A clinical and histopathological study of 22 patients with membranous lipodystrophy

Premortem Skin Biopsy Assessing Microthrombi, Interferon Type I Antiviral and Regulatory Proteins, and Complement Deposition Correlates with Coronavirus Disease 2019 Clinical Stage

Apart from autopsy, tissue correlates of coronavirus disease 2019 (COVID-19) clinical stage are lacking. In the current study, cutaneous punch biopsy specimens of 15 individuals with severe/critical COVID-19 and six with mild/moderate COVID-19 were examined. Evidence for arterial and venous microthrombi, deposition of C5b-9 and MASP2 (representative of alternative and lectin complement pathways, respectively), and differential expression of interferon type I-driven antiviral protein MxA (myxovirus resistance A) versus SIN3A, a promoter of interferon type I-based proinflammatory signaling, were assessed. Control subjects included nine patients with sepsis-related acute respiratory distress syndrome (ARDS) and/or acute kidney injury (AKI) pre-COVID-19. Microthrombi were detected in 13 (87%) of 15 patients with severe/critical COVID-19 versus zero of six patients with mild/moderate COVID-19 (P < 0.001) and none of the nine patients with pre-COVID-19 ARDS/AKI (P < 0.001). Cells lining the microvasculature staining for spike protein of severe acute respiratory syndrome coronavirus 2, the etiologic agent of COVID-19, also expressed tissue factor. C5b-9 deposition occurred in 13 (87%) of 15 patients with severe/critical COVID-19 versus zero of six patients with mild/moderate COVID-19 (P < 0.001) and none of the nine patients with pre-COVID-19 ARDS/AKI (P < 0.001). MASP2 deposition was also restricted to severe/critical COVID-19 cases. MxA expression occurred in all six mild/moderate versus two (15%) of 13 severe/critical cases (P < 0.001) of COVID-19. In contrast, SIN3A was restricted to severe/critical COVID-19 cases co-localizing with severe acute respiratory syndrome coronavirus 2 spike protein. SIN3A was also elevated in plasma of patients with severe/critical COVID-19 versus control subjects (P ≤ 0.02). In conclusion, the study identified premortem tissue correlates of COVID-19 clinical stage using skin. If validated in a longitudinal cohort, this approach could identify individuals at risk for disease progression and enable targeted interventions.

Membranous lipodystrophy: case report and review of the literature

Membranous lipodystrophy is a distinct type of membranocystic fat necrosis. It is associated with many local and systemic diseases, including vascular disorders. The histopathological changes which characterize this phenomenon are variably sized cysts in the fat lobules of the subcutaneous tissue, which are surrounded by eosinophilic membranes projecting into the cystic space. We report a case of secondary membranous lipodystrophy associated with both hypertension and venous insufficiency.

Membranous lipodystrophy: skeletal findings on CT and MRI

Membranous lipodystrophy, also known as Nasu-Hakola disease, is a rare hereditary condition with manifestations in the nervous and skeletal systems. The radiographic appearance of skeletal lesions has been well described in the literature. However, CT and MRI findings of lesions in the bone have not been documented to date. This report describes the radiographic, CT, MRI, and histopathologic skeletal findings in a case of membranous lipodystrophy. With corroborative pathologic findings, a diagnosis of membranous lipodystrophy on imaging allows for appropriate clinical management of disease manifestations.

A case of membranous lipodystrophy observed in lichen amyloidosis

Membranous lipodystrophy is characterized by the presence of microcysts lined by amorphous, eosinophilic material with an arabesque appearance. We experienced a case of a 72-year-old man who had dark brownish, pruritic papules on the arms, legs, and back. Histopathologic examination of a biopsied lesion showed homogeneous, eosinophilic material in the papillary dermis, as well as membranous lipodystrophy. We report a case of membranous lipodystrophy observed in lichen amyloidosis.

The Erlenmeyer flask bone deformity in the skeletal dysplasias

Erlenmeyer flask bone deformity (EFD) is a long-standing term used to describe a specific abnormality of the distal femora. The deformity consists of lack of modeling of the di-metaphysis with abnormal cortical thinning and lack of the concave di-metaphyseal curve resulting in an Erlenmeyer flask-like appearance. Utilizing a literature review and cohort study of 12 disorders we found 20 distinct disorders were associated with EFD. We interrogated the International Skeletal Dysplasia Registry (ISDR) radiographic database (1988-2007) to determine which skeletal dysplasias or syndromes were highly associated with EFD, whether it was a uniform finding in these disorders, and if forms of EFD could be differentiated. EFD was classified into three groups. The first catogory was the typical EFD shaped bone (EFD-T) resultant from absent normal di-metaphyseal modeling with relatively normal appearing radiographic trabecular bone. EFD-T was identified in: frontometaphyseal dysplasia, craniometaphyseal dysplasia, craniodiaphyseal dysplasia, diaphyseal dysplasia-Engelmann type, metaphyseal dysplasia-Pyle type, Melnick-Needles osteodysplasty, and otopalatodigital syndrome type I. The second group was the atypical type (EFD-A) due to absence of normal di-metaphyseal modeling with abnormal radiographic appearance of trabecular bone and was seen in dysosteosclerosis and osteopetrosis. The third group was EFD-marrow expansion type (EFD-ME) in which bone marrow hyperplasia or infiltration leads to abnormal modeling (e.g., Gaucher disease). Further, radiographic review determined that it was not always a consistent finding and that there was variability in both appearance and location within the skeleton. This analysis and classification aided in differentiating disorders with the finding of EFD.

An unusual case with membranous lipodystrophy in a hypertensive patient with transepidermal elimination

Membranous lipodystrophy represents a peculiar type of fat necrosis that is present in patients with various types of skin disease. It is characterized by the presence of microcysts and macrocysts and is lined by amorphous eosinophilic material with a crenelated arabesque appearance. These findings have been associated with lupus erythematosus, diabetes mellitus, erythema nodosum, trauma, etc. We report a case of a 43-year-old woman who had a red to purple asymptomatic indurated plaque, approximately seven cm in diameter and on the left arm. She was a chronic hepatitis B antigen carrier and had hypertension for four years. Histopathology of the biopsied lesion showed transepidermal elimination of altered collagen and elastic fibers, as well as membranous lipodystrophy changes. There were hypertensive vascular changes including lymphohistiocytic infiltration around the vascular wall, swelling of endothelial cells, increased thickness of the vascular walls, and narrowing of the lumen. We report a case showing transepidermal elimination with membranous lipodystrophy. We carefully suggest that the secondary phenomenon of transepidermal elimination was associated with membranous lipodystrophy and degenerate connective tissues.

Membranous lipodystrophy-like changes in two cases of traumatic lipogranuloma caused by safety belts

A few cases of subcutaneous nodules with the histological findings of membranous lipodystrophy-like changes have been reported in the literature. However, reports of membranous lipodystrophy-like changes caused by trauma are exceedingly rare. We report two cases of traumatic lipogranuloma that had linear and multiple lesions showing membranous lipodystrophy-like changes and were induced by safety belt trauma after a car accident. These patients showed peculiar changes in their subcutaneous fat and had linear patterned, multiple, nodular lesions with membranous lipodystrophy-like changes caused by trauma.

Membranous Fat Necrosis of the Breast: Diagnosis by Minimally Invasive Technique

Clinical and mammographic features of membranous fat necrosis (MFN) may simulate breast malignancy and tissue sampling is essential for accurate diagnosis. The aim of our study was to evaluate the clinical and imaging findings in these patients. Retrospective review of the records of breast biopsies (n = 1200) during the 5-year period 1998 to 2002 revealed eight (0.67%) cases of histologically proven MFN. Seven of the eight patients had a history of breast trauma or surgery. Seven patients underwent mammography: normal in two, a mass with curvilinear calcifications in one, and heterogeneous calcifications in four. Four patients underwent surgical excision of a palpable mass, one patient had complete excision of calcifications with large core biopsy technique, and three patients had stereotactic vacuum-assisted mammotome biopsy (VAMB). MFN should be included in the differential diagnosis of lesions in a breast with previous trauma or surgery. A minimally invasive diagnostic procedure should be considered in order to avoid excessive excisional surgery.

Nasu-Hakola disease (polycystic lipomembranous osteodysplasia with sclerosing leukoencephalopathy--PLOSL): a dementia associated with bone cystic lesions. From clinical to genetic and molecular aspects

The authors review the clinical, radiological, electrophysiological, pathological, and molecular aspects of Nasu-Hakola disease (polycystic lipomembranous osteodysplasia with sclerosing leukoencephalopathy or PLOSL). Nasu-Hakola disease is a unique disease characterized by multiple bone cysts associated with a peculiar form of neurodegeneration that leads to dementia and precocious death usually during the fifth decade of life. The diagnosis can be established on the basis of clinical and radiological findings. Recently, molecular analysis of affected families revealed mutations in the DAP12 (TYROBP) or TREM2 genes, providing an interesting example how mutations in two different subunits of a multi-subunit receptor complex result in an identical human disease phenotype. The association of PLOSL with mutations in the DAP12 or TREM2 genes has led to improved diagnosis of affected individuals. Also, the possible roles of the DAP12/TREM2 signaling pathway in microglia and osteoclasts in humans are just beginning to be elucidated. Some aspects of this peculiar signaling pathway are discussed here.

Multifocal disseminated lipoatrophy secondary to intravenous corticosteroid administration in a patient with adrenal insufficiency

Multifocal disseminated lesions of circumscribed lipoatrophy have not been described as an adverse reaction of intravenously applied drugs. A unique patient with adrenal insufficiency is reported who received corticosteroids intravenously and then had multiple lesions develop that were similar to focal lipoatrophy as known to occur secondary to faulty intradermal injections of corticosteroids.

Panniculitis. Part II. Mostly lobular panniculitis

The second part of our review of panniculitis summarizes the clinicopathologic features of the mostly lobular panniculitides. Erythema induratum of Bazin (nodular vasculitis) represents the most common variant of lobular panniculitis with vasculitis, although controversy persists about the nature of the involved vessels. Mostly lobular panniculitides without vasculitis comprise a series of disparate disorders. These include sclerosing panniculitis that results from chronic venous insufficiency of the lower extremities; panniculitis with calcification of the vessel walls such as calciphylaxis and oxalosis; and inflammatory diseases with crystals within the adipocytes such as sclerema neonatorum, subcutaneous fat necrosis of the newborn, and poststeroid panniculitis. Connective tissue diseases, such as systemic lupus erythematosus and dermatomyositis, pancreatic diseases, and alpha(1)-antitrypsin deficiency may also show a mostly lobular panniculitis with characteristic histopathologic features. Lobular panniculitis may also be an expression of infections, trauma, or factitial causes involving the subcutaneous fat. Lipoatrophy refers to a loss of subcutaneous fat due to a previous inflammatory process involving the subcutis, and it may be the late-stage lesion of several types of panniculitis. In contrast, lipodystrophy means an absence of subcutaneous fat with no evidence of inflammation and often the process is associated with endocrinologic, metabolic, or autoimmune diseases. Finally, cytophagic histiocytic panniculitis is the term that has been used to describe two different processes: one is inflammatory, a lobular panniculitis, and the other one is neoplastic, a subcutaneous T-cell lymphoma. The only common feature of these two different processes is the presence of cytophagocytosis in the lesions. (J Am Acad Dermatol 2001;45:325-61.)

LEARNING OBJECTIVE

At the completion of this learning activity, participants should be familiar with the pathogenesis, clinical manifestations, histopathologic findings, and treatment options for the most frequent variants of the lobular panniculitides.

Lipomembranous fat necrosis in three cases of testicular torsion

AIMS

To describe for the first time a lesion termed lipomembranous fat necrosis (LFN) in three patients with spermatic cord torsion.

METHODS AND RESULTS

We reviewed 386 testes and their epididymides and spermatic cords which had been removed for testicular infarction. For the three cases showing LFN, a battery of histochemical tests (including periodic acid-Schiff (PAS), orcein, Sudan black and Perls stains) was applied and clinical histories and laboratory data were also investigated. Findings were similar in the three specimens. The testes showed a central group of necrotic seminiferous tubules which were surrounded by granulation tissue consisting of macrophages, multinucleated giant cells, lymphocytes, plasma cells and fibrous connective tissue at the periphery of the lesion. The spermatic cord showed thrombosed veins surrounded by fat necrosis showing cystic cavities which were bounded by wavy hyaline membranes. These stained with Sudan black, PAS (before and after diastase digestion) and orcein and presented yellowish-green autofluorescence.

CONCLUSIONS

Lipomembranous fat necrosis of the spermatic cord is a distinctive entity which seems to be related to spermatic cord torsion and the differential diagnosis of which should be established with regard to the presence of parasites, sclerosing lipogranuloma and granuloma evoked by rupture of a testicular prosthesis.

Nasu-Hakola disease: a review of its leukoencephalopathic and membranolipodystrophic features

The clinicopathological features of Nasu-Hakola disease are described by reviewing previously reported cases and adding consideration to newly disclosed evidence. This disease is an autosomal recessive disorder characterized by membranocystic lipodystrophy in the skeletal system and sclerosing leukoencephalopathy in the nervous system. The leukoencephalopathic alterations are demyelinization of the cerebral white matter, associated with conspicuous fibrillary gliosis and preservation of the subcortical arcuate fibers. Sudanophilic granules are focally scattered in the perivascular space or widely infiltrated in the affected white matter, and some neuronal loss with deposits of calcospherites is encountered in the basal ganglia and also in the thalamus. Spheroid formation with an increased number of neurofilaments in the neuronal axon is considered a possible pathogenesis, and a primary vascular mechanism is also suggested. Interestingly, most of the reported cases of Nasu-Hakola disease are from Japan and Finland which suggests heredofamilial background as a cause.