Life-threatening haemorrhage as a complication of a congenital haemangioma

Life-threatening complications of congenital haemangiomas are rare. A case of haemorrhage in a neonate is reported here. A neonate presented a congenital haemangioma of the limb complicated by a massive life-threatening haemorrhage. Colour ultrasonography showed a hypervascularized, highly haemodynamically active mass with a large, superficial drainage vein just under the ulceration. Surgical resection was performed with satisfactory postoperative outcome and no evidence of recurrence.

CONCLUSION

Early surgical removal can be a good therapeutic option for complicated congenital haemangiomas.

Lupus-erythematosus-like eruption induced by Trichophyton mentagrophytes infection

BACKGROUND

Several factors are known to trigger acute manifestations of lupus erythematosus (drugs, ultraviolet radiation, bacterial or viral infections, pregnancy), but fungal infections have never been reported to induce lupus-like lesions. We describe 2 children with tinea capitis caused by Trichophyton mentagrophytes(TM), who developed transient skin and serological manifestations of systemic lupus erythematosus.

PATIENTS

Case 1, a 3-year-old girl, had a kerion due to TM transmitted by an octodon, and a facial skin eruption suggestive of systemic lupus erythematosus. Antinuclear antibodies (ANA) were positive at 1:250. After griseofulvin treatment, the lupus-like rash completely regressed, and the ANA titre decreased. Case 2, a 4-year-old girl, had occipital kerion and an annular scaly erythema on the shoulder caused by TM. She also had a non-scaly rash on the face and a recent history of photosensitivity. The ANA titre was positive at 1:8,000. Cutaneous lesions disappeared after an 8-week griseofulvin therapy, and ANA titres decreased progressively.

CONCLUSIONS

'New pets' are usually the vectors of TM, especially familiar rodents like the degu of Chile (also named octodon). In our 2 cases, lupus-like rashes began before the onset of griseofulvin treatment, suggesting a pathogenic role of the dermatophyte. A wide variety of lesions named 'mycides' was described several decades ago associated with TM infections. We hypothesize that these mycides and the TM-induced lupus-like lesions reported in our 2 cases could represent the same entity.

[Herpetic-like worsening of an epidermolysis bullosa simplex during pregnancy]

INTRODUCTION

Episodes of hereditary epidermolysis bullosa simplex are usually provoked by repeated cutaneous traumas or exposure to heat. We report a case of hereditary epidermolysis bullosa simplex worsened during pregnancy.

OBSERVATION

A 21 year-old woman suffering from hereditary epidermolysis bullosa simplex presented with unusual symptoms in the form of an extensive vesicular-bullous eruption at two months of her first pregnancy. Standard histological examination revealed an eosinophilic infiltrate in the bullae. The global results of the initial examinations suggested a herpetic-like episode of epidermolysis bullosa as is observed during the Dowling-Meara form of the disease.

DISCUSSION

Various physiopathological hypotheses can be advanced to explain the worsening of the eruption during pregnancy: a mechanical origin with scratching of pruritus, enhanced fragility of the inter-keratinocyte bridges secondary to edema provoked by salt-water retention or a loss in antigenic tolerance to muted keratins 5 and 14, as in pemphigoid gestationis. The presence of eosinophils in the dermis and epidermis may also participate directly in the formation of bullae due to the release of cationic proteins.

[Eccrine squamous syringometaplasia and cytomegalovirus infection]

BACKGROUND

Eccrine squamous syringometaplasia has been reported in some cases as an Herpeviridae complication. We report a case of eccrine squamous syringometaplasia associated with a severe cytomegalovirus infection in an immunocompromised patient, and we discuss about potential viral or drug triggering factors.

METHODS

A 22 years-old man was hospitalized in an intensive care unit for rejection of a renal graft associated with a disseminated cytomegalovirus infection. A papular and papulopustular eruption appeared on the trunk and the limbs.

RESULTS

Histological examination of a skin sample showed eccrine squamous syringometaplasia, with evidence of cytomegalovirus genomic sequences using PCR. Two weeks later, the patient developed toxic epidermal necrolysis, with fatal issue.

CONCLUSIONS

Eccrine squamous syringometaplasia is a rare condition, without specific clinical features. Numerous local affections have been reported to induce eccrine syringometaplasia (ulcer, scar, pyoderma gangrenosum, drug injection.), drugs (cytotoxic agents, non steroidal anti inflammatory therapies) and in cases of infection due to cytomegalovirus or herpes simplex virus. The potential implication of cytomegalovirus or foscarnet as triggering factors in our case is discussed. This observation and other similar reported cases lead to the conclusion that eccrine squamous syringometaplasia may be an underestimated complication of cytomegalovirus infections in immunocompromised patients.

[Kawasaki's disease with eruptive pustular and guttate psoriasis]

BACKGROUND

Kawasaki's disease may have numerous atypical forms and these must be recognized in order to avoid delay of treatment. We report a case of psoriasis, first pustular and then guttate, occurring during Kawasaki's disease, and discuss a common pathophysiological mechanism.

CASE-REPORT

A 3 year-old boy was seen for a febrile exanthema suggestive of Kawasaki disease (bilateral conjunctivitis, red and fissured lips, palmoplantar erythema, scarlet fever-like rash and perineal desquamation) associated with pustular lesions. A biopsy specimen of a pustular area showed histological features consistent with the diagnosis of pustular psoriasis. No coronary abnormality was found. The child was treated with intravenous immunoglobulins (2 g/kg) and oral aspirin (60 mg/kg/d). All the symptoms disappeared and immediate follow-up was marked by the appearance of guttate psoriasis.

DISCUSSION

Onset of psoriatic lesions during Kawasaki disease has been reported in 12 cases, either in acute phase or in immediate follow-up. Coronary complications have been found in 4 of 5 cases with acute psoriasis, suggesting a severe prognosis for this association. The hypothesis of a common pathophysiological mechanism is discussed with the intervention of a bacterial toxin acting as a superantigen and resulting in an strong activation of T-cells that leads to keratinocyte activation. The psoriatic lesions could hence be considered as a form of Köbner's phenomenon.

[Reflex sympathetic dystrophy of childhood: one case]

INTRODUCTION

Reflex sympathetic dystrophy (Complex Regional Pain Syndrome type 1) is little known by dermatologists. We report a pediatric case of reflex sympathetic dystrophy with predominant cutaneous involvement.

CASE REPORT

A 10 year-old girl presented a warm, painful and relapsing right hand edema for seven months (three outbreaks). The hand was cyanotic, pigmented and painful. Routine blood tests were normal. Radiography and radionuclide bone scan were consistent with stage 1 reflex sympathetic dystrophy. Physiotherapy led to dramatic improvement.

DISCUSSION

Reflex sympathetic dystrophy is known since the XVIIIth century. In the last decade, progress in radiology and bone scan have provided elements for understanding the physiopathology of the disease. Microvascular abnormalities under the control of sympathetic nervous system are characteristic of different stages of reflex sympathetic dystrophy. Recently, neurovascular system experiments showed that sympathetic reflex tonus changes may be controlled by the central nervous system. Dermatologic changes of reflex sympathetic dystrophy are well known: edema and erythema in first stage, cyanosis in second stage, sclerosis and atrophia in third stage, but pediatric cases are rarely reported.

CONCLUSION

Reflex sympathetic dystrophy is a complex disease, however its physiopathology is now understood. The clinical presentation can be atypical and the dermatologist may be the first to be consulted.

[Difficulty in the management of congenital insensitivity to pain]

We report a case of hereditary sensitive neuropathy associated with insensitivity to pain in an infant.

CASE REPORT

The girl was born after a normal full term pregnancy. She was hospitalized in the neonatal period because of hypotonia and recurrent cyanotic episodes due to false passage. The diagnosis of insensitivity to pain was suspected at nine months of age, as parallel with dentition, multiple mutilations of the tongue and the fingers were observed. The diagnosis was confirmed by biopsy taken from the sural nerve which showed a rarefaction of small myelinated fibres whereas unmyelinated fibres remained unaltered. At the age of six years, the general condition was good and the neurologic developement was satisfactory, neurotrophic and urologic complications currently being the main problem.

CONCLUSION

A multidisciplinary and specialized care associated with parental compliance was necessary to minimize the complications of this potentially severe disorder.

[Blood pressure monitoring in infants with hemangiomas treated with corticosteroids]

INTRODUCTION

Alarming hemangiomas can be successfully treated with corticosteroids. The risk of hypertension is poorly documented in this setting. We conducted a prospective study in infants with hemangiomas treated with orally administered prednisone.

PATIENTS AND METHODS

Thirty-seven patients with rapidly growing complicated hemangiomas were enrolled between January 1998 and November 1999. Steroid dosages varied from 1 mg/kg/d to 5 mg/kg/d. Blood pressure measurements were performed first twice a month, then monthly at rest with a Critikon Dynamap device. Hypertension was defined as blood pressure superior to 110/60 mmHg, and borderline if superior to 110/60 mmHg on only one or two measurements.

RESULTS

Increased blood pressure was found in seven infants (19 p. 100). One infant had hypertension requiring specific treatment and blood pressure was borderline on six patients at one or two occasions. Cardiac ultrasound examination was performed in five patients revealing two cases of myocardic hypertrophy, which regressed after stopping steroids and without relationship to hypertension.

CONCLUSION

Even though the definition of hypertension in still arbitrary in infants, the measurement of blood pressure is necessary when steroid therapy is given for the treatment of hemangiomas. Blood pressure measurement can be difficult in very young children and overestimation is frequent if an inadequate device is used. The exact place of cardiac ultrasound remains to be defined in the management of alarming hemangiomas.

[Color Doppler sonography of superficial capillary hemangiomas]

PURPOSE

Retrospective analysis of the morphologic and hemodynamic characteristics of hemangiomas in infants provided by color Doppler sonography.

MATERIALS AND METHODS

94 hemangiomas were studied in 87 children separated into four classes of age (0-3 months, 3-6 months, 6-12 months, > 12 months). Eleven were followed with several examinations. Echogenicity, compared to normal subcutaneous tissues, and degree of vascularization were assessed qualitatively. Resistive index (RI) was measured in 78 cases.

RESULTS

All lesions presented as vascularized solid masses: 63% were hypoechoic, 16% hyperechoic and 21% mixed. All hypoechoic and mixed lesions showed higher vascularity than hyperechoic ones. Hyperechoic hemanigomas were more frequent in the fourth class of age. Mean resistive index was significantly higher in the first (0.61 +/- 0.14) and the fourth (0.6 +/- 0.14) classes of age than in the second (0.51 +/- 0.12) (p = 0.01 and < 0.03, respectively), and higher in the hyperechoic group (0.7 +/- 0.13) than in the hypoechoic group (0.53 +/- 0.11), (p < 0.01). Seven of 11 cases moved from hypoechoic to hyperechoic or mixed. Increase of resistive index with age was noted in 9/11 cases.

CONCLUSIONS

Superficial hemangiomas have typical but variable gray-scale, spectral and color flow sonographic patterns. These fluctuations are probably related to phases of evolution.

[Ecthyma gangrenosum caused by Pseudomonas aeruginosa without septicemia in a neutropenic patient]

INTRODUCTION

Ecthyma gangrenosum is a rare skin infection caused by gram negative bacteria. It involves immunocompromised patients, especially neutropenic patients, and can be easily diagnosed.

EXEGESIS

We report a case of ecthyma gangrenosum without septicemia due to Pseudomonas aeruginosa in a myelodysplastic patient with severe neutropenia. Granulocyte growth factors adjunction was necessary in combination to antibiotics to obtain complete healing.

CONCLUSION

In neutropenic patient, ecthyma gangrenosum due to Pseudomonas aeruginosa should be rapidly diagnosed to avoid septicemic complications. In the case of antibiotic treatment failure, granulocyte growth factors may be added. Frequent Pseudomonas aeruginosa infections justify bacteriologic survey to look for hospital contamination.

Saline spa water or combined water and UV-B for psoriasis vs conventional UV-B: lessons from the Salies de Béarn randomized study

OBJECTIVE

To study the effects of UV-B therapy and saline spa water given alone or in combination for the treatment of psoriasis.

DESIGN

Randomized, controlled, comparative study with blinded observers.

SETTING

Salies de Béarn, saline spa water center located in the southwest of France.

PARTICIPANTS

Seventy-one adult patients with psoriasis with a Psoriasis Area and Severity Index (PASI) score greater than 10.

INTERVENTION

Patients were randomly assigned to 1 of 3 treatments: spa water alone (group A); UV-B 311-nm phototherapy alone (group B); and a combination of the 2 therapies (group C). The 3 groups were treated on a daily basis 5 days a week for a total of 21 days.

MAIN OUTCOME MEASURES

Change in PASI score from baseline as determined by an investigator blinded to randomization; variation in quality of life, adverse effects, and long-term effects (1 year after treatment).

RESULTS

Four patients dropped out because of secondary effects. Efficacy was similar in groups B and C, with changes in PASI of -64% and -55%, respectively at 3 weeks. For group A, change in PASI was -29%, thus showing a minor therapeutic effect of saline spa water alone and poor efficacy compared with groups B and C (P<.001). More adverse effects were reported in groups A and C but did not reach significance. Combined saline spa water and UV-B therapy had no sparing effect on UV-B dosages. One year after treatment, no long-term benefit could be attributed specifically to a given regimen, but the patients had overall significantly better PASI scores than at baseline.

CONCLUSIONS

Saline spa water alone had a minor therapeutic effect in psoriasis, and the beneficial effect of bathing to enhance phototherapy was not demonstrated.

Self-healing generalized infantile myofibromatosis with elevated urinary bFGF

We report a case of generalized infantile myofibromatosis with favorable outcome despite systemic involvement. Elevated urinary bFGF levels during the active phase of the disease suggested an angiogenic stimulation in the pathogenesis of myofibromatosis.

[Sensitization to cockroach allergens evaluated by skin tests in children with atopic dermatitis]

INTRODUCTION

Cockroach and house dust mites (Dermatophagoides pteronyssinus, Dp and farinae, Df) are the most often implicated aeroallergens in severe asthma, hay fever and conjunctivitis. Cockroach allergy is still unknown in atopic dermatitis.

PATIENTS AND METHOD

146 children with atopic dermatitis-aged 6 months to 15 years- have been patch tested with the European standard series and some aeroallergens. We have studied the sensitisation to cockroach allergens and compared to Dp and Df.

RESULTS

113 children reacted positively at least to one of the 3 aeroallergens (77 p. 100), 61 children had a positive reaction to cockroach (42 p. 100) and 29 simultaneously to the 3 allergens.

DISCUSSION

Delayed hypersensitivity to house dust mites in young children with atopic dermatitis suggests early epicutaneous sensitization due to an altered epidermal barrier. For us, cockroach could also be implicated in some flare-ups of atopic dermatitis. Eviction of cockroach and house dust mite should be proposed for children with a positive patch test to cockroach.

Diagnosis, classification, and management of erythema multiforme and Stevens-Johnson syndrome

BACKGROUND

In adults, erythema multiforme (EM) is thought to be mainly related to herpes infection and Stevens-Johnson syndrome (SJS) to drug reactions.

AIMS

To investigate this hypothesis in children, and to review our experience in the management of these patients.

METHODS

A retrospective analysis of 77 paediatric cases of EM or SJS admitted to the Children's Hospital in Bordeaux between 1974 and 1998.

RESULTS

Thirty five cases, inadequately documented or misdiagnosed mostly as urticarias or non-EM drug reactions were excluded. Among the remaining 42 patients (14 girls and 28 boys), 22 had EM (11 EM minor and 11 EM major), 17 had SJS, and three had isolated mucous membrane involvement and were classified separately. Childhood EM was mostly related to herpes infection and SJS to infectious agents, especially Mycoplasma pneumoniae. Only two cases were firmly attributed to drugs (antibiotics). No patient died. EM and SJS sequelae were minor and steroids were of no overall benefit.

CONCLUSION

In paediatric practice EM is frequently misdiagnosed. The proposal that SJS is drug related in adults does not apply to children, and in our recruitment EM and SJS are mostly triggered by infectious agents. The course of both diseases, even though dramatic at onset, leads to low morbidity and mortality when appropriate symptomatic treatment is given.

[Neonatal staphylococcal epidermolysis due to maternal-fetal transmission]

INTRODUCTION

The staphylococcal scalded skin syndrome (SSSS) is due to exfoliative toxins A or B excreted by some strains of Staphylococcus aureus. This syndrome is exceptional in the first hours of life. We report a case of SSSS due to materno-fetal infection.

CASE REPORT

At 31 weeks of pregnancy a 40-year-old mother was febrile (39 degrees C) and a premature rupture of the amniotic sac occurred the following day. SSSS was diagnosed at 6 hours of life in the newborn, a 1760 g female. Staphylococcus aureus grew on the blood and vaginal bacterial cultures of the mother, as well as, from cultures of skin, nose, throat, and umbilical catheter in the newborn. The strains of Staphylococcus aureus isolated in the mother and the child had identical characteristic antibiotype and genotype by Random-PCR. The genes for both exfoliations A and B were present. Epidermization was rapidly obtained and no septicemia or septic complication was noted.

DISCUSSION

Staphylococcus aureus is usually responsible for nosocomial infections which occur in the early newborn period. In most cases, the infection is transmitted by a carrier who manipulates the child (family, visitors, nurse or medical staff). In our case, onset of SSSS early after birth suggested a perinatal transmission, due to lower genital tract infection in the mother. The presence of SSSS in the child and not in the mother may be explained by a massive perinatal infection and low elimination of the toxin in the newborn resulting in higher concentrations of exfoliative toxins in the blood.

Asymmetric periflexural exanthem of childhood: a clinical, pathologic, and epidemiologic prospective study

OBJECTIVE

To assess the clinical, pathologic, and epidemiologic features of asymmetric periflexural exanthem of childhood (APEC), a clinically distinctive eruption, especially its link with pityriasis rosea and pattern of transmission.

DESIGN

A prospective case series, including an analysis of epidemiologic triggering factors and mode of transmission. Pathologic study, including immunohistochemistry of the inflammatory infiltrate.

SETTING

A mixed, community-based referral center.

PATIENTS

A total of 37 girls and 30 boys with typical APEC referred from April 1994 to December 1996 were included in the study; 82% came from the greater Bordeaux area in France.

INTERVENTION

None.

MAIN OUTCOME MEASURE

Possible interhuman transmission of APEC.

RESULTS

[corrected] No triggering factor was identified; no interhuman transmission occurred; and no demonstrable link with pityriasis rosea was apparent. Several new clinical variants were recognized or confirmed (high fever, facial and peripheral involvement, prolonged course). Distinctive perisudoral interface CD8+ infiltrate was suggestive of diagnosis.

CONCLUSIONS

Interhuman transmission was doubtful, but inoculation disorder was still possible. Histopathologic findings seem more specific than previously thought.

[Leprosy disclosed by polyarthritis]

BACKGROUND

We report a case of leprosy observed in a French woman who had lived in Africa 30 years earlier. The clinical presentation was misleading, suggesting connective tissue disease.

CASE REPORT

A 69-year-old woman was hospitalized in April 1996 for inflammatory joint disease. The first manifestations had developed three years earlier and the patient had been on systemic corticosteroid therapy associated with anti-malarials since 1993. The clinical presentation progressively included neurological and skin manifestations. Histology examination gave the diagnosis of lepromatous leprosy. Three-drug anti-leprosy treatment in one oral dose was initiated.

DISCUSSION

Chronic Mycobacterium leprae infection usually leads to overt leprosy with neurological and cutaneous involvement. Rheumatological forms are less common and found almost exclusively during leprous reactions. The association of inflammatory join pain with neurological and skin manifestations wrongly suggested vasculitis. In addition, the general corticosteroid therapy certainly was implicated in disease activation and progression to a purely lepromatous form.

Congenital cutaneous defects as complications in surviving co-twins. Aplasia cutis congenita and neonatal volkmann ischemic contracture of the forearm

BACKGROUND

During twin pregnancies, several complications may result in the death of a co-twin depending on the date of death. We describe herein 2 infant survivors of monozygotic twin pairs with 2 distinct possible complications: a aplasia cutis congenita and Volkmann ischemic contracture.

OBSERVATIONS

One infant had extensive aplasia cutis congenita with an associated monozygotic co-twin who died at 3 months of gestation, and the other child had a localized arm defect due to Volkmann ischemic contracture and brain damage, with a co-twin who died at approximately 6 weeks of gestation.

CONCLUSIONS

Congenital cutaneous defects may result in the death of a co-twin. The most common of these defects is aplasia cutis congenita associated with a fetus papyraceus or a dead fetus related to ischemic/thrombotic events in the placenta and fetus. Volkmann ischemic contracture is rare in the newborn but can cause neonatal cutaneous defects. The cause of Volkmann ischemic contracture in newborns is unknown; however, our second observation suggests the possible role of a dead fetus.

[Faun tail and sacral hemangioma associated with occult spinal dysraphism]

INTRODUCTION

Hemangiomas are the most frequent skin tumor of childhood. Usually, a "wait and see" policy is adopted. However, a sacral hemangioma may reveal occult neurodysraphism.

CASE REPORT

MRI discovered lipomyelomeningocele and a tethered spinal chord in an asymptomatic 4-month-old boy with sacral hemangioma and faun tail. Because of absence of neurological defect only surgery of the caudal appendage was performed for the moment.

DISCUSSION

Midline lombosacral lesions, as well as lipomas, hirsutism or pilonidal cyst, may be associated with occult spinal defect; the most severe is tethered chord. Renal or ano-genital anomalies can be also associated.

CONCLUSION

MRI is necessary in case of midline sacral hemangioma to detect underlying anomalies.

[Lichen planus in children: role of the campaign for hepatitis B vaccination]

INTRODUCTION

Cutaneous lichen planus in children is a rare entity. To study its specific clinical and therapeutic features, we report on 8 cases seen in 5 years in a pediatric dermatology clinic. In parallel, this study addresses the role of HBV immunization campaigns in childhood lichen planus.

OBSERVATIONS

Six boys and two girls with a diffuse form of lichen planus were studied. The mean age was 11 years. Four children were of skin types V and VI. Lesions followed Blaschko's lines in two children. One case was associated with atopic dermatitis. In half the cases--the most recent--the eruption was noted after HBV immunization. Biopsy specimens from seven children were reviewed and confirmed the diagnostic of lichen planus. Oral retinoids or corticosteroids were used successfully in six cases.

DISCUSSION

Half of our cases confirmed the atypical features of lichen planus in childhood. This study confirms the predominance of lichen planus in children with pigmented skin suggesting a genetic predisposition. The eruption following Blaschko's lines suggests that a clonal keratinocytic population is the target of lichenoid inflammation. HBV immunization could be a stimulus triggering a cytotoxic lymphocyte-mediated reaction. The proportion of affected children was low in comparison with all children immunized. So lichen planus arises probably in predisposed children. This justifies surveillance in the pediatric and dermatologic medical communities.