacial + leptomeningeal CM + eye anomalies +/-bone and/or soft tissue overgrowth
Maffucci syndromeVM +/-spindle-cell hemangioma + enchondroma
CLOVES syndromeLM + VM + CM +/-AVM+ lipomatous overgrowth
Proteus syndromeCM, VM and/or LM + asymmetrical somatic overgrowth
Bannayan-Riley-Ruvalcaba sdlower lip CM + face and neck LM + asymmetry and partial/generalized overgrowth
Limb CM + congenital non-progressive limb overgrowth
Macrocephaly-CM (M-CM / MCAP)
Microcephaly-CM (MICCAP)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Capillary malformations
 
 
Lymphatic malformations
 
 
Venous malformations
 
 
Arteriovenous malformations
 
 
Arteriovenous fistula
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Nevus simplex / salmon patch, “angel kiss”, “stork bite”
 
 
 
Common (cystic) LM
Macrocystic LM
Microcystic LM
Mixed cystic LM
 
 
 
Common VM
 
 
 
Sporadic
 
 
 
Sporadic
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Cutaneous and/or mucosal CM (also known as “port-wine” stain)
Nonsyndromic CM
CM with CNS and/or ocular anomalies (Sturge-Weber syndrome)
CM with bone and/or soft tissues overgrowth
Diffuse CM with overgrowth (DCMO)
 
 
 
Generalized lymphatic anomaly (GLA)
Kaposiform lymphangiomatosis (KLA)
 
 
 
Familial VM cutaneo-mucosal (VMCM)
 
 
 
In HHT
 
 
 
In HHT
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Reticulate CM
CM of MIC-CAP (microcephaly-capillary malformation)
CM of MCAP (megalencephaly-capillary malformation-polymicrogyria)
 
 
 
LM in Gorham-Stout disease
 
 
 
Blue rubber bleb nevus (Bean) syndrome VM
 
 
 
In CM-AVM
 
 
 
In CM-AVM
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
CM of CM-AVM
 
 
 
Channel type LM
 
 
 
Glomuvenous malformation (GVM)
 
 
 
Others
 
 
 
Others
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Cutis marmorata telangiectatica congenita (CMTC)
 
 
 
“Acquired” progressive lymphatic anomaly (so called acquired progressive "lymphangioma")
 
 
 
Cerebral cavernous malformation (CCM)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Others
 
 
 
Primary lymphedema
 
 
 
Familial intraosseous vascular malformation (VMOS)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Telangiectasia
Hereditary hemorrhagic telangiectasia (HHT)
Others
 
 
 
Others
 
 
 
Verrucous venous malformation (formerly verrucous hemangioma)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Others
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Tables

Anomalies of major named vessels

(also known as "channel type" or "truncal" vascular malformations)

Affect 
  lymphatics
  veins
  arteries

Anomalies of 

  origin
  course
  number
  length
  diameter (aplasia, hypoplasia, stenosis, ectasia / aneurysm)
  valves
  communication (AVF)
  persistence (of embryonal vessel)
Combined vascular malformations*
CM + VM capillary-venous malformation CVM
CM + LM capillary-lymphatic malformation CLM
CM + AVM capillary-arteriovenous malformation CAVM
LM + VM lymphatic-venous malformation LVM
CM + LM + VM capillary-lymphatic-venous malformation CLVM
CM + LM + AVM capillary-lymphatic-arteriovenous malformation CLAVM
CM + VM + AVM capillary-venous-arteriovenous malformation CVAVM
CM + LM + VM + AVM capillary-lymphatic-venous-arteriovenous m. CLVAVM


Vascular malformations associated with other anomalies
Klippel-Trenaunay syndrome * CM + VM +/-LM + limb overgrowth
Parkes Weber syndrome CM + AVF + limb overgrowth
Servelle-Martorell syndrome limb VM + bone undergrowth
Sturge-Weber syndrome facial + leptomeningeal CM + eye anomalies

+/-bone and/or soft tissue overgrowth

Limb CM + congenital non-progressive limb overgrowth
Maffucci syndrome VM +/-spindle-cell hemangioma + enchondroma
Macrocephaly-CM (M-CM / MCAP) *
Microcephaly-CM (MICCAP)
CLOVES syndrome * LM + VM + CM +/-AVM+ lipomatous overgrowth
Proteus syndrome CM, VM and/or LM + asymmetrical somatic overgrowth
Bannayan-Riley-Ruvalcaba sd lower lip CM + face and neck LM + asymmetry and partial/generalized overgrowth

Provisionally unclassified vascular anomalies

Intramuscular hemangioma

  • Characterized by benign proliferation of vascular channels. Majority of lesions occur in subcutaneous adipose tissues, followed by muscles. Thigh and calf are most common sites of occurrence. Majority of the lesions are asymptomatic. Typical clinical presentation includes chronic pain and swelling that both may increase with exercise of affected muscle due to increased blood flow. Other clinical manifestations may include pulsations, discoloration over the lesion, lesion enlargement when in dependent position, increased temperature, muscle contracture, tenderness, and muscle weakness and fatigue.[1][2]
  • Intramuscular hemangiomas may be associated with Kasabach-Merritt syndrome characterized by thrombocytopenia and/or consumptive coagulopathy. This lesion may also lead to functional impairment, congestive cardiac failure due to AV shunting, pressure symptoms, skin necrosis and may also erode bone.[2][3]
  • Etiology and pathophysiology are not clearly defined but majority of the lesions are congenital while a one fifth may be associated with trauma.[1]
  • MRI is the diagnostic study of choice although X-RAY and ultrasound may be used as initial studies. Treatment is generally not indicated for asymptomatic lesions. Management options for symptomatic, complicated and for cosmetic reasons may include laser ablation, systemic corticosteroids, cryotherapy, embolization, radiation, compression sclerotherapy, and surgical excision although surgical excision is usually treatment of choice in majority of the cases.[1][2][3][4][5][6]

Angiokeratoma

  • A muco-cutaneous vascular lesion with wart-like papular appearance characterized by dilated capillaries in the dermis and hyperkeratotis of the overlying epidermis. Clinically it may manifest as solitary or multiple hyperkeratotic papules that may be localized or generalized, most typically on scrotum, thighs, lower extremity, abdomen, trunk, tongue, penis and labia majora. Majority of the lesions are asymptomatic but some may ulcerate and/or bleed.[7][8]
  • It may be classified into following entities:[9]
    • Fordyce’s angiokeratoma (arising on the genitals)
    • Mibelli’s angiokeratoma (dorsum of toes and fingers)
    • Angiokeratoma circumscriptum naeviforme (unilateral large keratotic plaques)
    • Angiokeratoma corporis diffusum (ACD) (generalized lesions between umbilicus and the knee)
  • Angiokeratomas are more prevalent among males as compared to females. Increased venous pressure and radiation therapy have been cited as possible causes. Angiokeratomas have been associated with enzyme deficiencies such as alpha-galactosidase A (Fabry disease), α-fucosidase (fucosidosis), neuraminidase (sialodosis), aspartyl glycosaminase (aspartyl glucosaminuria), β-mannosidase (β- mannosidosis), α-N-acetyl galactosaminidase (Kansaki disease), and β-galactosidase (adult onset GM1 gangliosidosis).[7][8][9][10]
  • The diagnosis is mainly clinical but biopsy may be required. Associated enzyme deficiencies and systemic disorders must be ruled out. Treatment is generally not indicated but if so required then excision, electrocautery, cryotherapy, or laser ablations are the options.[7][10][9][11]

Sinusoidal hemangioma

  • A variant of cavernous hemangioma characterized histopathologically by presence of dilated thin-walled vascular channels, that vary in size, exhibiting nodular proliferation with sinusoidal arrangement. Pseudopapillary structures may also be present. Clinically majority of the lesions manifest in female adults as single, well-defined, painless, subcutaneous nodule with bluish color. Most frequent locations are trunk, extremities and breasts. Painless swelling is the most common patient complaint.[12][13][14]
  • Abnormalities of vasculogenesis and angiogenesis have been proposed as pathogenesis but it is not well-established.[13]
  • Combination of clinical manifestations and histopathological features is used for diagnosis. Surgery (wide excision of tumor) is the treatment of choice if treatment is required.[13][14][15]

Acral arteriovenous "tumour"

  • Congenital or acquired lesion manifesting clinically as asymptomatic mass or may present with pulsatile swelling, headache, localized throbbing pain, tinnitus and bleeding. Histopathologically they are characterized by arterio-venous connection without connecting capillary with or without intracranial component. The lesion derived its name from its acral distribution.[16][17]
  • Etiology can be classified as following: Congenital, traumatic, infection and inflammation and familial.[16][18]
  • Although diagnosis can be made clinically, angiography is the gold standard diagnostic modality to diagnose and define the extent of the lesion. Management regimen may include surgical excision, ligation of the supplying arteries, embolization, and intralesional sclerosing injection.[17][19][20][21][22]

Multifocal lymphangioendotheliomatosis with thrombocytopenia / cutaneovisceral angiomatosis with thrombocytopenia (MLT/CAT)

  • Rare congenital disorder characterized by proliferation of vascular channels in multiple organs associated with thrombocytopenia of variable degree. Lesions may manifest themselves on skin, gastrointestinal tract, lungs, brain, bone, liver, spleen and muscles. Majority of cutaneous lesions present as multiple red to blue papules, plaques, nodules on trunk and extremities. Gastrointestinal bleeding due to multiple hemorrhagic lesions is the cause of mortality in majority of the patients. Similar lesions in brain and lungs may cause severe cerebral edema and pulmonary hemorrhage.[23][24]
  • Disease may manifest without cutaneous involvement or thrombocytopenia. Biopsy typically reveals proliferation of well differentiated vascular channels with intravascular papillary structure and thrombi, sometimes with hobnail appearance of lining endothelial cells.[23][25]
  • Biopsy followed by histopathological and immunohistochemical are required for diagnosis. Management is not well-established and disorder has a poor prognosis with high mortality. Recently sirolimus and bevacizumab have been used to treat this diorder with some success.[23][26][27]

Fibro adipose vascular anomaly (FAVA)

  • Vascular disorder typically manifesting as infiltration of muscles by fibrofatty tissues, atypical venodilation associated with localized pain, and contracture of the affected muscles. Majority of the lesions involve calf muscles and may present as painful mass, contracture of the extremity, and decreased dorsiflexion at ankle joint. Skin is not typically involved. Histological studies demonstrates fibrous and adipose tissue and congregations of venous channels with abnormal lymphatic component.[28][29]
  • Somatic activating mutations in PIK3CA that encodes phosphatidylinositol 3-kinase (PI3K), an enzyme functioning in cell growth, proliferation, differentiation, and survival.[30]
  • Clinical and radiological findings are often sufficient to form the diagnosis. Inconclusive cases my require biopsy. Surgical resection is the often the preferred treatment and is more effective than sclerotherapy, the alternative therapy.[28][29]

Vascular malformations associated with other anomalies

Klippel-Trenaunay syndrome

  • First described by Klippel and Trenaunay in 1900, this congeital syndrome is characterized by presence of capillary malformations, venous malformations, and soft tissues and bone hypertrophy. Lymphatic malformations may or may not be present. Capillary malformations typically present in form of capillary hemangioma and can occur anywhere on the body while venous and lymphatic malformations, and soft tissue and bone hypertrophy usually involves the extremities.[31][32]
  • Clinical manifestations are unilateral in 85% of the cases and may include localized pain and discomfort, leg length discrepancy due to hemihypertrophy, developmental delay, limb abnormalities such as polydactyly, macrodactyly, syndactyly, thrombophlebitis, osteomyelitis, pathological fractures, heart failure, , erysipelas, venous thrombosis due to malformations, pulmonary embolism, gastrointestinal bleeding due to venous overload in the internal iliac vein and ophthalmic abnormalities such as telangiectasia, orbital varix, strabismus, oculosympathetic palsy, Marcus-Gunn pupil, iris coloboma and heterochromia, cataracts, persistent fetal vasculature, varicosities.[31][32][33]
  • Etiology and pathogenesis have not been established yet. Some suggestions include PIK3CA mutations, polygenic inheritance, VG5Q mutation and obstruction of the venous system.[31][33][34]
  • Diagnosis can be made on clinical manifestations and can be confirmed by Doppler ultrasound and magnetic resonance angiography. Management depends on clinical manifestations.[31][33][35]

Parkes Weber syndrome

  • Characterized by a cutaneous flush with underlying multiple micro-AVFs (arteriovenous fistulas), in association with soft tissue and skeletal hypertrophy of the affected limb. Clinical Presentation enlarged arteries and veins, capillary or venous malformations, cutaneous blush, arteriovenous fistulas, and enlargement of limb.
  • Mutation in the RASA1 gene has been found to be associated with this syndrome.
  • To learn more about Parkes Weber syndrome, click here.

Servelle-Martorell syndrome

  • Also called phlebectatic osteohypoplastic angiodysplasia, this rare syndrome is characterized by venous malformations such as abnormal location of vein, partial or complete absence of valves, and/or venous hypoplasia or aplasia and undergrowth of bone. These abnormalities may also be associated with limb hypertrophy and arterial malformations.[36]
  • Clinical manifestations may include cutaneous compressible lesions due to malformations, cellulitis, lesion limb shortening, joint and soft tissue pain and swelling, tortuous limbs, reduced muscle mass, venous thrombosis, consumption coagulopathy, pathological fractures and bone tenderness.[36][37]
  • Combination of clinical and radiological findings is used to form the diagnosis, MRI can assess the involvement and extent of lesions. Treatment is mainly conservative with surgery being used in some cases to excise and/or correct malformations.[36]

Sturge-Weber syndrome

  • Congenital syndrome characterized by capillary malformations involving face and laptomeninges and eye abnormalities. There may also be bone and/or overgrowth.[34]
  • Clinical manifestations may include seizures, port-wine stain on the forehead and upper eyelid of one side of the face, muscle weakness, developmental delays and mental retardation, glaucoma, and buphthalmos.
  • Associated with mutations in GNAQ gene that encodes for members of G protein family.
  • To learn more about Sturge-Weber syndrome, click here.

Maffucci syndrome

  • A rare disorder characterized by presence of venous malformations associated with multiple enchondromas, benign cartilage-forming tumors, and multiple soft tissues hemangiomas and lymphangiomas. These benign tumors have tendency to undergo malignant transformation in maffuci syndrome. People with maffuci syndrome are also at increased risk of developing other malignant tumors such as glioma, glioblastoma, acute myeloid leukemia, intrahepatic cholangiocarcinomas, hepatocellular carcinoma, pancreatic, and breast malignancies. Clinical manifestations depend on the coexixting lesions.[38][39][40]
  • Mutations in isocitrate dehydrogenase 1 (IDH1) and isocitrate dehydrogenase 2 (IDH2), enzymes involved in metabolism of isocitrate and α-ketoglutarate, and TP53, a cell-cycle regulator, have been found in tumors in maffuci syndrome.[39][41][42]
  • Patients should be evaluated to check for malignant transformation. Some recommend CT scans and PET scans at regular intervals.[38][43]
  • To learn more about maffuci syndrome, click here.

CLOVES syndrome

  • CLOVES is an acronym for congenital lipomatous overgrowth, vascular malformations, epidermal nevi, skeletal and spinal anomalies. Vascular malformations in this syndrome include venous, capillary and lymphatic malformations with or without combined arteriovenous malformations. Pulmonary thromboembolism and respiratory failure are the cause of mortality in majority of the patients. Lipomatous and vascular abnormalities are often segmental and asymmetric in distribution and present typically on chest and abdominal wall.[34][44][45]
  • Clinical and imaging findings may include swellings due to lipomatous growths, skin discoloration, port wine stain bilateral epidermal nevi,leg length discrepancy, developmental limb anomalies such as increased gap between the first and second toes, hemorrhage, seizures, ascites, pleural effusions, hypotension, bilateral multicystic venous lymphatic malformations, chest wall venous dilatation, multiple congenital hemangiomas, asymmetric septal hypertrophy, renal hypoplasia, dislocated knees, scoliosis, and neural tube defect.[44][45][46]
  • Activating mutations in PICK3CA gene that encodes part of PI3K has been thought to be associated with this syndrome. These mutations may help enable the cells to grow independent of growth factors.[44][47]
  • This syndrome can be detected prenatally and its manifestations have been identified on prenatal ultrasound and fetal MRI. Treatment options include supportive management, surgical debulking and scletherapy but treatment is often complicated by severity of the disease resulting in anemia, coagulopathy and poor wound healing.[44][46]

Proteus syndrome

  • Congenital syndrome characterized by asymmetric overgrowth of multiple tissues in limbs, hamartomas and vascular lesions such as capillary malformations, venous malformations, lymphatic malformations. Cerebriform connective tissue nevi, a pathognomonic lesion if present alone, are helpful in diagnosing Proteus syndrome. It may affect multiple organs such as eyes, spleen, liver, thymus, intestine, and lungs, and may cause facial dysmorphia. Some benign and malignant neoplasms such as testicular papillary adenocarcinoma and mesothelioma.[48][49][50][51]
  • Clinical manifestations and findings may include hemihypertrophy, asymmetry of the limbs, scoliosis, subcutaneous tumors, soft tissues tumors such as lipoma, limb abnormalities such as macrodactyly, hyperpigmented lesions on skin, verrucous epidermal nevi, lung diseases, pulmonary embolism, venous thrombosis, glaucoma, strabismus, nystagmus, pseudopapileudema, cardiac defects such as ARVC, healed myocardial infarctions, cardiomyopathies, cardiac lipomas, and central nervous system findings. These findings may be detected prenatally or at birth but majority of the patients present after 6 months of birth.[48][49][50][52][53][54]
  • Somatic mutations in AKT1 gene that encodes proteins functioning in AKT/PI3K signaling pathway has been proposed to be the cause of this syndrome. This pathway functions in cell growth, differentiation and survival.[52][55]
  • Diagnosis is based on clinical and radiological findings and must meet general and specific criteria. Management consists of clinical and psychological assistance. This may include orthopedic consultation to stop or delay bone growth, physical rehabilitation, surgical correction of deformities such as scoliosis, dermatology consultation fro skin lesions, workup and followup for vein thrombosis and pulmonary embolism (, intervention for developmental delay, and evaluation for associated neoplasms at regular intervals.[48][55][56]
  • To learn more, click here.

References

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  2. ↑ 2.0 2.1 2.2 Brown RA, Crichton K, Malouf GM (June 2004). "Intramuscular haemangioma of the thigh in a basketball player". Br J Sports Med. 38 (3): 346–8. PMC 1724833. PMID 15155443.
  3. ↑ 3.0 3.1 Patnaik S, Kumar P, Nayak B, Mohapatra N (2016). "Intramuscular Arteriovenous Hemangioma of Thigh: A Case Report and Review of Literature". J Orthop Case Rep. 6 (5): 20–23. doi:10.13107/jocr.2250-0685.612. PMC 5404154. PMID 28507959.
  4. ↑ Tang P, Hornicek FJ, Gebhardt MC, Cates J, Mankin HJ (June 2002). "Surgical treatment of hemangiomas of soft tissue". Clin. Orthop. Relat. Res. (399): 205–10. PMID 12011711.
  5. ↑ Kim DH, Hwang M, Kang YK, Kim IJ, Park YK (June 2007). "Intramuscular hemangioma mimicking myofascial pain syndrome: a case report". J. Korean Med. Sci. 22 (3): 580–2. doi:10.3346/jkms.2007.22.3.580. PMC 2693661. PMID 17596677.
  6. ↑ Babu D, Bhamre R, Katna R, Pai P (September 2014). "Intramuscular haemangioma of the tongue". Ann R Coll Surg Engl. 96 (6): e15–7. doi:10.1308/003588414X13946184903126. PMC 4474220. PMID 25198963.
  7. ↑ 7.0 7.1 7.2 Hussein RS, Kfoury H, Al-Faky YH (2014). "Eyelid angiokeratoma". Middle East Afr J Ophthalmol. 21 (3): 287–8. doi:10.4103/0974-9233.134702. PMC 4123288. PMID 25100920.
  8. ↑ 8.0 8.1 Trickett R, Dowd H (October 2006). "Angiokeratoma of the scrotum: a case of scrotal bleeding". Emerg Med J. 23 (10): e57. doi:10.1136/emj.2006.038745. PMC 2579622. PMID 16988295.
  9. ↑ 9.0 9.1 9.2 Chowdappa V, Narasimha A, Bhat A, Masamatti SS (May 2015). "Solitary Angiokeratoma: Report of Two Uncommon Cases". J Clin Diagn Res. 9 (5): WD01–2. doi:10.7860/JCDR/2015/12163.5946. PMC 4484136. PMID 26155544.
  10. ↑ 10.0 10.1 Rees R, Freeman A, Malone P, Garaffa G, Muneer A, Minhas S (May 2009). "Case study: the surgical management of angiokeratoma resulting from radiotherapy for penile cancer". ScientificWorldJournal. 9: 339–42. doi:10.1100/tsw.2009.23. PMC 5823195. PMID 19468654.
  11. ↑ Jha AK, Sonthalia S, Jakhar D (2018). "Dermoscopy of Angiokeratoma". Indian Dermatol Online J. 9 (2): 141–142. doi:10.4103/idoj.IDOJ_278_17. PMC 5885630. PMID 29644211.
  12. ↑ Song BH, Youn SH, Park EJ, Kwon IH, Kim KH, Kim KJ (October 2011). "A case of sinusoidal hemangioma with lipoma". Ann Dermatol. 23 (Suppl 2): S250–3. doi:10.5021/ad.2011.23.S2.S250. PMC 3229078. PMID 22148063.
  13. ↑ 13.0 13.1 13.2 Ciurea M, Ciurea R, Popa D, Pârvănescu H, Marinescu D, Vrabete M (2011). "Sinusoidal hemangioma of the arm: case report and review of literature". Rom J Morphol Embryol. 52 (3): 915–8. PMID 21892538.
  14. ↑ 14.0 14.1 Konda P, Bavle RM, Makarla S, Muniswamappa S (January 2016). "Intramuscular sinusoidal haemangioma with secondary Masson's phenomenon". BMJ Case Rep. 2016. doi:10.1136/bcr-2013-201457. PMC 4716435. PMID 26729822.
  15. ↑ Salemis NS (February 2017). "Sinusoidal hemangioma of the breast: diagnostic evaluation management and literature review". Gland Surg. 6 (1): 105–109. doi:10.21037/gs.2016.11.06. PMC 5293651. PMID 28210560.
  16. ↑ 16.0 16.1 Gupta R, Kayal A (2014). "Scalp arteriovenous malformations in young". J Pediatr Neurosci. 9 (3): 263–6. doi:10.4103/1817-1745.147587. PMC 4302550. PMID 25624933.
  17. ↑ 17.0 17.1 Özkara E, Özbek Z, Özdemir AÖ, Arslantaş A (2018). "Misdiagnosed Case of Scalp Arteriovenous Malformation". Asian J Neurosurg. 13 (1): 59–61. doi:10.4103/1793-5482.181137. PMC 5820896. PMID 29492122.
  18. ↑ Khodadad G (January 1973). "Arteriovenous malformations of the scalp". Ann. Surg. 177 (1): 79–85. PMC 1355509. PMID 4682507.
  19. ↑ Chowdhury FH, Haque MR, Kawsar KA, Sarker MH, Momtazul Haque AF (January 2013). "Surgical management of scalp arterio-venous malformation and scalp venous malformation: An experience of eleven cases". Indian J Plast Surg. 46 (1): 98–107. doi:10.4103/0970-0358.113723. PMC 3745130. PMID 23960313.
  20. ↑ El Shazly AA, Saoud KM (October 2012). "Results of surgical excision of cirsoid aneurysm of the scalp without preoperative interventions". Asian J Neurosurg. 7 (4): 191–6. doi:10.4103/1793-5482.106651. PMC 3613641. PMID 23559986.
  21. ↑ Kasdon DL, Altemus LR, Stein BM (June 1976). "Embolization of a traumatic arteriovenous fistula of the scalp with radiopaque Gelfoam pledgets. Case report and technical note". J. Neurosurg. 44 (6): 753–6. doi:10.3171/jns.1976.44.6.0753. PMID 1271098.
  22. ↑ Hendrix LE, Meyer GA, Erickson SJ (December 1996). "Cirsoid aneurysm treatment by percutaneous injection of sodium tetradecyl sulfate". Surg Neurol. 46 (6): 557–60, discussion 560–1. PMID 8956889.
  23. ↑ 23.0 23.1 23.2 Droitcourt C, Boccara O, Fraitag S, Favrais G, Dupuy A, Maruani A (August 2015). "Multifocal Lymphangioendotheliomatosis With Thrombocytopenia: Clinical Features and Response to Sirolimus". Pediatrics. 136 (2): e517–22. doi:10.1542/peds.2014-2410. PMID 26148948.
  24. ↑ Uller W, Kozakewich HP, Trenor CC, O'Hare M, Alomari AI (October 2014). "Cutaneovisceral angiomatosis with thrombocytopenia without cutaneous involvement". J. Pediatr. 165 (4): 876–876.e1. doi:10.1016/j.jpeds.2014.06.042. PMID 25088066.
  25. ↑ Zegpi MS, Zavala A, del Puerto C, Cárdenas C, González S (2012). "Newborn with multifocal lymphangioendotheliomatosis with thrombocytopenia". Indian J Dermatol Venereol Leprol. 78 (3): 409. doi:10.4103/0378-6323.95494. PMID 22565464.
  26. ↑ Takahashi H, Nagatoshi Y, Kato M, Koh K, Kishimoto H, Kawai M, Fukuzawa R, Hanada R (March 2012). "Multifocal skin lesions and melena with thrombocytopenia in an infant". J. Pediatr. 160 (3): 524–524.e1. doi:10.1016/j.jpeds.2011.09.034. PMID 22074937.
  27. ↑ Kline RM, Buck LM (April 2009). "Bevacizumab treatment in multifocal lymphangioendotheliomatosis with thrombocytopenia". Pediatr Blood Cancer. 52 (4): 534–6. doi:10.1002/pbc.21860. PMID 19101995.
  28. ↑ 28.0 28.1 Fernandez-Pineda I, Marcilla D, Downey-Carmona FJ, Roldan S, Ortega-Laureano L, Bernabeu-Wittel J (2014). "Lower Extremity Fibro-Adipose Vascular Anomaly (FAVA): A New Case of a Newly Delineated Disorder". Ann Vasc Dis. 7 (3): 316–9. doi:10.3400/avd.cr.14-00049. PMC 4180696. PMID 25298836.
  29. ↑ 29.0 29.1 Alomari AI, Spencer SA, Arnold RW, Chaudry G, Kasser JR, Burrows PE, Govender P, Padua HM, Dillon B, Upton J, Taghinia AH, Fishman SJ, Mulliken JB, Fevurly RD, Greene AK, Landrigan-Ossar M, Paltiel HJ, Trenor CC, Kozakewich HP (January 2014). "Fibro-adipose vascular anomaly: clinical-radiologic-pathologic features of a newly delineated disorder of the extremity". J Pediatr Orthop. 34 (1): 109–17. doi:10.1097/BPO.0b013e3182a1f0b8. PMID 24322574.
  30. ↑ Luks VL, Kamitaki N, Vivero MP, Uller W, Rab R, Bovée JV, Rialon KL, Guevara CJ, Alomari AI, Greene AK, Fishman SJ, Kozakewich HP, Maclellan RA, Mulliken JB, Rahbar R, Spencer SA, Trenor CC, Upton J, Zurakowski D, Perkins JA, Kirsh A, Bennett JT, Dobyns WB, Kurek KC, Warman ML, McCarroll SA, Murillo R (April 2015). "Lymphatic and other vascular malformative/overgrowth disorders are caused by somatic mutations in PIK3CA". J. Pediatr. 166 (4): 1048–54.e1–5. doi:10.1016/j.jpeds.2014.12.069. PMC 4498659. PMID 25681199.
  31. ↑ 31.0 31.1 31.2 31.3 Baba A, Yamazoe S, Okuyama Y, Shimizu K, Kobashi Y, Nozawa Y, Munetomo Y, Mogami T (February 2017). "A rare presentation of Klippel-Trenaunay syndrome with bilateral lower limbs". J Surg Case Rep. 2017 (2): rjx024. doi:10.1093/jscr/rjx024. PMC 5400491. PMID 28458832.
  32. ↑ 32.0 32.1 Tetangco EP, Arshad HM, Silva R (August 2016). "Klippel-Trenaunay Syndrome of the Rectosigmoid Colon Presenting as Severe Anemia". ACG Case Rep J. 3 (4): e161. doi:10.14309/crj.2016.134. PMC 5126491. PMID 27921060.
  33. ↑ 33.0 33.1 33.2 Chagas C, Pires L, Babinski MA, Leite T (2017). "Klippel-Trenaunay and Parkes-Weber syndromes: two case reports". J Vasc Bras. 16 (4): 320–324. doi:10.1590/1677-5449.005417. PMC 5944310. PMID 29930667. Vancouver style error: initials (help)
  34. ↑ 34.0 34.1 34.2 "www.issva.org" (PDF).
  35. ↑ Lei H, Guan X, Han H, Qian X, Zhou X, Zhang X, Tian L (June 2018). "Painless Urethral Bleeding During Penile Erection in an Adult Man With Klippel-Trenaunay Syndrome: A Case Report". Sex Med. 6 (2): 180–183. doi:10.1016/j.esxm.2017.12.001. PMC 5960021. PMID 29452831.
  36. ↑ 36.0 36.1 36.2 Karuppal R, Raman RV, Valsalan BP, Gopakumar T, Kumaran CM, Vasu CK (May 2008). "Servelle-Martorell syndrome with extensive upper limb involvement: a case report". J Med Case Rep. 2: 142. doi:10.1186/1752-1947-2-142. PMC 2394530. PMID 18454870. Vancouver style error: initials (help)
  37. ↑ Weiss T, Mädler U, Oberwittler H, Kahle B, Weiss C, Kübler W (February 2000). "Peripheral vascular malformation (Servelle-Martorell)". Circulation. 101 (7): E82–3. PMID 10683361.
  38. ↑ 38.0 38.1 Prokopchuk O, Andres S, Becker K, Holzapfel K, Hartmann D, Friess H (February 2016). "Maffucci syndrome and neoplasms: a case report and review of the literature". BMC Res Notes. 9: 126. doi:10.1186/s13104-016-1913-x. PMC 4769492. PMID 26920730.
  39. ↑ 39.0 39.1 Moriya K, Kaneko MK, Liu X, Hosaka M, Fujishima F, Sakuma J, Ogasawara S, Watanabe M, Sasahara Y, Kure S, Kato Y (March 2014). "IDH2 and TP53 mutations are correlated with gliomagenesis in a patient with Maffucci syndrome". Cancer Sci. 105 (3): 359–62. doi:10.1111/cas.12337. PMC 4317937. PMID 24344754.
  40. ↑ Verdegaal SH, Bovée JV, Pansuriya TC, Grimer RJ, Ozger H, Jutte PC, San Julian M, Biau DJ, van der Geest IC, Leithner A, Streitbürger A, Klenke FM, Gouin FG, Campanacci DA, Marec-Berard P, Hogendoorn PC, Brand R, Taminiau AH (2011). "Incidence, predictive factors, and prognosis of chondrosarcoma in patients with Ollier disease and Maffucci syndrome: an international multicenter study of 161 patients". Oncologist. 16 (12): 1771–9. doi:10.1634/theoncologist.2011-0200. PMC 3248776. PMID 22147000.
  41. ↑ Borger DR, Tanabe KK, Fan KC, Lopez HU, Fantin VR, Straley KS, Schenkein DP, Hezel AF, Ancukiewicz M, Liebman HM, Kwak EL, Clark JW, Ryan DP, Deshpande V, Dias-Santagata D, Ellisen LW, Zhu AX, Iafrate AJ (2012). "Frequent mutation of isocitrate dehydrogenase (IDH)1 and IDH2 in cholangiocarcinoma identified through broad-based tumor genotyping". Oncologist. 17 (1): 72–9. doi:10.1634/theoncologist.2011-0386. PMC 3267826. PMID 22180306.
  42. ↑ Saha SK, Parachoniak CA, Ghanta KS, Fitamant J, Ross KN, Najem MS, Gurumurthy S, Akbay EA, Sia D, Cornella H, Miltiadous O, Walesky C, Deshpande V, Zhu AX, Hezel AF, Yen KE, Straley KS, Travins J, Popovici-Muller J, Gliser C, Ferrone CR, Apte U, Llovet JM, Wong KK, Ramaswamy S, Bardeesy N (September 2014). "Mutant IDH inhibits HNF-4α to block hepatocyte differentiation and promote biliary cancer". Nature. 513 (7516): 110–4. doi:10.1038/nature13441. PMC 4499230. PMID 25043045.
  43. ↑ Al-Katib S, Al-Faham Z, Grant P, Palka JC (June 2015). "The Appearance of Maffucci Syndrome on 18F-FDG PET/CT". J Nucl Med Technol. 43 (2): 131–2. doi:10.2967/jnmt.114.146480. PMID 25537758.
  44. ↑ 44.0 44.1 44.2 44.3 Emrick LT, Murphy L, Shamshirsaz AA, Ruano R, Cassady CI, Liu L, Chang F, Sutton VR, Li M, Van den Veyver IB (October 2014). "Prenatal diagnosis of CLOVES syndrome confirmed by detection of a mosaic PIK3CA mutation in cultured amniocytes". Am. J. Med. Genet. A. 164A (10): 2633–7. doi:10.1002/ajmg.a.36672. PMC 4496426. PMID 25044986.
  45. ↑ 45.0 45.1 Gopal B, Keshava SN, Selvaraj D (2015). "A rare newly described overgrowth syndrome with vascular malformations-Cloves syndrome". Indian J Radiol Imaging. 25 (1): 71–3. doi:10.4103/0971-3026.150166. PMC 4329693. PMID 25709171.
  46. ↑ 46.0 46.1 Sarici D, Akin MA, Kurtoglu S, Tubas F, Sarici SU (2014). "A Neonate with CLOVES Syndrome". Case Rep Pediatr. 2014: 845074. doi:10.1155/2014/845074. PMC 4221976. PMID 25400966.
  47. ↑ Kurek KC, Luks VL, Ayturk UM, Alomari AI, Fishman SJ, Spencer SA, Mulliken JB, Bowen ME, Yamamoto GL, Kozakewich HP, Warman ML (June 2012). "Somatic mosaic activating mutations in PIK3CA cause CLOVES syndrome". Am. J. Hum. Genet. 90 (6): 1108–15. doi:10.1016/j.ajhg.2012.05.006. PMC 3370283. PMID 22658544.
  48. ↑ 48.0 48.1 48.2 Rocha R, Estrella M, Amaral D, Barbosa AM, Abreu M (2017). "Proteus syndrome". An Bras Dermatol. 92 (5): 717–720. doi:10.1590/abd1806-4841.20174496. PMC 5674710. PMID 29166516. Vancouver style error: initials (help)
  49. ↑ 49.0 49.1 El-Sobky TA, Elsayed SM, El Mikkawy DM (December 2015). "Orthopaedic manifestations of Proteus syndrome in a child with literature update". Bone Rep. 3: 104–108. doi:10.1016/j.bonr.2015.09.004. PMC 5365241. PMID 28377973.
  50. ↑ 50.0 50.1 Sarman ZS, Yuksel N, Sarman H, Bayramgurler D (June 2014). "Proteus syndrome: report of a case with developmental glaucoma". Korean J Ophthalmol. 28 (3): 272–4. doi:10.3341/kjo.2014.28.3.272. PMC 4038735. PMID 24882963.
  51. ↑ Popescu MD, Burnei G, Draghici L, Draghici I (2014). "Proteus Syndrome: a difficult diagnosis and management plan". J Med Life. 7 (4): 563–6. PMC 4316140. PMID 25713623.
  52. ↑ 52.0 52.1
  53. ↑ Trivedi D, Lee SY, Brundler MA, Parulekar MV (August 2013). "Fibrous tumor of the superior oblique tendon in Proteus syndrome". J AAPOS. 17 (4): 420–2. doi:10.1016/j.jaapos.2013.03.019. PMID 23896365.
  54. ↑ Mayatepek E, Kurczynski TW, Ruppert ES, Hennessy JR, Brinker RA, French BN (March 1989). "Expanding the phenotype of the Proteus syndrome: a severely affected patient with new findings". Am. J. Med. Genet. 32 (3): 402–6. doi:10.1002/ajmg.1320320327. PMID 2729359.
  55. ↑ 55.0 55.1 Adam MP, Ardinger HH, Pagon RA, Wallace SE, Bean L, Stephens K, Amemiya A, Biesecker LG, Sapp JC. PMID 22876373. Vancouver style error: initials (help); Missing or empty |title= (help)
  56. ↑ Biesecker L (November 2006). "The challenges of Proteus syndrome: diagnosis and management". Eur. J. Hum. Genet. 14 (11): 1151–7. doi:10.1038/sj.ejhg.5201638. PMID 16883308.
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