Lipoid Proteinosis: A Rare Cause of Hoarseness

Advances in treatment for lipoid proteinosis (Urbach-Wiethe disease): a case report and systematic review

BACKGROUND

Lipoid proteinosis (LP), also known as Urbach-Wiethe disease, is a rare autosomal recessive genodermatosis, caused by mutations in the ECM1 gene. This results in the deposition of periodic acid-Schiff (PAS)-positive, hyaline-like material on the skin, mucosae and internal organs.

OBJECTIVES

To present a case report of LP and a systematic review to synthesize the scientific literature on the management of this uncommon and frequently missed diagnosis.

METHODS

We present a case report of a 48-year-old man with LP who exhibited significant improvement after oral acitretin therapy. To address the lack of large case-control studies on LP treatment, we performed a systematic review of the literature following the PRISMA 2020 criteria. The search was conducted in PubMed, Web of Science, Cochrane and Scopus databases from inception until June 2023. To assess the methodological quality of case reports and case series, we used the Joanna Briggs Collaboration critical appraisal tool.

RESULTS

We included 25 studies that met eligibility criteria. Data from 44 patients with a histopathologically confirmed diagnosis were analysed. Treatment ranged from systemic therapies (acitretin, etretinate, dimethyl sulfoxide, corticosteroids, penicillamine) to surgical or laser procedures. Regarding methodological quality, the main discrepancies arose in the reporting of participant characteristics and treatment interventions.

CONCLUSIONS

Low-dose oral acitretin could have potential in managing LP, exhibiting fewer side-effects compared with other therapeutic agents. Further research is needed to establish more comprehensive and evidence-based treatment guidelines.

Laryngeal features in Lipoid proteinosis: a systematic review and meta-analysis of individual participant data

PURPOSE

Lipoid proteinosis (LP) or Urbach-Wiethe disease (OMIM 247100) is a rare syndrome characterised by early vocal folds infiltration and subsequent multi-organ involvement. LP is often unrecognised and its associated hoarseness is overlooked. The main objective of the study was to investigate hoarseness in LP and implement a diagnosis among otolaryngologists.

METHODS

PubMed/MEDLINE and OMIM databases were systematically searched. Authors concentrated the search on published articles starting from the discovery of the pathogenesis of LP by Hamada et al. in 2002. Only cases in which a diagnosis was reported both clinically and through biopsy and/or genetic molecular testing were included. Characteristics of the LP cases were extracted from each included study. Results were obtained through Generalized Estimating Equations.

RESULTS

The search strategy yielded 217 articles, of which 74 (34.1%) met the selection criteria. A total of 154 cases were included. Hoarseness was described in all LP cases and clearly stated as the onset symptom in 68.8%. The onset was on average at 19 months of age (CI: 3.00-20.00), while the mean age at diagnosis was 15 years (CI: 10.00-30.00). Therefore, the diagnostic delay amounted to 13.42 years (CI: 8.00-23.83). Hoarseness alone was responsible for an LP diagnosis in only 14.3% of cases. In 43.5% of cases, genetic analysis of the ECM1 gene was performed and exon 6 was the most frequently altered portion.

CONCLUSION

Analysing the largest number of published cases, the study underlined that hoarseness is the key symptom for diagnosing LP since early childhood, though frequently overlooked.

A Sporadic Family of Lipoid Proteinosis with Novel ECM1 Gene Mutations

Lipoid proteinosis (LP) is an uncommon, autosomal recessive genetic disorder. Multigene panel testing was conducted to confirm the diagnosis of a sporadic family with suspected LP. In the proband, we identified two mutations of ECMI and provided genetic evidence for informed genetic counselling.

Pediatric Voice Disorders from the Perspective of Rare Diseases

OBJECTIVE

This study aims to present rare pediatric voice disorders, which are usually reported as case reports in the literature, with their clinical features, treatment options, and prognosis, and to emphasize clinical findings that may be associated with rare diseases.

METHODS

The clinical records of the pediatric patients presented with dysphonia were reviewed between 2014 and 2019. The terminology "rare disease" is used to describe diseases where the average prevalence thresholds are between 40 to 50 cases/100,000 people. Age, gender, symptoms, laryngeal examination findings, histopathological results, treatment modalities and follow-up results of rare laryngeal pathologies were reviewed.

RESULTS

274 children were diagnosed with and treated for voice disorders at our institution. Seven patients were identified with rare laryngeal pathologies. Four patients diagnosed with lipoid proteinosis, two patients with neurofibroma and one patient with amyloidosis. One patient was known to have neurofibromatosis type-1, while the others did not have any previously diagnosed diseases, dysphonia was the initial clinical presentation.

CONCLUSION

There are some clues that bring to mind rare entities. Firstly, these patients generally present with various systemic manifestations. Secondly, if there is any discrepancy between voice quality and endoscopic laryngeal examination, the diagnosis should be reconsidered. Thirdly, in the case of the prolonged dysphonia recalcitrant to treatment, the clinician should reassess the treatment or the diagnosis.

Evaluation of choroidal thickness and ocular manifestations in lipoid proteinosis

PURPOSE

To assess choroidal thickness in patients with lipoid proteinosis versus healthy subjects using enhanced depth imaging optical coherence tomography.

METHODS

Twenty eyes of 20 patients and the same number of age and sex-matched healthy individuals were enrolled. Comprehensive ocular examinations including measurement of best-corrected visual acuity, spherical equivalent values of refractive errors, and axial length were performed. Choroidal thickness at three points (subfoveal, 500 µm nasal and temporal regions) were measured automatically using MATLAB software.

RESULTS

The mean age was 15.68 ± 5.98 years in the patient group and 16.48 ± 5.69 years in the control group. Mean choroidal thickness was statistically significantly thicker at each point in patients with lipoid proteinosis compared to the healthy controls: subfoveal, temporal and nasal choroidal thickness measurements were 425.65 ± 51.42, 380.20 ± 69.66, 334.05 ± 49.98 µm in the study group; 346.15 ± 47.76, 330.15 ± 44.35, 298.95 ± 44.21 µm in the control group, respectively (P < 0.05).

CONCLUSION

Patients with lipoid proteinosis have thicker choroid compared to control eyes. Hyalin deposition and ensuing potential inflammation in the disease process may explain this finding.

Assessment of dynamic thiol-disulfide homeostasis in patients with lipoid proteinosis (Urbach-Wiethe syndrome)

OBJECTIVE:

Lipoid proteinosis is a rare autosomal recessive genetic dermatological disease that occurs due to the accumulation of hyaline material in the skin and mucous membranes. This study aimed to investigate whether dynamic thiol-disulfide homeostasis is a new marker of oxidative stress in patients suffering from lipoid proteinosis.

METHODS:

The study group involved 17 patients with lipoid proteinosis and 17 healthy controls with same gender and age. Native thiol, total thiol, disulfide levels, and thiol-disulfide indexes were measured with the fully automated spectrophotometric method described by Erel and Neselioglu, and the results of the two groups were statistically analyzed.

RESULTS:

Serum total thiol and native thiol levels were significantly lower in lipoid proteinosis group compared to the control group (p=0.020 and p=0.014, respectively). The disulfide levels were found to be higher in lipoid proteinosis group, but there was no significant difference between two groups.

CONCLUSIONS:

Impaired dynamic thiol-disulfide homeostasis was observed in lipoid proteinosis patients, suggesting that thiol-disulfide homeostasis may have a role in the pathogenesis of this disease.

Late presentation of laryngeal lipoid proteinosis: a case report and review of the literature

Lipoid proteinosis (LP) is a rare autosomal-recessive disease characterized by the deposition of hyaline material infiltrating multiple body organs, including the larynx. The possible clinical presentations are wide-ranging. Laryngeal involvement results in dysphonia that is noted at birth or infantile years. The diagnosis is based on histological findings, and the management options vary depending on the severity of the symptoms. In this paper, we report an unusual case of LP with laryngeal involvement in an adult patient, along with a review of current literature.