The first Danish family reported with an AQP5 mutation presenting diffuse non-epidermolytic palmoplantar keratoderma of Bothnian type, hyperhidrosis and frequent Corynebacterium infections: a case report

Background

An autosomal dominant form of diffuse non-epidermolytic palmoplantar keratoderma, palmoplantar keratoderma of Bothnian type, is caused by mutations in the AQP5 gene encoding the cell-membrane water channel protein aquaporin 5 leading to defective epidermal-water-barrier function in the epidermis of the palms and soles.

Case presentation

We report the first Danish family diagnosed with diffuse non-epidermolytic palmoplantar keratoderma of Bothnian type in which fourteen individuals are potentially affected. The proband, a 36-year-old male had since childhood been affected by pronounced hyperhidrosis of the palms and soles along with palmoplantar keratoderma. He reported a very distinctive feature of the disorder, aquagenic wrinkling, as he developed pronounced maceration of the skin with translucent white papules and a spongy appearance following exposure to water. The patient presented recurrent fungal infections, a wellknown feature of the condition, but also periodic worsening with pitted keratolysis and malodour due to bacterial infections.

Conclusions

Palmoplantar keratoderma of Bothnian type, which may be associated with hyperhidrosis, is frequently complicated by fungal infections and may be complicated by Corynebacterium infections.

Electronic supplementary material

The online version of this article (doi:10.1186/s12895-016-0044-3) contains supplementary material, which is available to authorized users.

A child with mastocytosis and lymphomatoid papulosis

A change in clinical behavior of a disease should prompt search for differential diagnoses. Here, the appearance of ulcerated skin nodules in a preexisting cutaneous mastocytosis revealed a concurrent lymphomatoid papulosis – a CD30+ lymphoproliferative skin disease with histological features of a malignant lymphoma, but with a benign self‐healing course.

Odonto-onycho-dermal dysplasia in a patient homozygous for a WNT10A nonsense mutation and mild manifestations of ectodermal dysplasia in carriers of the mutation

Background

Odonto-onycho-dermal dysplasia (OODD) is a rare form of ectodermal dysplasia characterized by severe oligodontia, onychodysplasia, palmoplantar hyperkeratosis, dry skin, hypotrichosis, and hyperhidrosis of the palms and soles. The ectodermal dysplasias resulting from biallelic mutations in the WNT10A gene result in highly variable phenotypes, ranging from isolated tooth agenesis to OODD and Schöpf-Schulz-Passarge syndrome (SSPS).

Case presentation

We identified a female patient, with consanguineous parents, who was clinically diagnosed with OODD. Genetic testing showed that she was homozygous for a previously reported pathogenic mutation in the WNT10A gene, c.321C > A, p.Cys107*. The skin and nail abnormalities were for many years interpreted as psoriasis and treated accordingly. A thorough clinical examination revealed hypotrichosis and hyperhidrosis of the soles and dental examination revealed agenesis of permanent teeth except the two maxillary central incisors. Skin biopsies from the hyperkeratotic palms and soles showed the characteristic changes of eccrine syringofibroadenomatosis, which has been described in patients with ectodermal dysplasias. Together with a family history of tooth anomalies, this lead to the clinical suspicion of a hereditary ectodermal dysplasia.

Conclusion

This case illustrates the challenges of diagnosing ectodermal dysplasia like OODD and highlights the relevance of interdisciplinary cooperation in the diagnosis of rare conditions.

Antiviral treatment of a boy with EBV-associated hydroa vacciniforme

Hydroa vacciniforme is one of the rarest forms of photosensitivity disorders of the skin. Effective treatment options are scarce and mainly constitute of strict sun protection. Lately, hydroa vacciniforme has been associated with Epstein-Barr virus infection. We present a patient with hydroa vacciniforme and concomitant previous/chronic Epstein-Barr virus infection. In this case, antiviral treatment was successful.

Congenital self-healing reticulohistiocytosis - an important diagnostic challenge

AIM

To present current and new knowledge on congenital self-healing reticulohistiocytosis, a benign variant of cutaneous Langerhans cell histiocytosis presenting with skin lesions in the neonatal period.

METHODS

We describe and photo document two cases of this rare disease and review the literature.

RESULTS

Only few newborns have acute access to a neonatal dermatologist, and we demonstrate how the spontaneous cutaneous involution may happen even prior to the first dermatological assessment. As no sole criterion can reliably distinguish the self-healing form from disseminated disease, multidisciplinary assessment and follow-up are essential.

CONCLUSION

Our data document how easily the diagnosis congenital self-healing reticulocytosis may be missed and emphasize the importance and value of instant clinical photographing at the neonatal unit and the use of teledermatology whenever congenital self-healing reticulohistiocytosis is suspected.

Extraction of high-quality epidermal RNA after ammonium thiocyanate-induced dermo-epidermal separation of 4 mm human skin biopsies

To obtain a separation of the epidermal and dermal compartments to examine compartment specific biological mechanisms in the skin, we incubated 4 mm human skin punch biopsies in ammonium thiocyanate. We wanted to test (i) the histological quality of the dermo-epidermal separation obtained by different incubation times; (ii) the amount and quality of extractable epidermal RNA and (iii) its impact on sample RNA expression profiles assessed by large-scale gene expression microarray analysis in both normal and inflamed skin. At 30-min incubation, the split between dermis and epidermis was not always histologically well-defined (i.e. occurred partly intra-epidermally), but also varied between subjects. Consequently, curettage along the dermal surface of the biopsy was added to the procedure. This modified method resulted in an almost perfect separation of the epidermal and dermal compartments, and satisfactory amounts of high-quality RNA were obtained. Hybridization to Affymetrix HG_U133A 2.0 GeneChips showed that ammonium thiocyanate incubation had a minute effect on gene expression resulting in only one significantly downregulated gene (cystatin E/M). We conclude that epidermis can be reproducibly and almost completely separated from the dermis of 4 mm skin biopsies by 30 min incubation in 3.8% ammonium thiocyanate combined with curettage of the dermal surface, producing high-quality RNA suitable for transcriptional analysis. Our refined method of dermo-epidermal separation will undoubtedly prove valuable in the many different settings, where the epidermal and dermal compartments need to be evaluated separately.

[Calciphylaxis]

Calciphylaxis is a serious condition including ischaemic, nodular necrosis of the subcutaneous tissue and occlusion of small and medium-sized arteries. The prevalence of calciphylaxis among patients on chronic haemodialysis constitutes 1-4 percent. The condition is associated with high mortality due to co-morbidity. Calciphylaxis seems to be preventable by optimized control of calcium-phosphorous metabolism in susceptible individuals. New and promising therapies are evolving. It is important to focus on this condition in order to provide the relevant therapy to the affected cases.

Sequential studies of lymphocytes, neutrophils and serum proteins during prednisone treatment

Seven patients (6 with connective tissue diseases, 1 with bronchial asthma) have been studied before, during, and after prednisone therapy. Maximum dose was 15 mg daily, which was tapered off to zero within three months. All patients showed striking subjective improvement during therapy. The ESR reflected this improvement but the acute phase proteins did not. The serum concentration of prealbumin rose significantly during the period of most intensive steroid treatment. IgE decreased in the patient with bronchial asthma, but otherwise the immunoglobulins did not change, and positive serological tests remained unchanged. Contact sensitization to haptens was induced without impairment during therapy. Prednisone induced rises in blood lymphocyte and neutrophil concentrations. Lymphocyte transformation, both mitogen- and antigen-induced, was not influenced by therapy, but PPD-induced inhibition of leucocyte migration decreased. Neutrophil phagocytosis was unimparied, but bactericidal capacity, stimulated nitroblue tetrazolium reduction, and neutrophil and plasma lysozyme concentrations were all depressed during treatment with prednisone.

[Glucagonoma syndrome without diabetes mellitus]

A patient developed depression, weight loss, ulcers and a migrating, denuded erythematous skin area. Punch biopsy revealed necrolytic migrating erythema. Computerised tomography and endoscopic ultrasound showed a solid tumour of the pancreas. A blood sample showed an increased level of glucagon without diabetes. Glucagonoma syndrome is characterized by glucagon overproduction, diabetes, depression, deep venous thrombosis and necrolytic migrating erythema. Glucagonoma is frequently diagnosed late which increases the risk of metastases. It is important not to rule out glucagonoma in patients with a relevant clinical picture but without diabetes.

Staging patients with cutaneous malignant melanoma by same-day lymphoscintigraphy and sentinel lymph node biopsy: A single-institutional experience with emphasis on recurrence

BACKGROUND AND OBJECTIVES

Different techniques have been employed in mapping sentinel lymph nodes (SLN) in patients with malignant melanoma (MM). We present a single-institutional experience.

METHODS

Sentinel lymph node biopsies were performed in a consecutive series of 278 patients with 279 cutaneous MMs in clinical stage I. All underwent dynamic lymphoscintigraphy with 15-20 MBq 99mTc-rhenium-colloid followed on the same day by radioprobe-guided surgery completed approximately 4 hr after injection of radiopharmaceutical.

RESULTS

In 274 (98.2%) cases, a median of two SLNs (range 1-7) were removed. In five patients, no SLN was removed. Seventy-nine patients (28%) had metastatic SLNs. Median Breslow thickness in this group was 2.3 mm. Nodal dissection of the positive basin was done in 75 of these 79 patients and revealed further positive lymph nodes in 10 (13%). Eighteen of the 79 (23%) patients died after a median of 17.5 months post-operatively from metastatic disease. In 195 cases (194 patients) (70%), removed SLNs were negative. The median Breslow thickness in this group was 1.6 mm. Four patients (2%) had regional lymph node recurrence ("false negative SLN procedures"). Eight of the 194 patients (4.1%) died after a median of 24.5 months post-operatively from metastatic disease. One of these was one of the four patients with a false negative SLN procedure, and in all eight, histological re-evaluation of SLNs was negative. Local recurrence occurred in 6 of the 195 cases. The rate of recurrence at any site among the SLN-negative cases was 8.8%. The complication rate was 5%.

CONCLUSIONS

Same-day lymphoscintigraphy and radioprobe-guided surgery identified, with a high sensitivity and a low false negative rate, MM patients with microscopic nodal disease. Our results do at least equal other comparable studies.

Loose anagen hair syndrome associated with colobomas and dysmorphic features

Loose anagen hair syndrome is an uncommon congenital disorder. It may occur in association with other syndromes and dysmorphic features. We report a girl who fulfilled the diagnostic criteria for this syndrome as proposed by Tosti (Arch Dermatol 2002, 138: 521-522). She also had several other anomalies including colobomas. We suggest that the combination of features in this patient may constitute a specific syndromic phenotype.

IgA pemphigus: the first two Scandinavian cases

IgA pemphigus is a rare neutrophilic acantholytic skin disorder with only approximately 70 cases reported in the indexed literature to date. Here we describe two patients with IgA pemphigus (subcorneal pustular dermatosis type and intraepithelial neutrophilic type) that to our knowledge are the first Scandinavian patients with this disease. Initially, both patients were misdiagnosed as subcorneal pustular dermatosis of Sneddon and Wilkinson and only subsequent careful immunofluorescence studies (in one case with confocal laser scanning microscopy) led to the correct diagnosis. Apart from the expected IgA depositions on epidermal cell surfaces, both patients demonstrated some degree of intercellular IgG-specific immunofluorescence. No circulating IgA autoantibodies were detected. One patient was treated with the standard regime comprising dapsone and prednisolone, whereas in the other case a novel methotrexate and prednisolone combination treatment showed marked clinical efficacy.

Diagnostic value of PCR for detection of Borrelia burgdorferi DNA in clinical specimens from patients with erythema migrans and Lyme neuroborreliosis

BACKGROUND

The aim of the study is to evaluate the diagnostic sensitivity of a 16S ribosomal RNA-based PCR on clinical specimens from patients with erythema migrans (EM) and neuroborreliosis and to compare the sensitivities with those obtained by in vitro culture and serological testing. A semiquantitative detection system, representing the input amount of specific DNA and thus the density of spirochetes in clinical specimens, indicated the preferred clinical sample to obtain for PCR testing.

METHODS AND RESULTS

Skin biopsy and urine samples from 31 patients with EM and cerebrospinal fluid (CSF) and urine samples from 30 patients with neuroborreliosis were investigated. Borrelia burgdorferi DNA was detected in 71% of the skin biopsy specimens and 13% of the urine samples from patients with EM. Forty-one percent of the patients with EM were found to have B burgdorferi-specific antibodies in serum, and B burgdorferi was cultured in 29% of the EM specimens. For patients with neuroborreliosis, the diagnostic sensitivities in CSF and urine samples were 17% and 7%, respectively. Specific intrathecal antibody production was found in 90% of the patients, and 87% showed elevated B burgdorferi antibodies in serum. In general, PCR of skin biopsy samples yielded very high amounts of amplicons versus low amounts for CSF and urine samples.

CONCLUSIONS

PCR of skin biopsy specimens is currently the most sensitive and specific test for the diagnosis of patients with EM, superior to culture and serological testing. For B burgdorferi-specific CSF disgnosis in patients with neuroborreliosis, the measurement of specific intrathecal antibody synthesis is superior to PCR. However, in patients with a short duration of disease (<14 days), PCR may be a useful diagnostic supplement. PCR of urine samples cannot be recommended at the present time for routine diagnosis of patients with EM or neuroborreliosis.

Comparison of in vitro culture, immunohistochemical staining, and PCR for detection of Borrelia burgdorferi in tissue from experimentally infected animals

An avidin-biotin-amplified immunophosphatase staining method with a purified polyclonal rabbit anti-Borrelia burgdorferi hyperimmune serum was developed for identification of B. burgdorferi in tissue specimens. The diagnostic efficacy was compared with those of in vitro culture and PCR with fresh and fixed, paraffin-embedded tissues. A nested PCR assay was developed for identification of a 276-bp fragment of the B. burgdorferi flagellin gene. The diagnostic sensitivities of the different techniques were evaluated with spleen, renal, and urinary bladder tissues from eight experimentally infected gerbils. A systemic infection was verified by positivity of 23 of 24 (96%) organ cultures. B. burgdorferi was visualized immunohistochemically in 9 of 23 (39%) of the specimens. Among these nine specimens, an average of 33% of the 15 sections examined were positive. The spirochetes accumulated in discrete clusters and were associated with focal lymphocytic infiltration. The diagnostic sensitivity obtained by PCR with fixed, paraffin-embedded tissue was 21%, considerably lower than that with fresh tissue (71%). Thus, the reliable demonstration of B. burgdorferi by immunohistochemical staining is possible but extremely laborious, and considering the fact that the density of B. burgdorferi in human tissue is even lower than that in experimentally infected animals, the method is not useful in a clinical setting. It may, however, still be valuable in pathogenetic research. Detection of B. burgdorferi DNA by PCR should be performed with fresh tissue specimens and not with fixed, paraffin-embedded specimens.

Abnormalities of lymphocyte function and phenotypic pattern in a case of toxic epidermal necrolysis

We examined the blood lymphocyte function and phenotypic pattern in a patient with toxic epidermal necrolysis after taking salazopyrin. We studied cell surface markers, natural killer cell activity and mitogen-induced lymphocyte transformation. Our results point to temporary immunosuppression as evidenced by lymphopenia with a large "null cell" population, reduced natural killer cell activity, and impaired lymphocyte response to mitogens.

Adenocarcinoma arising in a foregut cyst of the mediastinum

A case of malignant transformation in a mediastinal cyst of the esophageal reduplication type is presented. The cyst had been recognized 39 years previously, but remained asymptomatic until sudden growth occurred. It was resected totally from the esophagus and the patient recovered well. A review of the literature showed that malignancy in mediastinal foregut cysts is extremely rare.

Antigen-presenting activity of non-Langerhans epidermal cells in contact hypersensitivity reactions

Despite the critical role of the Langerhans cells in the induction of contact hypersensitivity reactions, non-Langerhans antigen-presenting cells in already sensitized individuals may play a role in the elicitation phase of a contact hypersensitivity reaction. Following epicutaneous challenge with antigens, the number of CD1+DR+ epidermal Langerhans cells increased in a time-dependent way and, concomitantly, CD1-OKM5+DR+ epidermal non-Langerhans cells appeared. In parallel with this, the capacity of epidermal cells to present both alloantigens and auto/nominal antigens increased, and 4 days after initiation of the contact hypersensitivity reactions 33-53% of the epidermal antigen-presenting capacity was due to CD1- non-Langerhans antigen-presenting cells. Thus, contact hypersensitivity skin reactions are accompanied by the appearance of non-Langerhans antigen-presenting cells capable of presenting both alloantigens and auto/nominal antigens.

Herpes gestationis

A case of clinically typical herpes gestationis is presented. The diagnosis was confirmed by light microscopy and immunofluorescence studies. The symptoms subsided at delivery, but recurred during subsequent oral contraceptive medication. The newborn infant was affected temporarily. The treatment, the fetal risk and the implications of the diagnosis on future pregnancies and contraceptive therapy are discussed.

Porphyria cutanea tarda and systemic lupus erythematosus

Fifty-five patients with porphyria cutanea tarda (PCT) were examined for the simultaneous occurrence of systemic lupus erythematosus (SLE). The diagnostic criteria for SLE were those set up by the American Rheumatism Association (ARA). No patient fulfilled the ARA criteria for SLE. Clinical and laboratory features characteristically associated with SLE (although they were not ARA criteria) were simultaneously evaluated. A total of 120 items occurred in those cases but only 15 of these were ARA criteria. These findings, which may suggest the presence of SLE in patients with PCT, might be ascribed to the concomitant liver disease. The simultaneous occurrence of SLE and PCT is reviewed from the literature. The ARA criteria were fulfilled in one third of the reported cases. The coexistence of SLE and PCT might be less frequent than formerly believed.

Perioral contact urticaria from sorbic acid and benzoic acid in a salad dressing

Contact urticaria was observed in a kindergarten in 18 of 20 children following the intake and accidental perioral application of a mayonnaise salad cream. In healthy adult controls, stinging tests and closed 20 minute patch test with the salad dressing were positive in 9 out of 12 and 4 out of 10 cases respectively. Twenty minute patch tests with the different components of the salad dressing were positive only so sorbic acid (SA) and benzoic acid (BA). Urticaria was provoked by inunction of the salad dressing periorally in two healthy boys. Serial 20 minute closed patch testing with varying concentrations of SA in 91 patients and BA in 41 patients gave almost identical results: positive reactions in two thirds of the patients with the highest concentrations. The response was only partially blocked by antihistamine applied locally before testing. Non-immunologic mechanisms are probably responsible for the transient reaction, and no restriction in the extensive use of SA or BA as preservatives in food should be considered.

Contact sensitivity to aluminium in a patient hyposensitized with aluminium precipitated grass pollen

Standard patch testing of a patient with eczema revealed positive reactions to the aluminium discs used for testing. Patch tests with various aluminium allergens were positive in the patient and negative in 53 controls. The patient was having hyposensitization for hay-fever with an aluminium precipitated allergen. Intradermal testing with aluminium was positive in the patient and negative in nine controls. The eczema disappeared when hyposensitization was discontinued. The possibility of primary sensitization by the hyposensitization procedure is discussed.

A case of multiple neonatal haemangiomatosis successfully treated by systemic corticosteroids

A case of multiple neonatal haemangiomatosis is reported. The disease entity is rare and probably always combined with haemangiomas of internal organs. When visceral involvement provokes clinical symptoms (cardiac, cerebral, gastrointestinal), the spontaneous course often proves fatal. The prognosis seems to improve substantially if treatment with systemic corticosteroids is instituted. The patient reported, who had concomitant cardiac and gastrointestinal symptoms, recovered completely following corticosteroid treatment. It is concluded that steroid treatment is indicated without hazards in complicated cases of multiple neonatal haemangiomatosis.

Cell-mediated immunity of Yersinia enterocolitica serotype 3 in patients with thyroid diseases

The cellular immunity to Yersinia enterocolitica serotype 3 and crude human thyroid extract in 64 patients with thyroid diseases and 25 controls was studied by the leucocyte migration test. In the patient group as a whole and in patients with Graves' disease and nontoxic diffuse goitre a significantly reduced leucocyte migration towards Yersinia was found when compared with the controls. In controls the migration index was not related to the presence or titre of circulating yersinia antibodies, whereas the migration index of patients with yersinia antibodies was lower than the migration index of patients without yersinia antibodies as well as that of the controls. The leucocyte migration inhibition in two patients with recent yersinosis was normal during the recovery phase. In the presence of thyroid extract leucocyte migration inhibition differed only significantly in Graves' disease. However, a significantly positive correlation between inhibition of migration by thyroid extract and by Yersinia was found, while no correlation could be demonstrated in the controls. The cell-mediated immunity towards Yersinia in thyroid diseases thus demonstrated adds further evidence to the association between Yersinia and thyroid disease.