1
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Arnal C, Richert B. Nail disorders to be kept in mind. HAND SURGERY & REHABILITATION 2024; 43S:101640. [PMID: 38215878 DOI: 10.1016/j.hansur.2024.101640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 12/18/2023] [Indexed: 01/14/2024]
Abstract
Recognizing and diagnosing the most common nail diseases is essential, to be able to guide patients and provide appropriate treatment. However, uncommon nail disorders should not be neglected, in order to avoid inadequate treatment and above all to ensure that no severe underlying disorder, with severe prognosis, is overlooked.
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Affiliation(s)
- Charlotte Arnal
- Dermatology Department, Université Libre de Bruxelles, University Hospital Brugmann - Saint-Pierre - Children Hospital Queen Fabiola, Brussels, Belgium.
| | - Bertrand Richert
- Dermatology Department, Université Libre de Bruxelles, University Hospital Brugmann - Saint-Pierre - Children Hospital Queen Fabiola, Brussels, Belgium.
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2
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Yamada A, Umemoto N, Demitsu T, Kitamura O. Acrokeratosis neoplastica (Bazex syndrome): Report of two cases and literature review. Heliyon 2024; 10:e26411. [PMID: 38434419 PMCID: PMC10906289 DOI: 10.1016/j.heliyon.2024.e26411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 02/05/2024] [Accepted: 02/13/2024] [Indexed: 03/05/2024] Open
Abstract
The skin often reflects the presence of internal diseases. Acrokeratosis neoplastica (Bazex syndrome) is a unique skin manifestation characterized by its erythematous hyperkeratosis with yellowish, adherent scales on the palm, sole, or other acral locations. There is a potentially high association between Bazex syndrome and malignant pathology, especially squamous cell carcinomas (SCC). To date, various skin conditions have been recognized as diagnostic indicators of insidious malignancies. The recognition of paraneoplastic dermatoses has a strong potential for prompt cancer detection and early therapeutic intervention. Here we describe clinical and forensic cases of Bazex syndrome that are associated with SCC of the glottis and lung. Bazex syndrome has been reported to be associated with a variety of cancers in addition to SCC. We review the clinical manifestations of Bazex syndrome and include updated knowledge on disease pathogenesis.
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Affiliation(s)
- Atsushi Yamada
- Department of Legal Medicine, 6-20-2, Shinkawa, Mitaka-shi, Tokyo, 181-8611, Japan
- Department of Dermatology, Jichi Medical University Saitama Medical Center, 1-847, Amanuma-cho, Omiya-ku, Saitama, 330-0834, Japan
| | - Naoka Umemoto
- Department of Dermatology, Jichi Medical University Saitama Medical Center, 1-847, Amanuma-cho, Omiya-ku, Saitama, 330-0834, Japan
| | - Toshio Demitsu
- Department of Dermatology, Jichi Medical University Saitama Medical Center, 1-847, Amanuma-cho, Omiya-ku, Saitama, 330-0834, Japan
| | - Osamu Kitamura
- Department of Legal Medicine, 6-20-2, Shinkawa, Mitaka-shi, Tokyo, 181-8611, Japan
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3
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Shah MH, Ferrazzano C, Karthikeyan A, Hejazi H, Bhattacharya A, Andrew Awuah W, Isik A. Bazex Syndrome (Acrokeratosis Paraneoplastica): A Narrative Review of Pathogenesis, Clinical Manifestations, and Therapeutic Approaches. Cureus 2023; 15:e45368. [PMID: 37720135 PMCID: PMC10505057 DOI: 10.7759/cureus.45368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/16/2023] [Indexed: 09/19/2023] Open
Abstract
Acrokeratosis paraneoplastica, also known as Bazex syndrome, is a relatively understudied yet clinically important dermatological condition that is inextricably associated with squamous cell carcinoma, predominantly of the upper respiratory and gastrointestinal tracts. Manifesting as unique psoriasis-like cutaneous lesions, Bazex syndrome functions as an early warning signal for underlying malignancies, underscoring the urgent need for its timely diagnosis and intervention. Notwithstanding its clinical relevance, the molecular and cellular mechanisms underpinning its pathogenesis are not fully understood. To address these gaps, this comprehensive literature review undertook a meticulous search across reputable databases such as EMBASE, MEDLINE/PubMed, and Web of Science. Our analysis ventures into multiple putative pathogenic pathways, including shifts in Th2 immune responses, aberrant secretion of growth factors, and immunological reactions to tumor-specific antigens. We also detail the clinical phenotypes of Bazex syndrome and their chronological linkage with the corresponding malignancies. Finally, the review evaluates the therapeutic effectiveness of various approaches, including but not limited to targeted cancer treatments, PUVA therapy, and topical corticosteroids. This synthesis aims to arm healthcare providers with a nuanced understanding of Bazex syndrome, facilitating more accurate diagnosis and tailored treatment paradigms.
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Affiliation(s)
- Muhammad Hamza Shah
- Centre for Anatomy, Deanery of Biomedical Sciences, The University of Edinburgh, Edinburgh, GBR
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, GBR
| | - Carlo Ferrazzano
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, GBR
| | - Anhukrisha Karthikeyan
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, GBR
| | - Hamad Hejazi
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, GBR
| | - Anushri Bhattacharya
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, GBR
| | | | - Arda Isik
- Surgery, University of Pittsburgh Medical Center, Pittsburgh, USA
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4
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Shah R, Truong T, Schwartz RA, Lambert MW, Parish LC, Janniger E, Lambert WC. Annular and acral/facial dyskeratotic paraneoplastic disorders. Clin Dermatol 2023; 41:396-404. [PMID: 37423265 DOI: 10.1016/j.clindermatol.2023.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/11/2023]
Abstract
Annular and acral/facial dyskeratotic paraneoplastic disorders are inflammatory dermatoses that occur in association with distant cancers but are not precursors, extensions, or metastases of them. There are four classical entities under this rubric: two gyrate entities, erythema annulare centrifugum and erythema gyratum repens, and two acral/facial dyskeratotic entities, acrokeratosis paraneoplastic (Bazex syndrome) and tripe palms. Each of these entities may also occur in association with another etiopathogenesis and may present either as a classical entity or as a barely recognizable disease. We discuss these entities, their associated causes, and their differential diagnoses in turn.
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Affiliation(s)
- Rohan Shah
- Rutgers-New Jersey Medical School, Newark, New Jersey, USA
| | - Thu Truong
- Rutgers-New Jersey Medical School, Newark, New Jersey, USA
| | - Robert A Schwartz
- Departments pf Dermatology and of Pathology, Immunology, and Laboratory Medicine, Rutgers-New Jersey Medical School, Newark, New Jersey, USA
| | - Muriel W Lambert
- Departments pf Dermatology and of Pathology, Immunology, and Laboratory Medicine, Rutgers-New Jersey Medical School, Newark, New Jersey, USA
| | - Lawrence Charles Parish
- Department of Dermatology and Cutaneous Biology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA; Jefferson Center for International Dermatology, Philadelphia, Pennsylvania, USA
| | - Edmund Janniger
- Departments pf Dermatology and of Pathology, Immunology, and Laboratory Medicine, Rutgers-New Jersey Medical School, Newark, New Jersey, USA
| | - W Clark Lambert
- Departments pf Dermatology and of Pathology, Immunology, and Laboratory Medicine, Rutgers-New Jersey Medical School, Newark, New Jersey, USA.
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5
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Overview of familial syndromes with increased skin malignancies. Arch Dermatol Res 2022; 315:707-727. [PMID: 36342513 DOI: 10.1007/s00403-022-02447-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Accepted: 10/21/2022] [Indexed: 11/09/2022]
Abstract
The vast majority of skin cancers can be classified into two main types: melanoma and keratinocyte carcinomas. The most common keratinocyte carcinomas include basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). Multiple familial syndromes have been identified that can increase the risk of developing SCC, BCC, and/or melanoma. The major syndromes include oculocutaneous albinism for SCC, basal cell nevus syndrome for BCC, familial atypical multiple mole-melanoma syndrome, and hereditary breast and ovarian cancer syndrome for melanoma. In addition, familial syndromes that can predispose individuals to all three major skin cancers include xeroderma pigmentosum and Li-Fraumeni syndrome. This review highlights the epidemiology, risk factors, pathogenesis, and etiology of the major and minor syndromes to better identify and manage these conditions. Current investigational trials in genomic medicine are making their way in revolutionizing the clinical diagnosis of these familial syndromes for earlier preventative measures and improvement of long-term prognosis in these patients.
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6
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Shakshouk H, Erickson LA, Johnson EF, Lehman JS. Updates and Proposed Diagnostic Approach to Psoriasiform Dermatoses. Adv Anat Pathol 2022; 29:263-274. [PMID: 35180737 DOI: 10.1097/pap.0000000000000333] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Psoriasiform dermatoses represent a wide array of skin diseases commonly encountered by clinicians and pathologists. While they may present a diagnostic challenge, thorough observation coupled with proper interpretation of subtle additional clinical or histopathologic features provide clues to the correct diagnosis. In this review, we provide updates on emerging entities and develop a systemic approach to establish the pathologic diagnosis, with emphasis on the importance of clinicopathologic correlation.
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Affiliation(s)
- Hadir Shakshouk
- Departments of Dermatology
- Department of Dermatology, Alexandria University, Alexandria, Egypt
| | - Lori A Erickson
- Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Emma F Johnson
- Departments of Dermatology
- Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Julia S Lehman
- Departments of Dermatology
- Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
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7
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Diao W, Liang Y, Gao L, Zhu Y, Zhu X, Yu S, Xia X, Chen X. Clinical characteristics of paraneoplastic syndromes in patients with head and neck cancer. Laryngoscope Investig Otolaryngol 2022; 7:1002-1010. [PMID: 36000027 PMCID: PMC9392377 DOI: 10.1002/lio2.849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 06/01/2022] [Accepted: 06/04/2022] [Indexed: 11/09/2022] Open
Abstract
Background To summarize the clinical manifestations, diagnosis, and prognosis of head and neck cancer (HNC) patients with paraneoplastic syndromes (PNS). Methods The clinical data of 1958 patients with HNC admitted to our hospital from January 1996 to December 2020 were retrospectively analyzed. Demographic and cancer‐related characteristics were extracted. Kaplan–Meier survival curves were compared by log‐rank test. Cox regression was performed to evaluate prognostic factors and hazard ratio. Results Totally 40 HNC patients with PNS were included in the final analysis, including 36 men and four women with a mean age of 60.4 years (range 40–82). PNS was dermatologic or cutaneous in 23 (57.50%) patients, endocrine in 10 (25.00%), neurologic in five (12.50%), and osteoarticular or rheumatologic in two (5.00%). Twenty‐five (62.50%) patients had Stage III/IV cancer. PNS regressed after antitumor therapy in 28 (70.00%) patients. Recurrence of PNS was observed in nine of 12 (75.00%) patients with cancer recurrence or metastasis. The 5‐year overall survival (OS) and disease‐free survival (DFS) rates of patients with PNS were 51.52% and 44.44%, respectively. The DFS (p = .001) and OS (p = .003) of patients presented with PNS prior to HNC diagnosis were significantly longer than those of patients with synchronous or metachronous PNS. PNS diagnosed before HNC (adjusted hazard ratio [aHR]: 0.31, 95% confidence interval [CI]: 0.11–0.85, p = .02), Stage IV disease (aHR: 3.27, 95% CI: 1.18–9.05, p = .02), and smoking history (aHR: 3.69, 95% CI: 1.04–13.05, p = .04) were significantly associated with OS and DFS. Conclusions Early recognition of PNS could provide clues about underlying tumor condition and result in early diagnosis. Prompt detection of cancer‐associated syndromes could lead to a more favorable prognosis for these patients.
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Affiliation(s)
- Wenwen Diao
- Department of Otolaryngology–Head and Neck Surgery Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences Beijing China
| | - Ya Liang
- Department of Otorhinolaryngology Affiliated Hospital of Guizhou Medical University Guiyang China
| | - Liming Gao
- Department of Otolaryngology–Head and Neck Surgery Beijing Tiantan Hospital, Capital Medical University Beijing China
| | - Yingying Zhu
- Department of Otolaryngology–Head and Neck Surgery Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences Beijing China
| | - Xiaoli Zhu
- Department of Otolaryngology–Head and Neck Surgery Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences Beijing China
| | - Shuting Yu
- Department of Otolaryngology–Head and Neck Surgery Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences Beijing China
| | - Xin Xia
- Department of Otolaryngology–Head and Neck Surgery Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences Beijing China
| | - Xingming Chen
- Department of Otolaryngology–Head and Neck Surgery Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences Beijing China
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8
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Suga K. F-18-FDG PET/CT findings of paraneoplastic dermatoses. Jpn J Radiol 2022; 40:863-875. [PMID: 35713794 PMCID: PMC9441418 DOI: 10.1007/s11604-022-01286-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 04/18/2022] [Indexed: 11/28/2022]
Abstract
Paraneoplastic dermatoses (PD) are defined as nonspecific skin disorders which are associated with internal neoplasms, but without direct association to primary tumors or metastases. Recognition of PD and the following surveillance may lead to the diagnosis of internal malignant neoplasms including early stage ones. Accurate imaging examinations in the following searching is essential in identifying the underlying neoplasms. Since whole-body 18-fluoro-2-deoxyglucose (F-18-FDG)-positron emission (PET)/computed tomography (CT) has been widely used in early diagnosis, staging of various malignant tumors, it may play a role for detection of underlying or occult malignant neoplasms in patients with PD. However, to date, only a few reports of FDG PET/CT findings of the associated neoplasms in PD patients have been cited in the literature. The present paper shows the cases of FDG-avid associated neoplasms in patients with PD in our 10-year experience in our institute, and reviews the well-known and/or relatively common PD and their associated neoplasms, and the previously reported cases of FDG-avid associated neoplasms in these patients.
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Affiliation(s)
- Kazuyoshi Suga
- Department of Radiology, St. Hill Hospital, 3-7-18 Imamurakita, Ube, Yamaguchi, 755-8505, Japan.
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9
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Ikeda K, Kanno K, Otani Y, Ito M. A Case of Bazex Syndrome. Intern Med 2022; 61:443-444. [PMID: 34334566 PMCID: PMC8866786 DOI: 10.2169/internalmedicine.7568-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Kotaro Ikeda
- Department of General Internal Medicine, Hiroshima University Hospital, Japan
| | - Keishi Kanno
- Department of General Internal Medicine, Hiroshima University Hospital, Japan
| | - Yuichiro Otani
- Department of General Internal Medicine, Hiroshima University Hospital, Japan
| | - Masanori Ito
- Department of General Internal Medicine, Hiroshima University Hospital, Japan
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10
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Paraneoplastic Syndromes in Patients with Keratinocyte Skin Cancer. Cancers (Basel) 2022; 14:cancers14010249. [PMID: 35008413 PMCID: PMC8750284 DOI: 10.3390/cancers14010249] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 12/25/2021] [Accepted: 01/02/2022] [Indexed: 01/19/2023] Open
Abstract
Simple Summary The aim of the present review is to compile and evaluate the literature data on paraneoplastic syndromes (PNS) associated with keratinocyte skin cancer (KSC). Forty relevant entries were assembled, reporting a total of 41 PNS cases associated with a KSC (34 male). No review paper compiling this topic was found. Six distinct PNS entities were identified, and malignancy associated hypercalcemia (MAH; 78%), anemia (10%) and Bazex syndrome (5%) were the most frequently reported among them. 85% of the PNS were reported in association with SCC, 10% with BCC, and the rest with adnexal tumors. The median age of the patients at the time of PNS diagnosis was 58 years (range: five–83 years). KSC predisposing conditions, as scars (22%) or hidradenitis suppurativa (20%), were reported in >70% of the PNS cases. In conclusion, PNS are rarely reported in association with KSC, possibly reflecting a limited capacity of KSC to provoke overt PNS. Abstract A variety of well-characterized cutaneous paraneoplastic syndromes (PNS) are diagnosed during internal malignancies; however, the spectrum of keratinocyte skin neoplasms (KSC) related to PNS is still obscure. The aim of the present review is to compile and evaluate the literature data on PNS associated with a keratinocyte skin neoplasm (KSC). Employing Pubmed, MEDLINE was searched for KSC-associated PNS reports. Forty relevant entries were assembled, reporting a total of 41 PNS cases associated with a KSC (34 male). No review paper compiling this topic was found. Six distinct PNS entities were identified, and malignancy associated hypercalcemia (MAH; 78%), anemia (10%) and Bazex syndrome (5%) were the most frequently reported among them. 85% of the PNS were reported in association with SCC, 10% with BCC, and the rest with adnexal tumors. The median age of the patients at the time of PNS diagnosis was 58 years (range: five–83 years). In most cases the PNS was diagnosed either concurrently or after the KSC diagnosis. KSC predisposing conditions, as scars (22%) or hidradenitis suppurativa (20%), were reported in >70% of the PNS cases. Most PNS resolved after KSC treatment. In conclusion, PNS of a rather limited spectrum of entities are reported in association with KSC. They also seem to be rare, possibly reflecting a limited capacity of KSC to provoke overt PNS.
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11
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Dysphagia with Psoriasiform Skin Lesions: Clue to Diagnosis. Dysphagia 2021; 37:1330-1332. [PMID: 34677680 DOI: 10.1007/s00455-021-10378-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 10/13/2021] [Indexed: 10/20/2022]
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12
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Vaibhav V, Meshram R, Kalonia T. An Unusual Encounter of Skin Condition Mimicking Acrokeratosis Paraneoplastica (Bazex Syndrome). Cureus 2021; 13:e17849. [PMID: 34660055 PMCID: PMC8502012 DOI: 10.7759/cureus.17849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/09/2021] [Indexed: 11/08/2022] Open
Abstract
Acrokeratosis paraneoplastica is a rare paraneoplastic skin disease in which there are erythematous violaceous, scaly plaques on the hands, feet, and acral locations. There is a relationship between various carcinomas of the aerodigestive tract and skin eruptions. These were the pioneering work done pertaining to a clinical entity that was showing some inter-relationship between a skin condition and carcinoma anywhere inside the body. Bazex syndrome is mostly associated with carcinomas of the upper aero-digestive tract, but other malignancies were also being reported. In this case, the patient was in advancing age with cachexic features along with liver and lung lesions which prompted us to investigate histologically for evidence of malignancy which came out to be negative. In our case, lungs showed features of pulmonary edema with normal histology. When we examined the liver, gross lesions were present but no evidence of malignancy was noted and the liver showed normal parenchyma histologically. Specimens taken from hand and foot showed hyperkeratosis along with bacterial colonies in the overlying epidermis. The spleen showed red pulp with congestion and hemorrhage. Similarly, sections from the kidneys were showing interstitial inflammation and congestion of blood vessels. Specimens from the brain and heart showed unremarkable histology.
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Affiliation(s)
- Vikas Vaibhav
- Forensic Medicine and Toxicology, All India Institute of Medical Sciences, Rishikesh, Rishikesh, IND
| | - Raviprakash Meshram
- Forensic Medicine, All India Institute of Medical Sciences, Rishikesh, Rishikesh, IND
| | - Tushar Kalonia
- Pathology, All India Institute of Medical Sciences, Rishikesh, Rishikesh, IND
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13
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[Alopecia and cancers: From basics to clinical practice]. Bull Cancer 2021; 108:963-980. [PMID: 34304865 DOI: 10.1016/j.bulcan.2021.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 03/30/2021] [Accepted: 04/19/2021] [Indexed: 11/22/2022]
Abstract
Alopecia, although long considered an unavoidable consequence of cancer therapy, currently presents a multifaceted challenge. The knowledge of the physiology of the hair and consequently of the pathophysiology of alopecia has led to show that there is not one but several types of alopecia. Transposed to the world of oncology, different types of alopecia and subsequently molecular pathways have been characterized, allowing a better understanding of the underlying mechanisms. Thus, in patients with cancer, alopecia can be iatrogenic (chemotherapies, endocrine therapies, targeted therapies, immunotherapies, radiotherapy, surgery) or directly the consequence of the disease itself (malnutrition, scalp metastases, paraneoplastic syndromes). Knowledge of the incriminated mechanism(s) could thus make it possible to deploy an appropriate care component, whether on the preventive or curative sides or in terms of supportive care. These are particularly essential regarding the psychological repercussions caused by alopecia, with significant consequences on the quality of life of patients and with a potential impact on treatment compliance. On the preventive side, the last few years have seen the advent of the automated scalp cooling therapy, supported by several randomized clinical trials. On the curative side, several therapeutic proposals are currently deployed or under development in order to provide relevant treatments.
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Abstract
Describing and listing all nail symptoms and signs in systemic disorders has already been widely detailed in dedicated textbooks. To be tutorial, this article described most common nails signs and the systemic disorders one may encounter in routine dermatologic consultation. Capsule summaries are presented for each section.
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Affiliation(s)
- Florence Dehavay
- Saint-Pierre, Brugmann and Queen Fabiola Children University Hospitals, Université Libre de Bruxelles, Belgium
| | - Bertrand Richert
- Saint-Pierre, Brugmann and Queen Fabiola Children University Hospitals, Université Libre de Bruxelles, Belgium.
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15
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Roy B, Lipner SR. A Review of Nail Changes in Acrokeratosis Paraneoplastica (Bazex Syndrome). Skin Appendage Disord 2021; 7:163-172. [PMID: 34055903 DOI: 10.1159/000513828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 12/07/2020] [Indexed: 11/19/2022] Open
Abstract
Acrokeratosis paraneoplastica (Bazex syndrome) is a rare paraneoplastic dermatosis associated with internal malignancies. Clinical presentation is characterized by erythematous or violaceous scaly plaques involving the digits, nose, ears, palms, and soles. Nail changes commonly present concurrently with cutaneous manifestations. In this review, we characterize nail changes associated with acrokeratosis paraneoplastica. A total of 48 cases were analyzed. Nail findings were nonspecific, with the most common being nail plate thickening, onycholysis, subungual hyperkeratosis, longitudinal ridging, discoloration, and nail plate loss. In most patients, nail changes involved the majority of fingernails and toenails and most often appeared prior to the diagnosis of malignancy. The most common associated underlying malignancies were squamous cell carcinomas of the head and neck. A diagnosis of acrokeratosis paraneoplastica should be considered in patients with onychodystrophy involving multiple nails with accompanying atypical psoriasiform dermatoses. Screening for internal malignancies may significantly decrease morbidity and mortality for these patients.
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Affiliation(s)
- Bipasha Roy
- New York Medical College School of Medicine, Valhalla, New York, USA
| | - Shari R Lipner
- Department of Dermatology, Weill Cornell Medicine, New York, New York, USA
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16
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Abstract
The cutaneous paraneoplastic syndromes are rare and intrinsically devoid of any neoplastic nature. The manifestations on the skin and the nails are due to various mechanisms caused by the tumor, either due to production of bioactive substances or in response to it. These disorders evolve in parallel to the malignancy, in that, they regress when the tumor is removed and reappear in the case of tumor recurrence. The aim of this article is to aid with the early recognition of the signs, leading to the early detection of cancer and therefore to better clinical outcomes for the patients.
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Affiliation(s)
- Athina Fonia
- Department of Dermatology, Queen Elizabeth Hospital, London SE18 4QH, UK.
| | - Robert Baran
- Nail Disease Centre, Rue des Serbes 42, Cannes 06400, France
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17
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Horton L, Bedford LM, Daveluy S. Acrokeratosis paraneoplastica (Bazex syndrome) as the presenting sign of pancreatic adenocarcinoma. BMJ Case Rep 2020; 13:13/12/e236514. [PMID: 33318269 PMCID: PMC7737062 DOI: 10.1136/bcr-2020-236514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Acrokeratosis paraneoplastica (Bazex syndrome) is a rare paraneoplastic skin condition characterised by acral psoriasiform plaques, with a predilection for the nose, ears, hands and feet. It typically presents before the discovery of an internal malignancy and is often misdiagnosed as an inflammatory dermatitis that does not respond to treatment. It is associated with squamous cell carcinoma of the aerodigestive tract and lung, as well as adenocarcinoma of the lung, colon and gastrum. Here, we describe the second reported case of Bazex syndrome in the setting of pancreatic adenocarcinoma and the first such case in a patient of African ancestry.
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Affiliation(s)
- Luke Horton
- Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Lisa M Bedford
- Dermatology, Wayne State University School of Medicine, Dearborn, Michigan, USA
| | - Steven Daveluy
- Dermatology, Wayne State University School of Medicine, Dearborn, Michigan, USA
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18
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Eckstein J, Healy E, Jain A, Hawkins D, Ho Q, Agrawal A, Ozer E, Rupert R, Diavolitsis VM, Bhatt AD. A series of typical and atypical cases of Bazex syndrome: Identifying the red herring to avoid delaying cancer treatment. Clin Case Rep 2020; 8:2259-2264. [PMID: 33235772 PMCID: PMC7669396 DOI: 10.1002/ccr3.3133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 05/25/2020] [Accepted: 06/13/2020] [Indexed: 11/12/2022] Open
Abstract
Bazex syndrome is a rare paraneoplastic dermatosis that precedes diagnosis of cancer. Awareness of this syndrome is important, as it allows early detection of underlying malignancy and may prevent misdiagnosis and delays in cancer treatment.
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Affiliation(s)
- Jacob Eckstein
- Radiation OncologyLong Island Jewish Medical CenterNorthwell Health Cancer InstituteNew Hyde ParkNYUSA
| | - Erin Healy
- Radiation OncologyThe Ohio State University Medical CenterColumbusOHUSA
| | - Angita Jain
- Kasturba Medical College MangaloreMangaloreIndia
| | - Daniel Hawkins
- Radiation OncologySeidman Cancer CenterUniversity HospitalsClevelandOHUSA
| | - Quoc‐Anh Ho
- Radiation OncologyThe Ohio State University Medical CenterColumbusOHUSA
| | - Amit Agrawal
- OtolaryngologyThe Ohio State University Medical CenterColumbusOHUSA
| | - Enver Ozer
- OtolaryngologyThe Ohio State University Medical CenterColumbusOHUSA
| | - Robert Rupert
- Medical OncologyThe Ohio State University Medical CenterColumbusOHUSA
| | | | - Aashish D. Bhatt
- Radiation OncologySeidman Cancer CenterUniversity HospitalsClevelandOHUSA
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19
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Kandemir Alibakan Ö, Demirel N, Nizam N, Eren R. An Unconventional Presentation of Multiple Myeloma: Bazex Syndrome. Turk J Haematol 2020; 37:294-296. [PMID: 32830932 PMCID: PMC7702651 DOI: 10.4274/tjh.galenos.2020.2020.0308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Affiliation(s)
- Özlem Kandemir Alibakan
- University of Health Sciences Turkey, Prof. Dr. Cemil Taşçıoğlu Training and Research Hospital, Clinic of Internal Medicine, İstanbul, Turkey
| | - Naciye Demirel
- University of Health Sciences Turkey, Prof. Dr. Cemil Taşçıoğlu Training and Research Hospital, Clinic of Hematology, İstanbul, Turkey
| | - Nihan Nizam
- İstanbul University İstanbul Faculty of Medicine, Department of Internal Medicine, İstanbul, Turkey
| | - Rafet Eren
- University of Health Sciences Turkey, Prof. Dr. Cemil Taşçıoğlu Training and Research Hospital, Clinic of Hematology, İstanbul, Turkey
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20
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Koumaki D, Koumaki V, Haniotis V, Galanakis N, Katoulis A, Boumpoucheropoulos S, Evangelou G, Stefanidou M, Krueger-Krasagakis SE, Krasagakis K. An Unusual Etiology for an Acral Psoriasiform Dermatosis. Indian J Dermatol 2020; 65:530-532. [PMID: 33487714 PMCID: PMC7810066 DOI: 10.4103/ijd.ijd_144_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Dimitra Koumaki
- Department of Dermatology, University Hospital of Heraklion, Crete, Greece
| | | | | | | | | | | | - George Evangelou
- Department of Dermatology, University Hospital of Heraklion, Crete, Greece
| | - Maria Stefanidou
- Department of Dermatology, University Hospital of Heraklion, Crete, Greece
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21
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Elsner P, Agner T. Hand eczema: treatment. J Eur Acad Dermatol Venereol 2019; 34 Suppl 1:13-21. [DOI: 10.1111/jdv.16062] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 11/06/2019] [Indexed: 12/11/2022]
Affiliation(s)
- P. Elsner
- Department of Dermatology University Hospital Jena Jena Germany
| | - T. Agner
- Department of Dermatology Bispebjerg Hospital University of Copenhagen Copenhagen Denmark
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22
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Aoshima Y, Karayama M, Sagisaka S, Yasui H, Hozumi H, Suzuki Y, Furuhashi K, Enomoto N, Fujisawa T, Nakamura Y, Inui N, Suda T. Synchronous Occurrence of Bazex Syndrome and Remitting Seronegative Symmetrical Synovitis with Pitting Edema Syndrome in a Patient with Lung Cancer. Intern Med 2019; 58:3267-3271. [PMID: 31292397 PMCID: PMC6911753 DOI: 10.2169/internalmedicine.3032-19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
A 69-year-old man developed bilateral polyarthritis, edematous extremities, and skin desquamation on the fingers and ears. He did not meet the criteria for any connective tissue disease, including rheumatoid arthritis. An examination revealed advanced lung cancer. His systemic manifestations were attributed to paraneoplastic Bazex syndrome and remitting seronegative symmetrical synovitis with pitting edema (RS3PE) syndrome. Treatment with pembrolizumab (an anti-programmed death-1 antibody) for lung cancer relieved his symptoms and shrank the lung tumor. Bazex and RS3PE syndromes are rare paraneoplastic diseases. We herein report this unique case of synchronous development of these two paraneoplastic syndromes in the presence of advanced lung cancer.
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Affiliation(s)
- Yoichiro Aoshima
- Second Department of Internal Medicine, Hamamatsu University School of Medicine, Japan
| | - Masato Karayama
- Second Department of Internal Medicine, Hamamatsu University School of Medicine, Japan
- Department of Clinical Oncology, Hamamatsu University School of Medicine, Japan
| | - Shinya Sagisaka
- Department of Respiratory Medicine, Juzen Memorial Hospital, Japan
| | - Hideki Yasui
- Second Department of Internal Medicine, Hamamatsu University School of Medicine, Japan
| | - Hironao Hozumi
- Second Department of Internal Medicine, Hamamatsu University School of Medicine, Japan
| | - Yuzo Suzuki
- Second Department of Internal Medicine, Hamamatsu University School of Medicine, Japan
| | - Kazuki Furuhashi
- Second Department of Internal Medicine, Hamamatsu University School of Medicine, Japan
| | - Noriyuki Enomoto
- Second Department of Internal Medicine, Hamamatsu University School of Medicine, Japan
| | - Tomoyuki Fujisawa
- Second Department of Internal Medicine, Hamamatsu University School of Medicine, Japan
| | - Yutaro Nakamura
- Second Department of Internal Medicine, Hamamatsu University School of Medicine, Japan
| | - Naoki Inui
- Second Department of Internal Medicine, Hamamatsu University School of Medicine, Japan
| | - Takafumi Suda
- Second Department of Internal Medicine, Hamamatsu University School of Medicine, Japan
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23
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Wetzel M, Owen CE, Callen JP. Paraneoplastic Syndromes for the Inpatient Dermatologist. CURRENT DERMATOLOGY REPORTS 2019. [DOI: 10.1007/s13671-019-00277-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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24
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Mititelu R, Powell M. A case report of resolution of acrokeratosis paraneoplastica (Bazex syndrome) post resection of non-small-cell lung carcinoma. SAGE Open Med Case Rep 2019; 7:2050313X19881595. [PMID: 31636907 PMCID: PMC6785924 DOI: 10.1177/2050313x19881595] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Acrokeratosis paraneoplastica (Bazex syndrome) is a paraneoplastic syndrome frequently associated with squamous cell carcinoma of the aerodigestive tract. We present a case of acrokeratosis paraneoplastica associated with non-small-cell lung carcinoma, which completely resolved once the carcinoma was resected.
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Affiliation(s)
- Roxana Mititelu
- Roxana Mititelu, Division of Dermatology, Montreal General Hospital, McGill University Health Centre, Montreal, QC Canada, H3G 1A4.
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25
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Keller JJ, Fett NM, Morrison LH. Dermatology in the Diagnosis of Noncutaneous Malignancy. Dermatol Clin 2019; 37:537-544. [DOI: 10.1016/j.det.2019.05.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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26
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Duran-Vian C, Gómez C, Navarro I, Reguero L, Alonso L, González-Vela MC, González-López MA. Acrokeratosis paraneoplastica (Bazex syndrome) with bullous lesions. Indian J Dermatol Venereol Leprol 2019; 86:335. [PMID: 31339109 DOI: 10.4103/ijdvl.ijdvl_288_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- C Duran-Vian
- Division of Dermatology, University Hospital of Marqués de Valdecilla, University of Cantabria, Santander, Cantabria, Spain
| | - C Gómez
- Division of Dermatology, University Hospital of Marqués de Valdecilla, University of Cantabria, Santander, Cantabria, Spain
| | - I Navarro
- Division of Dermatology, University Hospital of Marqués de Valdecilla, University of Cantabria, Santander, Cantabria, Spain
| | - L Reguero
- Division of Dermatology, University Hospital of Marqués de Valdecilla, University of Cantabria, Santander, Cantabria, Spain
| | - L Alonso
- Division of Oncology, University Hospital of Marqués de Valdecilla, University of Cantabria, Santander, Cantabria, Spain
| | - M C González-Vela
- Division of Pathology, University Hospital of Marqués de Valdecilla, University of Cantabria, Santander, Cantabria, Spain
| | - M A González-López
- Division of Dermatology, University Hospital of Marqués de Valdecilla, University of Cantabria, Santander, Cantabria, Spain
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27
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Nguyen S, Grosber M, Gutermuth J. Acrokeratosis Can Be a Warning Sign of an Underlying Malignancy. Eur J Case Rep Intern Med 2019; 6:001108. [PMID: 31157185 PMCID: PMC6542486 DOI: 10.12890/2019_001108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 04/17/2019] [Indexed: 12/01/2022] Open
Abstract
Introduction Some cutaneous manifestations can be the first presentation of an underlying malignancy. These so-called paraneoplastic syndromes can sometimes be very subtle or strongly resemble other benign cutaneous diseases. Aims In this report, we want to emphasize the need for further investigation of eczema-like cutaneous presentations which develop at a later age and are recalcitrant to therapy. Exclusion of an underlying malignancy needs to be considered. Patients and Methods A 53-year-old man with thickening of the skin, more pronounced on the hands, feet and face, was diagnosed with classic nodular sclerosing Hodgkin disease based on cutaneous presentation. Results After two rounds of chemotherapy (adriamycin, bleomycin, vinblastine and dacarbazine), the cutaneous symptoms had disappeared. After six rounds of chemotherapy and 14 months of follow-up, the patient is still in remission without recurrence of the cutaneous symptoms. Conclusions Cutaneous symptoms recalcitrant to adequate treatment should raise suspicion and prompt further investigation to exclude an underlying malignancy. A multidisciplinary approach with the dermatology department can accelerate diagnosis and improve the patient’s prognosis. LEARNING POINTS
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Affiliation(s)
- Sara Nguyen
- Department of Dermatology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Martine Grosber
- Department of Dermatology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Jan Gutermuth
- Department of Dermatology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel (VUB), Brussels, Belgium
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28
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Abstract
A variety of cutaneous abnormalities can be seen in patients with malignant diseases, some of which are infectious, with others representing direct involvement of the skin by the underlying disorder. Yet another group of lesions can be regarded as associated markers of the malignant process, and, as such, are termed "paraneoplastic." This review considers the latter collection of conditions, grouping them by the generic type of malignancy that is usually linked to the paraneoplasia. Some of the processes show a predominant association with alimentary tract malignancies (acanthosis nigricans, acrodermatitis paraneoplastica, florid cutaneous papillomatosis, necrolytic migratory erythema, palmoplantar keratoderma, pancreatic fat necrosis, and pityriasis rotunda). Others are usually linked to a hematolymphoid malignancy (acquired ichthyosis, exfoliative erythroderma, necrobiotic xanthogranuloma, pemphigus paraneoplastica, plane xanthoma, pyoderma gangrenosum, scleromyxedema, Sweet syndrome, and leukocytoclastic vasculitis). Finally, yet another collection of paraneoplastic skin disorders can associate themselves with anatomically-diverse malignancies (Leser-Trelat syndrome, Trousseau syndrome, dermatomyositis, erythema gyratum repens, hypertrichosis lanuginosa acquisita, papuloerythroderma of Ofuji, tripe palms, and multicentric reticulohistiocytosis). Recognition of these processes by the pathologist can be a valuable step in the characterization of underlying malignant diseases.
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Affiliation(s)
- Mark R Wick
- PRW Laboratories, Charlottesville, VA, United State.
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29
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McClatchey TM, Haynes D, Korcheva VB, Keller J. Acrokeratosis paraneoplastica (Bazex syndrome) associated with peripheral T-cell lymphoma. JAAD Case Rep 2018; 5:86-88. [PMID: 30581941 PMCID: PMC6297902 DOI: 10.1016/j.jdcr.2018.10.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
| | - Dylan Haynes
- Department of Dermatology, Oregon Health and Science University, Portland, Oregon
| | - Veselina B Korcheva
- Department of Dermatology, Oregon Health and Science University, Portland, Oregon
| | - Jesse Keller
- Department of Dermatology, Oregon Health and Science University, Portland, Oregon
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30
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[Acrokeratosis paraneoplastica in hemato-oncological disease]. Hautarzt 2018; 69:42-44. [PMID: 30264310 DOI: 10.1007/s00105-018-4178-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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31
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Ben-Hassen N, Roche-Gamón E, Hernández-Bel P. Detection of laryngeal squamous cell carcinoma in a context of acrokeratosis paraneoplastica: Case report. OTOLARYNGOLOGY CASE REPORTS 2018. [DOI: 10.1016/j.xocr.2018.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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32
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Caccavale S, Brancaccio G, Agozzino M, Vitiello P, Alfano R, Argenziano G. Obligate and facultative paraneoplastic dermatoses: an overview. Dermatol Pract Concept 2018; 8:191-197. [PMID: 30116663 PMCID: PMC6092071 DOI: 10.5826/dpc.0803a09] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 03/09/2018] [Indexed: 12/17/2022] Open
Abstract
Dermatological paraneoplastic syndromes are a group of cutaneous diseases associated with malignancy, but not directly related to the primary tumor itself or to its metastases. It is of utmost importance for the dermatologist to recognize the major cutaneous paraneoplastic syndromes to diagnose the underlying tumors that trigger them as early as possible. In this overview, skin conditions that are highly correlated with malignancy, whose recognition implies a mandatory investigation of internal cancer, are described.
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Affiliation(s)
- Stefano Caccavale
- Dermatology Unit, University of Campania Luigi Vanvitelli, Naples, Italy
| | | | - Marina Agozzino
- Dermatology Unit, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Paola Vitiello
- Dermatology Unit, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Roberto Alfano
- Department of Anesthesiology, Surgery and Emergency, University of Campania Luigi Vanvitelli, Naples, Italy
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33
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Affiliation(s)
- Keiichi Iwanami
- Department of Rheumatology, Nerima Hikarigaoka Hospital, Japan
| | - Mori Nakai
- Department of General Internal Medicine, Nerima Hikarigaoka Hospital, Japan
| | - Koichi Kitamura
- Department of General Internal Medicine, Nerima Hikarigaoka Hospital, Japan
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34
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35
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Suzon B, Arnaud E, Galy C, Broner J. [Hands and feet lesions]. Rev Med Interne 2017; 40:56-57. [PMID: 28942058 DOI: 10.1016/j.revmed.2017.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 08/13/2017] [Accepted: 08/24/2017] [Indexed: 10/18/2022]
Affiliation(s)
- B Suzon
- Service de médecine interne, CHU Carémeau Nîmes, place du Professeur-Robert-Debré, 30000 Nîmes, France.
| | - E Arnaud
- Service de médecine interne, CHU Carémeau Nîmes, place du Professeur-Robert-Debré, 30000 Nîmes, France
| | - C Galy
- Service d'oto-rhino-laryngologie, CHU Carémeau Nîmes, place du Professeur-Robert-Debré, 30000 Nîmes, France
| | - J Broner
- Service de médecine interne, CHU Carémeau Nîmes, place du Professeur-Robert-Debré, 30000 Nîmes, France
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