Congenital pyloric atresia in a newborn with extensive aplasia cutis congenita and epidermolysis bullosa simplex

Challenges in the management of extensive aplasia cutis congenita

Aplasia cutis congenita (ACC) is a rare group of congenital disorders characterised by focal or widespread absence of skin, predominantly affecting the scalp. A Malay female infant was born at 37 weeks with extensive ACC, affecting 37% of total body surface area, including her scalp and trunk. There is no consensus on the management of ACC given the rarity and variable presentation. A multi-disciplinary team comprising neonatologists, paediatric dermatologists, plastic surgeons and medical laboratory scientists at the skin bank, employed a more aggressive surgical approach with the aim of avoiding potentially catastrophic morbidity, including sagittal sinus haemorrhage and brain herniation. Out of several surgical options, the team used a staged artificial dermal matrix (Integra) and cultured epithelial autograft application, followed by regular wound dressing, and eventually allowed the child to achieve complete epithelialisation of her trunk, and most of scalp before she was discharged from hospital.

Dominant dystrophic epidermolysis bullosa with congenital absence of skin and brachydactyly of the great toes

Epidermolysis bullosa (EB) encompasses a phenotypically and genetically heterogeneous group of inherited skin disorders characterized by blistering and erosions of the skin with minimal trauma. Dystrophic EB (DEB), both dominant and recessive, can be associated with several extracutaneous manifestations, including musculoskeletal deformities. Congenital deformities of the feet have rarely been reported in the literature. We describe an infant with dominant DEB and congenital absence of the skin who presented with congenital brachydactyly of the bilateral great toes.

Epidermolysis bullosa with congenital absence of skin: Review of the literature

BACKGROUND/OBJECTIVES

Bart syndrome was initially described as association of congenital absence of skin (CAS), nail abnormalities, and epidermolysis bullosa (EB). Further reports of patients with CAS and EB have been made with wide clinical heterogeneity among them. Current guidelines recommend the elimination of eponyms and use of the descriptive term EB with CAS.

METHODS

We performed a PubMed and Medline database search of patients with Bart syndrome or EB with CAS. We included case reports or case series that contained clinical and demographic information.

RESULTS

After review, 55 articles were included, reporting 96 patients. CAS involved the lower extremities in all patients, with additional upper limb, trunk, or head involvement in 17%. In all patients, the time to healing ranged from 2 weeks to 6 months; most received only conservative treatment. The subtype and frequency of associated EB most frequently reported were recessive dystrophic EB (41.4%) and dominant dystrophic EB (22.8%). Extracutaneous features were present in 29 patients; with pyloric atresia and ear malformations being the most common. The prognosis varied based on the subtype of EB and the presence of additional comorbidities; 50% of the patients with junctional EB with pyloric atresia and CAS died during the first months of life, while mortality among those with recessive dystrophic EB was 6.8%.

CONCLUSION

Epidermolysis bullosa with CAS is a clinically heterogeneous disorder, most often associated with recessive dystrophic EB, but other EB subtypes may occur. Further investigations are necessary to better establish a pathological mechanism for CAS, and its association with EB.

Phenotypic Spectrum of Epidermolysis Bullosa: The Paradigm of Syndromic versus Non-Syndromic Skin Fragility Disorders

The heritable forms of epidermolysis bullosa (EB), a phenotypically heterogeneous group of skin fragility disorders, is currently associated with mutations in as many as 21 distinct genes. EB is primarily a disorder affecting the epithelial layers of skin and mucous membranes, without extracutaneous manifestations, and thus is nonsyndromic. However, recent demonstrations of skin blistering in multisystem disorders with single gene defects highlight the concept of syndromic EB. Here, we review the phenotypic and genotypic features of syndromic forms of EB to delineate the concept of syndromic versus nonsyndromic skin fragility disorders.

Long-term follow-up of patients with Herlitz-type junctional epidermolysis bullosa

BACKGROUND

Junctional epidermolysis bullosa, type Herlitz (JEB-H) is a rare, autosomal recessive disease caused by absence of the epidermal basement membrane adhesion protein laminin-332. It is characterized by extensive and devastating blistering of the skin and mucous membranes, leading to death in early childhood.

OBJECTIVES

To present the results of the long-term follow-up of a cohort of patients with JEB-H, and to provide guidelines for prognosis, treatment and care.

METHODS

All patients with JEB-H included in the Dutch Epidermolysis Bullosa (EB) Registry between 1988 and 2011 were followed longitudinally by our EB team. Diagnosis was established using immunofluorescence antigen mapping, electron microscopy and DNA analysis.

RESULTS

In total, we included 22 patients with JEB-H over a 23-year period. Their average age at death was 5.8 months (range 0.5-32.6 months). The causes of death were, in order of frequency: failure to thrive, respiratory failure, pneumonia, dehydration, anaemia, sepsis and euthanasia. The pattern of initial weight gain was a predictor of lifespan in these patients. Invasive treatments to extend life did not promote survival in our patients.

CONCLUSIONS

It is important to diagnose JEB-H as soon as possible after birth so that the management can be shifted from life-saving to comfort care. The palliative end-of-life care can take place in hospital, but is also safe in the home setting. Suffering in patients with JEB-H can become so unbearable that in some patients who do not respond to adequate analgesic and sedative treatment, newborn euthanasia, performed according to the Groningen protocol, is legally permitted in the Netherlands.

[Epidermolysis bullosa. An update]

Epidermolysis bullosa (EB) represents a group of diseases characterized by skin fragility usually developing blisters after minimal trauma. The clinical picture ranges from mild subtypes with minor skin reactions to severe forms with lethal outcome within the first months of life. In the severe generalized subtypes, complications such as aggressive squamous cell carcinoma of the skin, anemia, esophageal stenosis and cardiomyopathy can occur so that multidisciplinary patient care is necessary. EB can be divided in four types--EB simplex (EBS), junctional EB (JEB), dystrophic EB (DEB) and Kindler syndrome. All together 33 subtypes can be distinguished. In 2008 a revised EB classification was introduced. Several eponyms for EB subtypes were replaced by descriptive names. The review presents the EB subtypes based on the new EB classification system, the molecular background and new therapeutic options.

A comparative study between transmission electron microscopy and immunofluorescence mapping in the diagnosis of epidermolysis bullosa

The classification of epidermolysis bullosa (EB) into 3 main subtypes has been based on transmission electron microscopy (TEM) that is able to directly visualize and quantify specific ultrastructural features. Immunofluorescence antigenic mapping (IFM) is a technique that determines the precise level of skin cleavage by determining binding sites for a series of antibodies. To date, no study has compared the accuracy of these two techniques in diagnosing the major types of EB. A prospective cohort of 33 patients thought to have EB on clinical grounds had TEM, IFM, and genetic testing performed. The sensitivities and specificities of TEM and IFM were calculated compared with the genetic results. Of 33 cases, 30 had a positive EB diagnosis. TEM subclassified EB into its three major forms in 24/30 cases (80%) and IFM in 29/30 cases (97%). Overall, TEM sensitivities and specificities when compared with genetic results were 71% and 81%, respectively. IFM sensitivities and specificities when compared with genetic results were 97% and 100%, respectively. If a patient tested positive for EB by IFM, the likelihood ratio of having a particular type of EB was consistently greater than 20 against the reference standard (compared with a likelihood ratio less than 10 for TEM). Our results indicate that the diagnosis of EB is improved (sometimes substantially) by the use of IFM compared with TEM.

Epidermolysis bullosa simplex associated with pyloric atresia is a novel clinical subtype caused by mutations in the plectin gene (PLEC1)

Epidermolysis bullosa (EB) is an inherited mechano-bullous disorder of the skin, and is divided into three major categories: EB simplex (EBS), dystrophic EB, and junctional EB (JEB). Mutations in the plectin gene (PLEC1) cause EBS associated with muscular dystrophy, whereas JEB associated with pyloric atresia (PA) results from mutations in the alpha6 and beta4 integrin genes. In this study, we examined three EB patients associated with PA from two distinct families. Electron microscopy detected blister formation within the basal keratinocytes leading to the diagnosis of EBS. Surprisingly, immunohistochemical studies using monoclonal antibodies to a range of basement membrane proteins showed that the expression of plectin was absent or markedly attenuated. Sequence analysis demonstrated four novel PLEC1 mutations. One proband was a compound heterozygote for a nonsense mutation of Q305X and a splice-site mutation of 1344G-->A. An exon-trapping experiment suggested that the splice-site mutation induced aberrant splicing of the gene. The second proband harbored a heterozygous maternal nonsense mutation, Q2538X and homozygous nonsense mutations R1189X. Analysis of the intragenic polymorphisms of PLEC1 suggested that R1189X mutations were due to paternal segmental uniparental isodisomy. These results indicate that PLEC1 is a possible causative gene in this clinical subtype, EBS associated with PA. Furthermore, two patients out of our three cases died in infancy. In terms of clinical prognosis, this novel subtype is the lethal variant in the EBS category.

Pyloric atresia associated with epidermolysis bullosa--three cases presenting in three months

Three neonates presenting with pyloric atresia and epidermolysis bullosa are described in this report. Two babies underwent surgery for pyloric atresia, and 1 of these has survived until 3 months of age with no complications. The clinical presentation and complications of the pyloric atresia-epidermolysis bullosa syndrome are discussed with a brief review of literature.

Pyloric atresia: a new operation to reconstruct the pyloric sphincter

BACKGROUND/PURPOSE

The standard method of surgical correction of pyloric atresia "solid segment" type is a gastroduodenostomy that can in the long term cause bilious duodenogastric reflux. The authors report 2 cases of pyloric atresia in which the pyloric sphincter was reconstructed by a new technique of gastroduodenal mucosal advancement anastomosis.

METHODS

Two premature babies with "solid segment"-type pyloric atresia, one with an associated junctional epidermolysis bullosa, underwent surgery for reconstruction of the pyloric sphincter. By a longitudinal incision of the atretic pylorus, the cul-de-sacs of gastric and duodenal mucosa were isolated in the respective gastric and duodenal sides, advanced into the opened pyloric canal, and sutured together using end-to-end anastomosis. The longitudinal pyloromyotomy then was closed above the reconstructed mucosal pyloric neocanal.

RESULTS

The postoperative course was normal. At 7 years (patient 1) and 2 years (patient 2) after the operation, both are well, and no gastrointestinal disorders are present. Good competence of the pyloric sphincter has been confirmed by x-ray barium meal in both cases, and by HIDA technetium 99m hepatic scintiscan and esophagogastroduodenoscopy (EGD) with biopsy in patient 1.

CONCLUSIONS

Our technique of surgical correction of pyloric atresia allows preservation of the pyloric sphincter, whose muscular layer, although hypoplastic, is present in these cases.