Internal jugular phlebectasia in Menkes disease

Abstract

Pediatric neck masses should trigger a high index of suspicion for certain genetic disorders of connective tissue. To highlight this, we report on three infants with Menkes disease, an inherited disorder of copper transport, who developed large, unilateral neck masses at between 7 and 17 months of age. All were identified in imaging studies as internal jugular phlebectasia. The masses, which enlarged on crying or exertion, have remained clinically benign in these patients for 20, 17, and 2 months, respectively. While arterial tortuosity and aneurysms have been reported often in Menkes disease, venous phlebectasia has rarely been described. We speculate that low activity of the copper-dependent enzyme, lysyl oxidase, leading to reduced tensile strength in the deep cervical fascia comprising the carotid sheath may predispose to internal jugular phlebectasia in these individuals. Improved survival and neurological outcomes in infants with Menkes disease due to advances in early diagnosis and treatment may be associated with recognition of novel clinical stigmata of this condition such as internal jugular phlebectasia.

Figures

Figure 1

Patient 1. A. Right cervical neck mass. B. Sagittal magnetic resonance image reveals a large saccular neck lesion (arrow).

Figure 2

Patient 2. A. Left sided neck mass. Note displacement of the ear pinna. B. The mass increased in size when the infant cried.

Figure 3

Patient 3. A. Axial computerized tomographic scan with contrast of the neck shows massive dilation of the left internal jugular vein. B. Rotated three-dimensional magnetic resonance angiography revealing extensive dilation of the left transverse sinus as well as the left internal jugular vein. On the right side, a dilated segment of the right external jugular vein (arrowhead) is evident.