The acrodermatitis enteropathica mutation affects protein expression in human fibroblasts: analysis by two-dimensional gel electrophoresis

The acrodermatitis enteropathica (AE) mutation affects zinc uptake in human fibroblasts. However, the specific biochemical lesion has not been identified. We have used the technique of two-dimensional gel electrophoresis to identify protein differences in total cell lysate isolated from normal and AE fibroblasts. Two proteins with estimated molecular weights of 49.6 and 49.9 kDa and an isoelectric point of 5.1 were identified in normal fibroblasts but absent from AE fibroblasts. The proteins were purified, subjected to in-gel trypsin digest and the resulting peptides separated by HPLC. Sequences from three peptide fragments (8, 15 and 18 amino acids) were obtained after Edman degradation. None of the fragments exhibited homology to any amino acid sequences in the nonredundant Genbank database. The 15 and 18 amino acid fragments each exhibited 100% homology to a 136 amino acid expressed sequence tag that was homologous (43%) to adipophilin. However, the 15 and 18 amino acid fragments were only 30 and 44% homologous, respectively, to corresponding regions within the expressed sequence tag. Therefore, the 49.6/49.9 kDa protein absent from AE fibroblasts was not related to adipophilin. The 8 amino acid fragment did not exhibit homology to any expressed sequence tag. Therefore, the 49.6/49.9 kDa proteins are novel and may be the cause of the reduced zinc uptake and abnormal zinc metabolism characteristic of fibroblasts carrying the AE mutation.

Co-existence of leukoderma with features of Dowling-Degos disease: reticulate acropigmentation of Kitamura spectrum in five unrelated patients

BACKGROUND

The spectrum of Dowling-Degos disease-reticulate acropigmentation of Kitamura (DDD-RAK) is a group of rare autosomal dominant disorders that have in common a unique histological picture of hyperpigmented digitate epidermal 'downgrowths'. Patients with the DDD-RAK spectrum may show hyperpigmented macules and papules, facial pits, breaks in dermatoglyphics and epidermoid cysts.

OBSERVATIONS

We examined 5 unrelated patients, 3 females and 2 males (age range 22-35 years), who presented with clinical and histological features of the DDD-RAK spectrum. In addition, the patients presented with hypo- or depigmented macules and papules. Histopathology of the lesions revealed features that were identical to DDD-RAK; there were, however, diminution or absence of pigmentation. Family histories for pigmented lesions and leukoderma were positive in all patients and consistent with autosomal dominant modes of inheritance.

CONCLUSION

These 5 cases, together with isolated reports in the literature of achromic lesions with histological features of DDD-RAK, point to the hypothesis that achromic macules and papules may be a feature of the DDD-RAK spectrum.

Zinc uptake into fibroblasts is inhibited by probenecid

Cellular zinc transport has not been fully characterized. The role of an anion carrier was investigated by treating normal human fibroblasts, and those carrying a mutation which affects zinc transport, acrodermatitis enteropathica (AE), with the anion carrier inhibitor, probenecid. Zinc uptake (2, 10, or 20 micromol 1(-1) 65zinc) was determined during initial rates of uptake (15 min) following treatment with 0, 10 or 20 mmol 1(-1) probenecid. Probenecid stimulated extracellular zinc binding in normal and AE fibroblasts. Probenecid inhibited the internalization of zinc in normal, but not AE, fibroblasts. Normal fibroblasts exhibited an apparent Km which was reduced by 53% and 44% in the 10 and 20 mmol 1(-1) probenecid treated cells. The Vmax was also reduced in the normal fibroblasts by 51% and 50% in the 10 and 20 mmol 1(-1) probenecid treated cells. The results suggest that a probenecid-sensitive anion carrier is involved in the internalization of zinc in human fibroblasts. The lack of an effect of probenecid on the internalization of zinc in the AE fibroblasts suggests that the mutation involves a probenecid-sensitive anion transport system, and that there may be a secondary mechanism for zinc transport in these cells.

Hereditary papulotranslucent acrokeratoderma

Hereditary papulotranslucent acrokeratoderma (HPA) is a rare autosomal dominant genodermatosis, characterized by persistent, asymptomatic, yellow-white translucent papules and plaques of the hands and feet. A case of HPA is presented and the literature of this variant of punctate keratoderma is reviewed.

Differences in the cellular zinc content and 5'-nucleotidase activity of normal and acrodermatitis enteropathica (AE) fibroblasts

The acrodermatitis enteropathica (AE) mutation affects zinc (Zn) metabolism in human fibroblasts. We hypothesize that the mutation affects the cell Zn content, which subsequently affects the activity of various zinc-dependent enzymes, such as 5'-nucleotidase. Therefore, normal and AE fibroblasts were grown in normal medium containing physiological levels of Zn (16 micromol/L) for approximately 24 h. The medium was replaced by normal medium (16 micromol/L Zn), Zn-depleted medium (1.5 micromol/L Zn), or Zn-supplemented medium (200 micromol/L Zn) for another 24 h. Regardless of the Zn concentration of the growth medium, the AE fibroblasts contained significantly less Zn than normal fibroblasts grown in comparable medium. Nevertheless, growth of the fibroblasts in 200 micromol/L Zn medium significantly increased the cell Zn content fourfold of both normal and AE fibroblasts. The activity of 5'-nucleotidase in the AE fibroblasts grown in 16 micromol/L Zn or 1.5 micromol/L Zn medium was also significantly lower than in normal fibroblasts. Changing the growth medium from 16 micromol/L Zn to 1.5 micromol/L Zn medium did not affect the activity of the enzyme in either genotype. Cells grown in 200 micromol/L Zn medium exhibited threefold greater 5'-nucleotidase activity in AE fibroblasts, but had no affect on enzyme activity in normal cells. In summary, altering the cell Zn content of normal fibroblasts did not result in a significant change in their 5'-nucleotidase activity. However, AE fibroblasts grown in 200 micromol/L Zn medium exhibited recovery of their 5'-nucleotidase activity to normal levels. These results support the hypothesis that the AE mutation affects the cellular Zn content. The lower cell Zn content subsequently affects the activity of 5'-nucleotidase.

Is the heredity of reticulate acro pigmentation of Kitamura always autosomal dominant?

Reticulate acropigmentation of Kitamura (RAK) in three patients and their families is described. In one family, 2 women and 2 men were affected out of 9 individuals. In the other family, 6 women had lesions of reticulate acropigmentation out of total of 27 over three generations. In the third family, one man was affected. All of the cases had palmar pits; onset of lesions was after puberty in all the cases. The apparently different hereditary patterns in these three families are striking, and autosomal dominant inheritance appears unlikely in every case.

Acrokeratoelastoidosis

An indian woman presented with crateriform and pearly papules along the lines of transgredience of the hands and feet. Her father and an older sister are similarly affected. Histology showed hyperkeratosis and elastorrhexis. The differential diagnosis of acrokeratoelastoidosis includes focal acral hyperkeratosis. The current classification of marginal papular acrokeratodermas is discussed.

Bovine hereditary zinc deficiency: lethal trait A 46

Bovine hereditary zinc deficiency, also referred to as Adema disease, is an autosomal recessive disorder which results in inadequate amounts of zinc being absorbed from the gastrointestinal tract and leads to a number of clinical abnormalities. Using semen from a homozygous affected bull and obligate heterozygote cows in embryo transfer studies, 7 offspring were obtained. These included 5 affected calves and 1 heterozygous carrier; the seventh calf died within 48 hours of birth undiagnosed. One unaffected, unrelated bull calf was raised as a control. All the calves were raised and maintained under similar management conditions designed to minimize secondary complications that would obscure the clinical and biochemical observations of a zinc deficient state. The first clinical manifestation of zinc deficiency was diarrhea, followed by skin lesions, poliosis, and a decreased ability to sustain a suckle reflex. Trace mineral analysis of plasma blood samples revealed that plasma zinc concentrations of all the calves were normal at birth; however, they gradually declined in affected calves over the course of 3-8 weeks postpartum to below 0.5 ppm. Biochemical analysis of serum samples showed alkaline phosphatase activity consistently paralleled changes in the plasma zinc concentrations. The oral administration of zinc acetate caused a reversal of all clinical, biochemical, and histologic abnormalities in affected calves. The study of these affected calves allows further insight into the biological role of zinc as well as provides an animal model for the continued investigation of the human homologue acrodermatitis enteropathica.

The acrodermatitis enteropathica mutation transiently affects zinc metabolism in human fibroblasts

The acrodermatitis enteropathica (AE) mutation has been shown to affect zinc transport in human intestinal biopsies. However, whether the mutation is also expressed in human fibroblasts has not been determined. The activity of the zinc-dependent enzyme, 5' nucleotidase, and cell zinc content were measured in normal and AE fibroblasts 2 and 4 d after subculturing to determine the effect of the AE mutation on zinc metabolism. The activity of 5' nucleotidase in AE cells was 68% of normal at 2 d after subculturing. Although 5' nucleotidase activity had decreased significantly in both normal and AE fibroblasts at 4 d after subculturing, there was no significant difference between the two genotypes. The zinc content of AE fibroblasts was also significantly reduced. Acrodermatitis enteropathica fibroblasts contained 62% less zinc than normal fibroblasts at 2 d. By 4 d the normal fibroblast zinc content had decreased to that of the AE fibroblasts. The uptake and transport of 65Zn into AE fibroblasts at 2 d was measured because these cells exhibited reduced 5' nucleotidase activity and cell zinc content at this time. The uptake of zinc over a 90-min time period was the same in the two genotypes. However, AE fibroblasts incubated with 2-10 mumol Zn/L for 15 min had significantly slower zinc transport compared with normal fibroblasts. In both genotypes, Michaelis-Menten kinetics were observed. Normal and AE fibroblasts had similar affinities for zinc (Km), but AE fibroblasts exhibited a Vmax which was reduced by 38%. These results indicate that the phenotypic expression of the AE mutation occurs in a time-dependent manner, is not restricted to the intestine and is also transiently expressed in human fibroblasts, resulting in abnormal zinc metabolism in these cells.

The effect of the acrodermatitis enteropathica mutation on zinc uptake in human fibroblasts

The acrodermatitis enteropathica (AE) mutation affects intestinal zinc absorption. Our goal was to determine whether the AE mutation affects zinc uptake in human fibroblasts. Zinc uptake was determined during initial rates of uptake (10 min) following incubation in HEPES/saline buffer. Zinc uptake (from 0.25 to 1 microM) into normal fibroblasts was significantly greater than into the AE fibroblasts (p < 0.05). In order to identify factors that may alter cellular zinc uptake and be affected by the AE mutation, zinc uptake in the presence of albumin or bicarbonate was measured. Albumin restricted zinc uptake in both normal and AE fibroblasts, whereas bicarbonate stimulated zinc uptake in the normal fibroblasts. The effect of bicarbonate on zinc uptake in the AE fibroblasts was significantly reduced in both the Pronase-sensitive and Pronase-resistant compartments. Following loading of the fibroblasts with 1 microM zinc for 60 min, zinc efflux and retention were measured. The AE mutation did not affect zinc retention compared to normal fibroblasts. We conclude that the AE mutation affects both zinc binding to the cell surface and its translocation across the plasma membrane into the cell, possibly mediated through a defective anionic exchange mechanism.

No evidence for Borrelia burgdorferi-specific DNA in lesions of localized scleroderma

A possible association of Borrelia burgdorferi with localized scleroderma is currently the focus of intense research and discussion. Skin biopsies from 30 patients with localized scleroderma (28 of the plaque type/morphea; two linear scleroderma) were analyzed for the presence of Borrelia burgdorferi using three different polymerase chain reaction systems for amplification of segments of borrelial genes. Formalin-fixed, paraffin-embedded biopsies of 14 patients and fresh-frozen, cryo-conserved biopsies of 16 patients with localized scleroderma were obtained. Lesions of all patients showed clear signs of scleroderma and disease progression at the time of biopsy. Fresh-frozen as well as formalin-fixed biopsies from patients with erythema migrans or acrodermatitis chronica atrophicans were used as positive controls. With all three polymerase chain reaction systems, borrelial DNA was detected in none of the 30 specimens of localized scleroderma. In contrast, with one polymerase chain reaction system, Borrelia burgdorferi-specific DNA was found in 24 of 27 frozen biopsies from patients with erythema migrans and in all 5 analyzed frozen biopsies of patients with acrodermatitis chronica atrophicans. In approximately half of the paraffin-embedded biopsies from patients with erythema migrans (nine of 23) and acrodermatitis chronica atrophicans (13 of 27), Borrelia burgdorferi-specific DNA was identified. These results question the association of localized scleroderma with known subtypes of Borrelia burgdorferi.

Molecular subtyping of Borrelia burgdorferi in erythema migrans and acrodermatitis chronica atrophicans

Recently, three subtypes of Borrelia burgdorferi have been identified: Borrelia burgdorferi sensu stricto, Borrelia garinii, and the VS 461 group of Borrelia burgdorferi. These subtypes differ by nucleotide sequence variations within several Borrelia burgdorferi specific genes and most likely by their pathogenetic potential. To assess whether different subtypes of Borrelia burgdorferi might be associated with different cutaneous manifestations and clinical courses of Lyme disease, lesional skin biopsies from 35 patients with erythema migrans and 18 patients with acrodermatitis chronica atrophicans were analyzed. A Borrelia burgdorferi specific gene segment encoding a 26-kD protein with subtype specific nucleotide sequence variations was amplified by a nested polymerase chain reaction technique. For molecular subtyping, the products were transcribed into complementary RNA. Upon polyacrylamide gel electrophoresis, complementary RNA molecules separate into several metastable conformational forms resulting in patterns of bands highly specific for the nucleotide sequence of the transcribed molecules. In biopsy specimens of erythema migrans, the VS 461 subtype was detected in 28 of 35 and the Borrelia garinii subtype in six of 35 cases. In one of 35 cases of erythema migrans Borrelia burgdorferi sensu stricto as well as Borrelia garinii was detected. In contrast, in all 18 biopsies of acrodermatitis chronica atrophicans, only the VS 461 subtype was identified. This subtype is rarely found in the USA, where acrodermatitis chronica atrophicans is almost unknown. These data indicate that acrodermatitis chronica atrophicans might be closely associated with the VS 461 group of Borrelia burgdorferi.

No association with HLA class II alleles in Swedish patients with cutaneous manifestations of Lyme borreliosis

The possibility of an association between manifestations of Lyme borreliosis and HLA class II alleles has been investigated with varying results. In the present study, we used genomic typing techniques to determine the DR, DQ and DP allele frequencies in 29 patients with erythema migrans and 36 patients with acrodermatitis chronica atrophicans. We did not find a significant deviation from controls in the distribution of the HLA class II alleles in any of these disease manifestations, nor in the subgroup of 8 patients with acrodermatitis chronica atrophicans and long-standing arthritis. With the additional information obtained by the typing techniques used, our results are thus in accord with those studies where no association between the development of the late disease manifestation acrodermatitis chronica atrophicans and HLA class II alleles has been found.

[Clinical aspects and therapy of Bureau-Barrière syndrome. Observations of 17 cases with review of the literature]

Bureau-Barrière syndrome can affect various organ systems. It is defined by the triad: painless ulcers at mechanically irritated and hyperkeratotic plantar areas of the feet, sensitive polyneuropathy of the lower legs and osteolysis in the forefoot area. The condition mainly affects middle-aged men suffering from alcoholism, liver disease, obesity or metabolic disorders such as diabetes mellitus. Successful treatment of the Bureau-Barrière syndrome requires an interdisciplinary approach.

Acrodermatitis enteropathica in Saudi Arabia

Four patients with acrodermatitis enteropathica (AE) are presented from three Saudi families. The clinical picture in these patients is basically similar to that described elsewhere. These patients, however, showed different degrees of involvement of various body systems. In all cases, low serum zinc levels were documented, and they responded well to zinc supplementation. In the follow-up evaluation, angular cheilitis was observed as a feature that appears to herald the relapse of disease. Interestingly, when patients are treated, it was the last sign to disappear. Current information on zinc is summarized.

[Association of idiopathic acropustuloses to HLA antigens and their relation to psoriasis]

Immunogenetical findings can contribute to the understanding of diseases of unknown etiology. It has, however, become difficult to define the borderlines between related diseases, since a vast amount of individual facts have been reported. For this reason, immunogenetical findings should only be seen as a part of general pathology. Our study, which makes use of HLA markers, is an attempt to provide a better definition of idiopathic acropustulosis, and to differentiate it more clearly from psoriasis.

Self-limiting acrodermatitis enteropathica. A follow-up study of three interrelated families

A variant of acrodermatitis enteropathica is described that has its onset before weaning and clears when the child starts its normal solid diet. A pedigree with three interrelated families is reported where 10 children were afflicted with this variant. They had symptoms of hypozincemia for a brief period during infancy. At the time of this study, they were symptom-free and their serum zinc levels were found to be within normal limits. The term "self-limiting acrodermatitis enteropathica" is proposed for the variant. In one lactating mother, the mammary zinc secretion was determined and was found to be deficient and unresponsive to oral zinc supplements. The possible mode of inheritance is also discussed.

Lethal acrodermatitis in bull terriers

A lethal syndrome characterized clinically by growth retardation, progressive acrodermatitis, chronic pyoderma and paronychia, diarrhea, pneumonia, and abnormal behavior was observed in 17 related Bull Terrier pups. Median survival time was 7 months. Laboratory evaluation revealed non-degenerative neutrophilia, consistently low activities of serum alkaline phosphatase and alanine transaminase, and frequently, hypercholesterolemia. Lymphocyte blastogenic responses were decreased and there was dysgammaglobulinemia in pups in which quantitative studies of immunoglobulins were made. The mean of plasma zinc concentrations in 5 affected pups was significantly lower than the mean of age- and breed-matched controls. Pathologic findings included parakeratosis, hyperkeratosis, and superficial bacterial infections of the skin. There was severe reduction of lymphocytes in T-lymphocyte areas of lymphoid tissue. Bronchopneumonia and dilatation of the cerebral ventricles were found in most affected pups. Family studies indicated that the syndrome is inherited as an autosomal recessive trait. In spite of its similarities to lethal trait A46 in Black Pied Danish cattle and acrodermatitis enteropathica in man, oral or parenteral treatment with zinc failed to ameliorate the clinical signs of the syndrome.

Interrelationships between zinc and immune function

Zinc deficiency is a common nutritional problem observed both in human and in animal populations that has profound effects on host defense mechanisms. Using the young adult mouse as a model, it has been demonstrated that a moderate period of suboptimal zinc causes thymic atrophy, lymphopenia, and alterations in the proportions of the various subsets of lymphocytes and mononuclear phagocytes. As a result, antibody-mediated responses to both T cell-dependent and T cell independent antigens are significantly reduced. Cytolytic T cell responses, natural killer (NK) cell activity, and delayed-type hypersensitivity (DTH) reactions are also depressed. Suboptimal zinc during in utero development of mice causes persistent states of immunodeficiency in the offspring that can even be transferred to subsequent generations. In regard to human immunological consequences of zinc deficiency, patients with the genetic disorder of zinc absorption, acrodermatitis enteropathica, also exhibit atrophic thymuses, lymphopenia, anergic DTH responses, and reduced NK cell activity. Patients suffering from sickle cell anemia or uremia with associated deficiencies in zinc exhibit similar immune deficiencies. An additional outcome of these studies has been shown to be an essential cofactor for thymulin, one of the thymic hormones. Furthermore, addition of zinc salts to culture can polyclonally activate lymphocytes as well as augment responses to mitogens in adjuvant-like manner.

Of mice and men, metals and mutations

Several mutations affecting the transport of copper and zinc in humans and in mice have been discovered over the last 15 years, joining the long known disturbance of copper transport in Wilson's disease. Menkes' disease (classical and mild variant forms) and X linked Ehlers-Danlos syndrome (type IX, X linked cutis laxa) have features in common with one another and with the brindled (Mobr) and blotchy (Moblo) mouse mutants, respectively. There may be one allelic series of mutants in each species or two loci may be involved in each. The toxic milk mutant (tx) in the mouse may be homologous to Wilson's disease in man. The defect of intestinal absorption of zinc in acrodermatitis enteropathica has no homologue yet in the mouse. However, the lethal milk (lm) mutant in the mouse may be homologous to a condition of zinc deficiency described in a few breastfed, low birth weight infants. Many more genetic defects of transport of copper and of zinc may await discovery. Conversely, these mutants are valuable in elucidating the normal processes of copper and zinc transport.

Inborn errors of trace element metabolism

Genetic disorders of trace element transport are now known in humans, mice, dogs and cattle. Those involving copper have been known longest and are best known clinically. Effects due to copper deficiency are seen in Menkes' disease, in X-linked cutis laxa and in the X-linked series of mottled mutants in the mouse. Copper accumulation is also harmful, causing damage initially to the liver and later to the kidneys and brain in Wilson's disease, in some Bedlington terriers and in toxic milk mice. Zinc deficiency is seen in acrodermatitis enteropathica and in premature babies born to women who seem to secrete milk that is zinc-deficient, as is seen in lethal milk mice. Study of animal mutants, especially mutant mice, is helpful in understanding the human diseases and identification of the basic defects in trace element transport in these diseases is improving knowledge relevant to trace element nutrition.

Familial juvenile generalized pustular psoriasis

The acral form of generalized pustular psoriasis is characterized by macroscopic pustules surmounting erythematous plaques that may progress from a localized distal eruption to involve the entire cutaneous surface. Juvenile-onset and familial-generalized pustular psoriasis are rare; familial-juvenile-generalized pustular psoriasis is exceptionally uncommon. A kindred of three children in the same generation had chronic, localized-acral pustular psoriasis and episodic-generalized pustular psoriasis.

Human leukocyte antigen in genodermatosis

Tissue typing performed on the lymphocytes of 41 patients, including: 23 patients with ichthyosis (15 of autosomal dominant and 8 of the x-linked variety; 8 patients with tuberous sclerosis (epiloia); and 10 patients with acrodermatitis enteropathica (AEP). In addition, tissue typing was performed for a control group of 80 healthy unrelated subjects of the same ethnic origin as the patients. A significant increase of A2 antigen or its crossreacting antigen A28 was detected among the three diseases studied. A significant increase of HLA-A2 antigen was found in autosomal dominant ichthyosis, while the x-linked variety showed significant association with HLA-Cw2. A significant association with HLA-A28 antigen was noticed in both epiloia and AEP. The suggested mechanisms of such association may be referred to as incidental genetic linkage with mutants causing disease or deficiency.

Serum and hair zinc as predictors of clinical symptoms in acrodermatitis enteropathica

Hair- and serum-zinc concentrations were measured in six patients with acrodermatitis enteropathica before and sequentially after cessation of zinc supplementation; supplementation was restarted when symptoms appeared. Serum zinc correlated accurately with zinc dosage and was lowest when symptoms of deficiency appeared. Hair zinc was initially age- and body size-related and was minimally influenced by the supplementation break. Adult patients had continuously normal concentrations. In paediatric patients hair zinc was low. Their serum concentrations should probably be maintained slightly above or at the upper limit of reference values for prolonged periods for normalization of hair and perhaps tissue zinc contents.

[Acrodermatitis enteropathica--hereditary parakeratosis in calves: contribution to comparative dermatology]

The treatment with oral zinc in the therapy of two zinc deficiency syndromes being identical in calves and man was discovered by veterinarians several years before the introduction of this life-saving therapy in human medicine. The importance of interdisciplinary contacts is emphasized.

Acrodermatitis enteropathica Reversibility of cerebral atrophy with zinc therapy

A six-month-old Saudi boy with acrodermatitis enteropathica confirmed by low serum zinc and alkaline phosphatase levels is described. Both the patient and a sibling developed acrodermatitis enteropathica while entirely breastfed. The mother had low serum zinc levels. Cranial computed tomography initially showed marked central and cortical "atrophy" that improved on treatment with zinc sulphate. The importance of zinc for normal brain growth and function is well known and the improvement on cranial computed tomography could be explained by improved myelination.

Hereditary acrodermatitis enteropathica in an adult

The condition of a 33-year-old woman who had a history of blisters following trauma on the hands, knees, and feet since 1 year of age previously had been diagnosed as epidermolysis bullosa. She also had psoriasiform plaques, a pustular crusted periorificial eruption, paronychia, alopecia, and photophobia. She had had minimal history of diarrhea. A markedly decreased serum zinc level was found, and treatment with zinc sulfate was instituted, resulting in clearing of all clinical manifestations. Since patients with hereditary acrodermatitis enteropathica may have minimal or no diarrhea and the correct diagnosis may be long delayed, the condition should not be considered strictly a disease of children.

Serum zinc levels in heterozygous carriers of the gene for acrodermatitis enteropathica: identification of a carrier state is not possible

Three cases of acrodermatitis enteropathica (a.e.) from two nonrelated families are described. Two siblings had characteristic symptoms of a.e. in childhood. Both survived to adulthood without treatment, at which time the clinical picture became uncharacteristic of a.e. Even so, the serum zinc levels confirmed the diagnosis in both cases. The third case showed classic symptoms of a.e.; the patient had a greatly reduced serum zinc level and responded at once to treatment with zinc sulphate. Heterozygous carriers of the gene for a.e. have often had slightly reduced serum zinc levels. The value of this test could probably be improved by correcting the normal range of serum zinc for factors known to influence this, such as the patient's age and serum albumin level. The normal range ought also to be corrected for diurnal and postprandial variations of serum zinc.

[Genetics of hereditary cutaneous diseases associated with digestive tract involvement]

Most of cutaneous hereditary diseases are associated with digestive symptoms but only four groups have a predominated digestive symptomatology: I. Hereditary disease with intestinal polyposis. II. Vascular dysplasias with intestinal haemorrhage. III. Connective tissue discover in hereditary diseases. IV. Acrodermatitis enteropathica with diarrhoea. Though very different with one another, Peutz-Jeghers syndrome and Gardner's syndrome are transmitted according to autosomal dominant trait. Only bi- or unigenic origin is still controversed. Rendu-Osler's disease and blue rubber bled naevus also transmit according to autosomal dominant trait. Pseudoxanthoma elasticum is very likely transmitted according to autosomal recessivity. But the main forms of Ehlers-Danlos disease are autosomal dominant conditions, the other form being either autosomal recessive or sex-linked (type V). Acrodermatitis enteropathica is transmitted according to autosomal recessivity but the gene has a very variable penetrance so that the mutations are very common.

[Acrodermatitis enteropathica. Anatomo-clinical study of 2 familial cases treated with zinc sulfate]

Two familial cases of acrodermatitis enteropathica began at the time of weaning, with characteristic dermatologic lesions and digestive signs, resulting in lack of weight gain: at 13 months of age growth future was evident in the elder child. The anatomic lesions were those of an exophagitis and, in the duodenal mucosa, a dilation of the capillaries of the chorion in the absence of villous atrophy. The ultrastructural study showed inclusions in Paneth's cells, and changes in keratin cells, with intra-cytoplasmic vacuoles and abnormal melanin pigment in the skin. The administration of zinc sulphate induced a rapid recovery of cutaneous lesions and resumption of growth. The interruption of treatment resulted twice in a quite immediate relapse of cutaneous signs in the first patient, which was rapidly reversible with the reintroduction of zinc sulphate.

[Acrodermatitis enteropathica; zinc sulfate therapy]

We present the case of two siblings with acrodermatitis enteropathica. Zinc levels were low. Oral administration of 100 mg of zinc sulfate allowed total regression of all signs. When zinc therapy was interrupted, the manifestations reappeared and disappeared again when treatment was resumed. A defect of genetic origin in digestive zinc absorption is suggested. Mohnahan's advocated zinc treatment of acrodermatitis enteropathica in 1973; it is a non-toxic treatment, which is always active and be considered as a diagnostic test.

Acrodermatitis enteropathica, zinc, and the Paneth cell. A case report with family studies

An infant with acrodermatitis enteropathica was studied before and after starting zinc therapy. Clinical recovery was rapid, and the plasma zinc, serum and mucosal alkaline phosphatase activities returned to normal. Light microscopy of small intestinal biopsies showed normal mucosa. Electron microscopy of the Paneth cells initially revealed abnormal inclusion bodies which disappeared during therapy, suggesting that the abnormality is secondary to zinc deficiency, and not a primary defect. These abnormal inclusions may represent altered secretory granules and a proliferation of lysosomes. We were unable to define the heterozygous state biochemically or histologically.

Acrokeratosis verruciformis: (Hopf)--A clinical entity?

Contrary to the unitarian concept of acrokeratosis verruciformis and Darier's disease, a comparative familial, clinical and histopathological analysis of six cases each of these two diseases has suggested that they are separate entities. Though clinically similar, acrokeratosis remained non-dyskeratotic throughout life, whereas the acral lesions of Darier's disease showed, on careful scrutiny and follow-up, various gradations of benign acantholytic dyskeratosis. Malignant transformation indicated that dyskeratosis in Hopf's disease would be very rare and of a different nature. The probability of a genetic linkage between the two genodermatoses is reviewed and discussed.

[Delayed manifestation of Costa's acrokeratoelastosis]

Acrokeratoelastoidosis, first described in 1952 bei O.G. Costa, belongs to the group of diffuse palmoplantar keratoses without associated symptoms. Probably it is an autosomal dominant trait. We observed a 49 year old female who has noticed her typical skin lesions for 2 years. The most marked histological features are proliferative hyperkeratosis, an almost complete lack of the fine subepithelial elastic fibre network and a marked rarefication of the coarse elastic fibres in the dermis.