[Kasabach-Merritt syndrome of the leg associated with osteolysis or Gorham sign]

INTRODUCTION

Kasabach-Merritt syndrome and Gorham's sign are two uncommon and severe, sometimes life-threatening, complications in infants with vascular lesions. Their association has been described in rare cases.

CASE REPORT

An infant with a vast congenital angiomatous lesion including an extensive lymphatic component, developed active regional osteolysis then suddenly suffered disseminated intravascular coagulation of the leg. Medical treatment was unsatisfactory. After unsuccessful use of low molecular weight heparin, pentoxifyllin and alpha interferon, amputation of the leg was required to avoid a fatal outcome.

DISCUSSION

Kasabach-Merritt syndrome does not develop on classic immature hemangiomas, despite some contradictory statements in the literature. In our case, a complex tumor developed in association with a lymphatic malformation. The association of Kasabach-Merritt syndrome with osteolysis (Gorham's sign) does not appear to be fortuitous. Therapeutic management of these severe complications is difficult and requires case by case analysis.

Infants with Kasabach-Merritt syndrome do not have "true" hemangiomas

OBJECTIVE

In 1940 Kasabach and Merritt described an infant with a vascular anomaly, extensive purpura, and thrombocytopenia; they called his lesion "capillary hemangioma." Hemangioma is a benign tumor that grows in infancy and is characterized by proliferation of endothelial cells and regression during childhood. Although Kasabach-Merritt syndrome (KMS) is frequently mentioned as a possible complication of hemangioma, our experience suggests that the anatomic vascular lesion underlying the thrombocytopenia is not a "true," classic, involuting type of hemangioma of infancy and childhood.

STUDY DESIGN

We reviewed the clinical and hemostasis data and the response to treatment in 22 cases of KMS, and we analyzed the biopsy specimens of 15 of them.

RESULTS

Clinically none of the 22 patients had classic hemangioma. There was no female preponderance. All patients had severe thrombocytopenia (lowest platelet count = 3000/mm3) and consumption of fibrinogen. Histologically, none had the typical "capillary," involuting type of hemangioma of infancy: they exhibited either a tufted angioma or a kaposiform hemangioendothelioma pattern; all specimens also contained numerous abnormal lymphatic-like vessels; lymphatic malformation was the major component in two patients. The infants exhibited a heterogeneous response to a number of therapeutic regimens, as noted in other reports. Severe morbidity was present; three of our patients died, and one had leg amputation. "Residua" were, in fact, residual vascular neoplasia, variable in duration, and not a stable fibrofatty residuum, as in classic involuted hemangioma; only the hematologic phenomenon was "cured" after a period of years.

CONCLUSIONS

KMS is a distinctive disease of infancy, but the underlying vascular lesion is not a "true," classic, involuting type of hemangioma of infancy. This is a different vascular tumor with a resemblance pathologically to either tufted angioma or kaposiform hemangioendothelioma in association with lymphatic-like vessels. Whether the underlying lesion in KMS is a single anatomic entity or heterogeneous cannot be definitely concluded from this study. We need a better understanding of the pathogenesis of KMS to improve our therapeutic management.

Scoring of atopic dermatitis by SCORAD using a training atlas by investigators from different disciplines. ETAC Study Group. Early Treatment of the Atopic Child

The ETAC (Early Treatment of the Atopic Child) study, a multi-national double-blind placebo-controlled randomized trials, has been in progress since 1994. Fifty-six centers in Europe and Canada participate in this study. A total of 817 children with atopic dermatitis [AD] were recruited. The severity of AD was scored using the SCORAD (objective criteria). Ninety-eight investigators (mostly pediatricians) were trained by three members of the European Task Force on Atopic Dermatitis [ETFAD] to standardize their objective SCORAD scoring (system developed by the ETFAD). The experts selected photographs and prepared a training atlas. The percentages of photographs assessed by the 98 non-expert investigators below, within and above the range of evaluations by the three experts were calculated. Taking over and underscoring together, edema/papulation was the easiest intensity item to score (82% within the range by the experts). The global symptom score, as well as lichenification, edema/papulation, oozing and excoriation registered by physicians with dermatological experience were not statistically significantly different from those by other. Erythema was statistically significantly better scored by those with dermatological experience. The results of the Euclidean Distance method showed that the item excoriations gave the largest distance. Erythema and excoriations were scored better by dermatologically experienced physicians (t-test, p = 0.042 and p = 0.063 respectively), but lichenification was better scored by non-dermatologically experienced physicians (p = 0.013). The extent of surface area involved in the disease was calculated on 3 sets of photographs. Most evaluations by the 98 nonexpert investigators were within the range of the experts. Dermatologically experienced physicians scored significantly better than the others (t-test, p = 0.006). This training program is useful for standardizing the scoring in AD and indicates that SCORAD can be used by investigators from different disciplines.

Clinical validation and guidelines for the SCORAD index: consensus report of the European Task Force on Atopic Dermatitis

BACKGROUND

We have previously reported how the SCORAD index was designed. This cumulative index combines objective (extent and intensity of lesions) and subjective (daytime pruritus and sleep loss) criteria.

AIMS

To study interobserver variability in scoring for objective SCORAD criteria and to optimize the scoring guidelines.

MATERIAL AND METHODS

Three scoring sessions were organized in 1993-1994 in Hamburg, Bordeaux and Rotterdam totalizing 19 patients (14 children and 5 adults) and 23 physicians, among whom 12 participated in at least 2 scoring sessions; 169 evaluation sheets have been processed using the SCORAD File Marker Pro software. At each session, total body photographs and close-up views were taken of each patient, and this material was reviewed at the final evaluation.

RESULTS

The extent of lesions according to the rule of nines showed interobserver variability mostly for patients with lesions of moderate intensity involving 20-60% of body surface. Intensity items were scored with more consistency overall, but variations subsided especially for oozing/crusts and lichenifications. Low and high scorer profiles and the benefit of training were noted.

CONCLUSIONS

This study has allowed to optimize clinical scoring using the SCORAD system. A proposal has been made to grade the severity of atopic dermatitis according to objective criteria in three groups for inclusion in clinical trials. The SCORAD index remains the major criterion for follow-up in trials.

Infantile acropustulosis in six immigrant children

Infantile acropustulosis is a recurrent, pruriginous, vesiculopustular eruption of the palms and soles first described in 1979. We report six cases of infantile acropustulosis in recently emigrated children treated for scabies. Clinical follow-up was obtained by questionnaire addressed to patients' families and general practitioners. Our study suggests infantile acropustulosis is frequent in immigrant infants and could be a non-specific hypersensitivity reaction to Sarcoptes scabiei.

Autosomal dominant Muckle-Wells syndrome associated with cystinuria, ichthyosis, and aphthosis in a four-generation family

Muckle-Wells syndrome is a rare autosomal dominant disorder characterized by chronic recurrent urticaria, periodic arthritis, sensorineural deafness, general signs of inflammation, and secondary amyloidosis (AA type). We report on a 4-generation family with 7 persons sharing various signs of this syndrome associated with bipolar aphthosis in 5 cases and cystinuria in one. Two other relatives in the family had ichthyosis.

Local steroid therapy and bacterial skin flora in atopic dermatitis

A double-blind, randomized trial was conducted to determine the influence of topical steroid therapy on atopic skin flora. The bacteriological and clinical effects of desonide (Locapred), compared with those of its excipient, were studied in 40 children. Clinical scoring and bacteriological sampling were performed before the start of the trial and after 7 days of once-daily topical treatment. Before treatment, no differences in clinical score or Staphylococcus aureus colonization were noted between the two groups. After treatment, the clinical score improved (P < 0.001) in the desonide group, and S. aureus density decreased dramatically (P < 0.001). In the excipient group, no significant differences in clinical score or S. aureus density were noted. A comparison of the two groups demonstrated statistically significant differences with regard to clinical score (P < 0.001) and S. aureus density (P < 0.05). These results show the efficacy of topical corticosteroid treatment alone on S. aureus colonization in atopic skin, and confirm the critical role of inflammation in bacterial colonization.

Role of aluminium in skin reactions after diphtheria-tetanus-pertussis-poliomyelitis vaccination: an experimental study in rabbits

The occurrence of subcutaneous nodules at the injection site is one of the complications of diphtheria-tetanus-pertussis-poliomyelitis vaccination, but the causes and mechanisms involved are still poorly understood. An experimental study in the New Zealand rabbit enabled us to determine the frequency of occurrence of these nodules, how long they persist and the histopathologic features of the cells involved. Aluminium (Al) assays by electrothermal atomic absorption spectrometry allowed us to study concentrations both in nodules and the organism (serum, normal skin). The results show an absence of Al diffusion outside nodules, a correlation between infiltrate intensity and Al concentration in nodules and modifications in the histological constituents of nodule cells. The histological picture indicates a foreign body reaction to Al. All these data underscore the role of Al in the formation of early postvaccinal nodules at the injection site.

[Acquired phimosis, or preputial sclero-atrophic lichen in children]

From 1979 to 1988, 8 cases of balanitis xerotica obliterans were histologically demonstrated in children at Nantes University Hospital. In 6 of these 8 patients, whose average age at the time of consultation was 9.4 years, the phimosis was obviously acquired or recurrent, and the prepuce was sclerous, thick, and produced a tight distal phimosis. One child coming to consultation for relapsing urinary infections at once presented with a long, tight stenosis of the anterior ureter, associated with a dilatation of the upstream ureter and a filiform stream of urine. All the children were circumcised, and the histological study of the specimen demonstrated characteristic lesions in the superficial derma. During the same operation, meatostomy was performed in two children presenting with meatal stenosis. Six of 8 children were followed up with an average time lapse of 6 months: one of them presented with an involvement of the glans penis and a moderate meatal stenosis, which disappeared spontaneously. No improvement occurred for the child presenting with an extensive stenosis of the anterior ureter, in spite of the local instillation of androgens then of corticoids, but his left kidney was dilated on sonograms. Balanitis xerotica obliterans in children is often not recognized and regarded as a common phimosis; it can be suspected because of the clinical features of the phimosis. The condition must be confirmed by the histological study of a circumcision specimen, then followed up regularly to prevent any risk of involvement of the glans, of the ureteral meatus or of the anterior ureter.

Linkage relationship between incontinentia pigmenti (IP2) and nine terminal X long arm markers

Linkage data for familial incontinentia pigmenti (IP2) and nine X chromosomal markers are reported. Previously found linkage between IP2 and the DXS52 locus is confirmed with the maximum lod score of 6.19 at a recombination fraction of 0.03. Linkage is also established with loci DXS134, DXS15 and DXS33. Multipoint analysis allows us to localize the IP2 locus outside a block of seven linked markers of the Xq28 region.

MY7 monoclonal antibody for diagnosis of cutaneous T-cell lymphoma

Infiltrate in cutaneous T-cell lymphomas (CTCLs) is composed mainly of CD4 helper cells with a phenotype very similar to that of benign cutaneous lymphoid infiltrate. MY7 (CD13) is a monoclonal antibody that is normally expressed on peripheral granulocytes and monocytes but also cross-reacts with an antigen expressed on epidermal basal cells. We studied MY7 expression on basal cells of the epidermis and CD4 cell infiltrate in 34 CTCLs, 11 pseudolymphomas, and 29 other benign cutaneous lesions. An indirect immunofluorescence technique with double labeling and an immunoperoxidase technique were used. We found that in benign inflammatory infiltrate, less than 10% of CD4 cells expressed MY7 antigen associated with normal MY7 monoclonal antibody labeling of basal cells, whereas in CTCLs more than 50% of CD4 tumoral cells in dermis expressed MY7 antigens; however, basal cells were MY7 negative. Thus, it is demonstrated that MY7 monoclonal antibody with its double modulation on epidermis (basal cells) and dermis (CD4 cells) has diagnostic value for differentiating CTCLs with CD4+ MY7+ tumor cells in dermis and MY7-negative basal cells from benign inflammatory lesions with CD4+ MY7- cells in dermis and MY7-positive basal cells. This modulation of MY7 labeling could be related to the secretion of epidermal cytokines.

Prognostic value of Langerhans cells in the epidermis of HIV patients

We measured the number of Langerhans cells in clinically normal epidermis and the number of T4 lymphocytes in the plasma in 24 patients infected with HIV, and related these to the stage of the disease. A correlation is demonstrated between the numbers of Langerhans cells and T4 lymphocytes. Numbers of Langerhans cells were lower in patients with disease stages III and IV than in those with disease stage II. Thus Langerhans cell numbers could be of prognostic value in this disease.

Discoid lupus erythematosus-like lesions in an autosomal form of chronic granulomatous disease

Chronic granulomatous disease (CGD) is characterized by a bactericidal defect involving the oxidative metabolism of polymorphonuclear leukocytes (PML) and is most often transmitted as an X-linked trait. The cutaneous features of this disorder include infections and lupus-like rashes. These have been described in female carriers as well as in males with the disease. Two cases of siblings presenting an autosomal form of CGD syndrome, with lupus-like cutaneous manifestations, are reported here.

Cutaneous immunological studies in diagnosis of acute graft-versus-host disease

A comparative study of the healthy skin of patients who had undergone bone marrow grafting and not developed graft-versus-host disease (GVHD) and of patients with cutaneous lesions of acute GVHD has been carried out. The aim of this study was to assess the diagnostic value of cutaneous immunopathology in the diagnosis of acute GVHD. A double-labelling immunofluorescence technique was used with a panel of monoclonal antibodies. The results showed a lack of specificity for GVHD in the distribution of Langerhans cells, but confirmed the diagnostic value of HLA-DR staining of epidermal keratinocytes. Cellular polymorphism of the T cell infiltrate in the dermis was observed (T helpers 40% and T suppressors 20%). The expression of the 55-57 Kd keratin polypeptide and of bullous pemphigoid antigen showed modification during acute GVHD while that of pemphigus antigen remained unchanged.

Plasma zinc is decreased only in generalized pustular psoriasis

Plasma and cutaneous zinc were studied in 22 psoriatic patients and 14 controls. The psoriatics were divided into three groups: 10 extensive psoriasis vulgaris, 5 palmoplantar psoriasis and 7 extensive pustular psoriasis. Low plasma zinc and decreased in vitro chemotaxis of polymorphonuclear leukocytes were found only in extensive pustular psoriasis, whereas zinc was not decreased but rather elevated in skin. This explains why conflicting results on plasma zinc have been previously reported in psoriasis and confirms that cutaneous zinc depletion is not a feature of psoriasis.