Scleromyxedema with dermato-neuro syndrome

Consensus statement on the diagnosis and treatment of sclerosing diseases of the skin, Part 2: Scleromyxoedema and scleroedema

The term 'sclerosing diseases of the skin' comprises specific dermatological entities, which have fibrotic changes of the skin in common. These diseases mostly manifest in different clinical subtypes according to cutaneous and extracutaneous involvement and can sometimes be difficult to distinguish from each other. The present consensus provides an update to the 2017 European Dermatology Forum Guidelines, focusing on characteristic clinical and histopathological features, diagnostic scores and the serum autoantibodies most useful for differential diagnosis. In addition, updated strategies for the first- and advanced-line therapy of sclerosing skin diseases are addressed in detail. Part 2 of this consensus provides clinicians with an overview of the diagnosis and treatment of scleromyxoedema and scleroedema (of Buschke).

Successful treatment of dermato-neuro syndrome with plasmapheresis

Altered mental status can have many causes ranging from emergent intracranial pathologies to more insidious, systemic toxic aetiologies. We report a rare case of dermato-neuro syndrome in a 71-year-old man with a known history of scleromyxoedema. The patient initially presented with encephalopathy which quickly progressed to generalised tonic-clonic seizures and coma. While his presentation fits with other, although rare, cases of dermato-neuro syndrome, it is imperative to rule out lethal, more common causes of altered mentation. Due to the rarity and difficulty in diagnosis of dermato-neuro syndrome, there is a significant debate regarding the optimal management as there are no standardised treatment protocols. In our case, the patient was successfully treated with plasmapheresis resulting in improved neurologic function.

Scleroderma Mimickers

Cutaneous fibrosing disorders encompass a diverse array of diseases united by the presence of varying degrees of dermal sclerosis. The quality and distribution of skin involvement, presence or absence of systemic complications and unique associated laboratory abnormalities often help to distinguish between these diseases. It is imperative that an effort is made to accurately differentiate between scleroderma and its mimics, in order to guide long-term management and facilitate implementation of the appropriate treatment modality where indicated.

Miscellaneous indications for extracorporeal photochemotherapy (ECP)

Extracorporeal photochemotherapy (ECP) has been applied to many T-cell mediated diseases where immunosuppressive drugs are insufficient or not tolerated. As ECP is mainly used in rare indications after failure of other therapies, controlled studies are hardly possible. In addition, the importance of the extracorporeal circuit imposes ethical doubts in organising sham ECP procedure, which explains the rarity of controlled double-blind studies. However, encouraging and even successful results have been reported in newly developed diabetes mellitus, erosive lichen planus, Crohn's disease, systemic sclerosis, nephrogenic fibrosing dermopathy, atopic dermatitis, rheumatoid arthritis, systemic lupus erythematodes, psoriasis arthritis, cutaneous mucinosis, scleromyxoedema, pemphigus vulgaris, multiple sclerosis, eosinophilic fasciitis and in the prevention of percutaneous transluminal coronary angioplasty (PTCA) restenosis. This article discusses the various levels of evidence in the above cited indications.

[Scleromyxedema. A chronic progressive systemic disease]

BACKGROUND

Scleromyxedema is a rare connective tissue disease that may affect numerous internal organs in addition to the skin. The disease is almost exclusively associated with monoclonal gammopathy.

MATERIAL AND METHODS

This retrospective study summarizes the clinical characteristics of four patients with scleromyxedema. In all of the patients a systematic serological and apparative check-up was performed.

RESULTS

The mean age of the four patients (three women and one man) was 51 years. In all cases, monoclonal gammopathy (3 cases of IgG lambda and 1 case of IgG kappa) was involved. In one patient, skin lesions were restricted to the upper part of the body and three patients had generalized disease. The internal organs of all patients were affected with fibrosis of the lungs, myositis and arthritis, peripheral polyneuropathy and hypomotility of the esophagus. The most effective forms of treatment in this patient collective were dexamethasone-pulse therapy, intravenous immunoglobulins and bortezomib. All patients had recurrences after finishing therapy. The mean observation period after the initial diagnosis of scleromyxedena was 6.25 years (range 2-11 years).

CONCLUSION

Scleromyxedema is a rare multisystemic disease. The heterogeneous affection of internal organs necessitates a comprehensive check-up. The response to recently published treatment strategies is low and recurrences after finishing therapy are frequent.

Treatment of scleromyxedema and the dermatoneuro syndrome with intravenous immunoglobulin

Scleromyxedema is a rare disease characterized by extensive mucin deposition with fibrosis, and is associated with a monoclonal gammopathy. Currently there is no consensus on optimal treatment of this potentially fatal disease because of the lack of randomized controlled trials and limited number of case reports. At the time of this writing, 24 cases were published reporting clinical improvement of scleromyxedema with intravenous immunoglobulin. Herein we report a case showing dramatic improvement of scleromyxedema symptoms, both cutaneous and extracutaneous (including the dermatoneuro syndrome), and review the use of intravenous immunoglobulin in the treatment of scleromyxedema. This is a single case. The rarity of scleromyxedema, especially the dermatoneuro syndrome, precludes impedes large trials. In conclusion, increasing evidence supports intravenous immunoglobulin as an effective and relatively safe treatment for both cutaneous and extracutaneous manifestations of scleromyxedema, including the dermatoneuro syndrome.

Scleromyxedema: An experience using treatment with systemic corticosteroid and review of the published work

Scleromyxedema, a rare cutaneous mucinosis of unknown cause, is a variant of generalized papular mucinosis that is also known as generalized lichen myxedematosus. It is characterized clinically by generalized papular or scleroderma-like eruptions. Histopathological examination reveals mucin deposition and a proliferation of fibroblasts in the upper dermis. We describe the case of a man with scleromyxedema treated with systemic corticosteroids whose skin lesions improved gradually within 4 weeks.

Tumorous variant of scleromyxedema. Successful therapy with intravenous immunoglobulins

We present an unusual tumorous variety of scleromyxedema mimicking facies leonina in lymphoma. In spite of pronounced and widespread cutaneous changes, hypergammaglobulinaemia and paraproteinaemia, the general condition of the patient was satisfactory, there was no internal involvement and no symptoms of any malignancy. Initially, melphalan and corticosteroids were applied but were not effective. High-dose intravenous immunoglobulin (IVIG) therapy had dramatic effect, and after five 5-day monthly courses the tumours almost regressed and the skin became less hard. After a further five courses in the following year there was complete clearance, which was sustained without any therapy for 1 year (until now). IVIG appears to be the therapy of choice for scleromyxedema. We stress, however, that at the start of therapy, IVIG applications should be supplemented with small doses of melphalan and/or corticosteroids.

Dementia associated with scleromyxoedema reversed by high-dose intravenous immunoglobulin

Scleromyxoedema is a rare skin disease, characterized by deposition of acid mucopolysaccharides in the dermis. Although the disease primarily affects the skin, cardiovascular, renal and rheumatological manifestations have been described. In addition to these noncutaneous manifestations, about 15% of patients have central neurological symptoms such as psychosis, convulsions and encephalopathy. Successful therapy is difficult but high-dose intravenous immunoglobulin (IVIg) has been reported to be a successful treatment. We describe a patient with scleromyxoedema who presented with novel central nervous system manifestations of chronic cognitive impairment and dementia (Folstein Mini Mental State test score 8/30), which improved within a week after treatment with high-dose IVIg, with full restoration (Folstein Mini Mental State test score 27/30) at 2 months.

Escleromixedema associado a miocardiopatia

Relato de um caso de escleromixedema com lesões cutâneas associadas a miopatia, disfunção esofageana e paraproteinemia. Durante a evolução, a paciente apresentou sintomas de insuficiência cardíaca congestiva (ICC) que foram relacionados à miocardiopatia, passível de ocorrer em até 10% dos portadores de escleromixedema. São discutidos os aspectos clínicos, etiológicos e terapêuticos.

Treatment of recalcitrant scleromyxedema with thalidomide in 3 patients

Scleromyxedema is a generalized, papular, and sclerodermoid form of lichen myxedematosus associated with monoclonal gammopathy and systemic changes. Despite anecdotal reports of success with various agents, no satisfactory treatments are currently available. We report 3 adult patients with recalcitrant scleromyxedema associated with paraproteinemia who were treated with thalidomide. All 3 patients had marked improvement of the skin lesions and joint mobility after the first 2 months of therapy, with further amelioration after 4 months, and reduction in paraprotein levels.

Scleromyxedema revisited

Scleromyxedema is a rare disease characterized by papular mucinous deposits, dermal fibroblast proliferation, and a monoclonal paraproteinemia. Its chronic course tends to be complicated by gastrointestinal, muscular, pulmonary, and neurologic disorders. We review the literature to identify the common systemic manifestations and suggest a clinical approach to this disorder. This should include: identification of the characteristic lesions, a skin biopsy, and serum protein electrophoresis. A thyroid evaluation may help differentiate this condition from others. An early neurologic, gastrointestinal, and cardiovascular evaluation should be considered.

Diffuse cutaneous mucinoses

The cutaneous mucinoses are a complex group of dermatologic diseases with local, follicular, or diffuse disease. The diffuse cutaneous mucinoses are remarkable not only for their dermal disease, but also for the numerous systemic manifestations. It is important that the clinical dermatologist be able accurately to diagnose and differentiate scleredema, scleromyxedema, REM, generalized myxedema of hypothyroidism, and pretibial myxedema of hyperthyroidism. Because of the variability of associated systemic manifestations, some with substantial morbidity and mortality, accurate diagnosis is vital for awareness and appropriate management.

Scleroderma-like cutaneous syndromes

Several distinct entities associated with dermal fibrosis can mimic scleroderma/systemic sclerosis. The list of scleroderma-like conditions or scleroderma variants includes eosinophilic fasciitis, localized forms of scleroderma, scleredema and scleromyxedema, keloids, and environmental exposure-associated conditions including eosinophilia-myalgia syndrome and pseudosclerodermas induced by various drugs. Although these conditions are relatively uncommon, their accurate recognition is essential to avoid misdiagnosis and inappropriate therapy. The pathogenesis of these scleroderma variants appears to share similarities with each other and with that of scleroderma. Better understanding of scleroderma-like disorders is emerging through epidemiologic investigations, and in vivo and in vitro experimental research. Activation of eosinophils and disordered regulation of fibroblast collagen synthesis, apoptosis, and proliferation are recurrent findings in these disorders. The etiologic role of infection with Borrelia species or other microorganisms remains controversial. Cytokines such as transforming growth factor-beta, interleukin-4, interleukin-13, and connective tissue growth factor contribute to fibrosis in these disorders by inducing an accentuated and persistent fibrogenic response to tissue injury. The role of genetic factors in susceptibility and clinical expression of scleroderma-like conditions remains to be systematically addressed. Because of the relative rarity of these conditions, few well-controlled clinical treatment trials have been performed. In addition, there is no consensus on optimal management. Much anecdotal information and small clinical series indicate that phototherapy may have a role in the treatment of scleroderma-like conditions.