FAQ CMTC
CMTC specific
Are there other/more risks as you get older – for example the risk of inflammation (although I haven’t had any so far) or the risk of a weakened leg?
It is advisable for older patients (>25 years) with vascular malformations to have regular check-ups because they may have a higher risk of complications such as inflammation, thrombophlebitis (vein inflammation), cellulite, bacterial inflammation of the leg. Oedema can cause inflammation. It is therefore important to prevent oedema.
Chance of a weakened leg? This is usually already present at a younger age. It depends on the type of malformation but we don’t see very often that this occurs later on.
People whose one leg is narrower than the other do not have so much less muscle. They sometimes have less fat tissue.
CMTC can cause asymmetrical body development.
Is it possible for the body to develop asymmetrically, especially in head to toe dimensions (so where one side of the body develops at a different rate than the other)? What can be done about this?
Yes, this is a possibility although not common and is known as Hemihypertrophy. In certain cases this can be connected with the complication known as primary lymphedema. This is a disorder of the lymph vessels which regulate the fluid balance in the body. With primary lymphedema there are too few lymph vessels to properly drain the body of fluids. As a result, one side of the body can become thicker than the other side.
When should any intervention be considered if there is a difference in leg lengths?
In The Netherlands the guideline is that physical intervention is only appropriate when the difference in leg length is larger than 3cm. In addition, it should be noted that the age of the patient also plays an important role in deciding when to intervene.
As a woman with CMTC, should I use the birth control pill?
If you have varicose veins then there is a risk of thrombosis. Discuss this with your doctor.
I live far away from the Netherlands. How can I get personal medical advice remotely?
Personal advice at a distance is possible. But for a really good diagnosis and advice it is better to make a personal visit to the specialized doctor/expertise center. This way the doctor can examine the condition in a much better way. You can ask your insurance company if it is possible to reimburse a visit.
If this is really not possible, we could try to find a specialized doctor or expert in your area who could do the diagnosis/treatment.
In CMTC the skin has a purple or blue ‘marbled’ or ‘fishnet’ appearance as a result of dilated (widened) surface blood vessels.
What is the cause of the dilated blood vessels in CMTC (or other related diseases)?
Dr. Millan Patel and colleagues suggest that defective vascular coverage of a certain type of cell, the ‘pericyte’, of the vasculature may be the cause of blood vessel abnormalities seen in Adams Oliver syndrome (AOS). AOS patients have similarities to CMTC patients (more than 20% of AOS have CMTC) and so this mechanism could also hold for CMTC.
What are pericytes?
Pericytes are contractile cells that wrap around the endothelial cells that line the interior surface of capillaries and venules throughout the body.
Adams Oliver syndrome
The scientists investigated two children with Adams – Oliver syndrome (AOS). AOS consists of congenital scalp defects with variable limb defects. The cardiovascular system is most frequently affected with nearly 20% of reported patients having congenital cardiac malformations and at least 21% of reported patients having cutis marmorata telangiectatica congenita (CMTC). In addition to these congenital features, pulmonary hypertension (PH) has recently been recognized as an important infantile complication of AOS.
The two children had AOS plus additional features including intrauterine growth retardation (IUGR), cutis marmorata telangiectatica congenita (CMTC), pulmonary hypertension (PH), bleeding in the brain. Both developed PH in infancy which ultimately resulted in their deaths.
Autopsy in one case revealed defective vascular smooth muscle cell/pericyte coverage of the vasculature associated with two blood vessel abnormalities. Pericyte absence correlated with vessel dilatation while hyperproliferation of pericytes correlated with abnormal narrowing in blood vessels. Defective pericyte coverage was found in multiple organs including the lungs, skin, diaphragm, and mesentery.
The researchers propose that abnormal pericyte recruitment to blood vessels is the underlying pathogenic mechanism of AOS. From several lines of experimental evidence, mainly from research in mice, it was found that pericytes play an important a role in the development of vessels. If they are absent all kinds of vascular abnormalities occur.
Literature:
Abnormal Pericyte Recruitment as a Cause for Pulmonary Hypertension in Adams–Oliver Syndrome , Millan S. Patel, Glenn P. Taylor, Simi Bharya, Nouriya Al-Sanna’a, Ian Adatia, David Chitayat, M.E. Suzanne Lewis, and Derek G. Human, American Journal of Medical Genetics 129A:294–299 (2004)
Did we do something wrong as parents.
No, whether a child has CMTC is down to chance.
Yes, getting a tattoo can make a vascular malformation less visible. It is a fairly new approach but you see it more and more. What you have to take into account is that the color of your skin can change over the years. In the beginning the tattoo can have the right color but that can not be the case later when the color of your skin has changed a lot. In addition, vascular malformations which are high in the skin can be a problem. It is not recommended to put tattoo lines in the vascular malformations in the lesions.
Can an infusion be applied or an injection be given in for example an arm or a leg that is affected by CMTC?
This is not recommended due to the chance of thrombosis (clotting in the bloodstream which could cause a stroke or heart attack for example).
Is CMTC genetically inherited?
As far as is known at present CMTC is not inherited. We do know of parents with CMTC that have children without CMTC.
CMTC is not life-threatening. In fact, as far as is known to date 6 children have died from complications which can occur with certain syndromes in combination with CMTC. These then concerned the presence of syndromal CMTC.
Blood vessels can be divided into the vessels that go to your heart (venes) and those that go away from your heart (arteries) and there are also the lymphatic vessels. In vascular malformations something goes wrong in one of these three vessels. The name of the malformation is linked to the type of vessel where the malformation occurs. So for example a lymphatic venous malformation or vascular malformation with a capillary part (the small vessels in the skin).
The deeper layers of the skin and the vessels originate from the same part of the embryo. The early embryo consists of three layers: ectoderm, mesoderm, endoderm.
- Ectoderm: later forms the (outer layer of the) skin and nervous system.
- Mesoderm: later forms the lower layers of the skin, blood, blood vessels, skeleton, muscles, connective tissue and urogenital system.
- Endoderm: later forms the digestive system and internal organs.
Laser treatment of the very youngest children would not be advised.
Any remaining wound/damage can be treated from an age of 7 years.
Possible complications:
EARLY
- Infections.
- Bleedings.
- Crust formation.
LATE
- Pigment changes. In which the skin can appear either lighter or darker.
- Scar formation.
CMTC can appear on many parts of the body.
Hereby an overview regarding which actions can be taken per part of the body.
Patches around the eyes and/or on the forehead
In this case there is a chance of glaucoma (raised pressure in the eyeball that can lead to blindness) and brain abnormalities. In the latter case, an MRI scan is recommended.
Patches around the nose and jaw area
Generally speaking no action needs to be taken.
Patches in the ears
Let an ENT specialist inspect the ears regularly and carry out a hearing test when needed.
Patches in the mouth
Let a dentist check development in the area regularly.
Patches on the head
Generally speaking no action needs to be taken.
Patches on the neck
Generally speaking no action needs to be taken.
Patches on the legs
In this case the legs may develop asymmetrically in length and girth. The most significant variation occurs mainly at a young age. During the physical development stage the patches are mostly less visible in terms of intensity.
Patches on the buttocks and/or torso
If there are likely to be other syndromes in combination with CMTC then the advice would be to determine with ecography (ultrasound) whether internal organs such as liver, kidneys, heart and lungs display abnormalities. Should this be the case, then an MRI scan can be used to get a better view of the precise nature of the variations.
My child is afraid of an injection.
This fear can arise from the pain caused by the injection especially the phase when it is pierced through the skin. A possible solution is to numb the skin. For this, the cream ‘Emla’ can be used. This cream is also called ‘magic ointment’. You can also use this term if you explain to your child that he/she will feel little/nothing.
To which other conditions is CMTC similar.
CMTC can appear similar to conditions such as Klippel-Trenaunay Syndrome or Sturge-Weber syndrome.
My child with CMTC has two toes that have grown together. Does this have anything to do with CMTC?
This can occur when the child has CMTC patches on the legs and/or feet. We have several members who have two toes that have grown together.
What is CMTC actually.
CMTC is the acronym for the Latin name Cutis Marmorata Telangiectatica Congenita. Translated into English this means a birth defect affecting the blood vessels that is visible as areas of marbled skin. The alternative name for this condition is Van Lohuizen syndrome. The Dutch paediatrician Van Lohuizen first described the syndrome in 1922. Internationally, both the names CMTC and Van Lohuizen Syndrome are in use.
People affected by CMTC have in common that one or more areas of their skin are marbled. Generally, this affects the limbs, sometimes the torso and less frequently the face. The condition is not limited to the skin however as this can also occur with defects in other tissues: too thin, too thick or too short bones; thin muscles and also some level of intellectual disability can be present. CMTC can also occur in the context of other syndromes, in which case it is itself a symptom.
Both mean the same thing. Hemihypertrophy is a unilateral growth deviation of one or more parts (e.g. skin or leg) of the body. This may be caused by a genetic disorder or something in the environment.
Vascular malformations are usually mosaic disorders. This means that the disease only occurs in limited locations in the body. This is because at the very beginning of the embryo, an error (mutation) occurred only in certain cells and not in other cells. The cells that are derived from a cell with an error also have the error. If the error occurs in all cells, it is often incompatible with life.
Sclerotherapy involves injecting a fluid (sclerosant) into the vascular malformation by means of an injection. This fluid causes the malformation to form a scar from the inside and shrink. This makes the malformation smaller in many cases. In some cases it is not possible to treat the malformation with sclerotherapy and/or embolization. If, for example, the malformation is close to important organs, this can make treatment more difficult. (For more information go to: https://www.cmtc.nl/en/pedia/ovm/treatment-of-vascular-malformations-with-interventional-radiology/) Go to a specialist in this field for advice.
The best way is to do an ultrasound scan to see if embryonic veins are present. Then an MRI is not really necessary for the diagnosis but can be used to see how the veins and arteries have developed. The complaints of the patient can then possibly better be explained and the doctor can decide on a therapy.
What is the cause of CMTC.
It is thought that CMTC comes about through a fault during cell division in the unborn embryo. Each new life starts as a ball of cells that grows into an embryo. In an embryo, a number of distinct layers can be identified and the cells of each of these layers later develop into the varied multiplicity of organs and tissues from which we exist. When a fault occurs in the layer known as the mesoderm then there is a chance that all tissues and organs that develop from this layer are affected. So aside from the skin, bones and muscles can also display abnormalities. When the genetic fault develops relatively late in pregnancy then only the skin will be affected. The fact that abnormalities frequently only occur on one side of the body supports this theory as to the cause.
Cutis marmorata (literally: marbled skin) occurs in about 50% of children and is usually seen during childhood. It can also occur in adults.
The mottled appearance of cutis marmorata is caused by superficial small blood vessels in the skin that dilate and contract at the same time. The dilation causes the red color of the skin to appear, while the contraction makes a pale impression. This phenomenon is most pronounced when the skin has cooled down. The contraction and dilation is regulated by nerves. This regulation is not yet optimal in neonates (newborns). This improves and/or disappears with age.
CMTC is a vascular anomaly that is present from birth. The skin is marbled but this does not go away when warmed up. Often the spots do fade as the child gets older. In general one can distinguish between the classic CMTC form and the more general form. The classic form is more severe: more ulcers occur than in the general form.
MCAP (megalencephaly-capillary malformation syndrome) previously known as M-CM (macrocephaly-capillary malformation) is a completely different disease than CMTC. MCAP patients often have a wine stain. In addition, they have an enlarged head. There may be multiple complications such as neurological problems and abnormalities of the limbs. Epilepsy is also possible. It looks a bit like Sturge-Weber Syndrome but is different.
With the laser it is possible to achieve good results but the beam doesn’t penetrate very deeply into the skin. Up to about a millimeter deep in the skin the laser can do its job. Affected vessels in the surface of the skin can be treated so that they become less visible. If a condition is deeper, treatment with the laser makes no sense. However, new types of lasers are being developed that may give better results. Sometimes the pulsed dye laser is combined with a CO2 laser (penetrates a little deeper into the skin) to treat underlying layers.
All parts of the body can be treated with lasers but in the face the best results can be achieved because the skin in the face is thinner. Incidentally, not all insurance companies reimburse the treatment of body parts other than the face.
For more information visit https://www.cmtc.nl/en/pedia/cmtc/laser-treatment/
What is a good age to start laser treatment.
The use of lasers for children can mean that the child will need to be put under general anaesthetic, primarily to prevent panic and to ensure that the child remains still. Going through this process several times a year is not advisable for children from both a physical and mental wellbeing point of view.
Should someone with CMTC patches be exposed to the sun?
This is generally not an issue if a good sun cream is used of at least factor 15.
My child has a CMTC patch on her knee. If she falls on this patch and the wound bleeds then it appears to take a long time before the knee recovers. Is this normal?
This is normal.
