Cutaneous manifestations in neurofibromatosis type 1

OBJECTIVE

To better understand the real prevalence of cutaneous manifestations, in Neurofibromatosis type 1.

MATERIALS AND METHODS

We reviewed all clinical charts of 1102 NF1 patients followed by February 1983 to February 2020 at the "Sapienza" University of Rome, Italy. NF1 patients are seen usually every year by a dermatologist.

RESULT

Café-au-lait macules were shown in 1063 patients (96.5%), axillary and inguinal freckling in 991 (90%) and neurofibromas in 861 (78.1%). Other skin manifestations included: lipoma (6.2%), nevus anemicus (3.9%), psoriasis (3.4%), spilus nevus (3.2%), juvenile xanthogranuloma (3.2%), vitiligo (2.3%), Becker's nevus (1.9%), melanoma (0.7%) and poliosis (0.5%).

CONCLUSION

Neurofibromatosis type 1 is a multisystem disorder primarily involving the skin and nervous system. The clinical manifestations are extremely variable even within a family. This study was performed to delineate the prevalence of cutaneous manifestations in NF1.

Ocular surface involvement in patients with neurofibromatosis type 1 syndrome

PURPOSE

The aim of this study is to evaluate ocular surface morphological and functional changes in patients with neurofibromatosis type 1 (NF1).

METHODS

Twenty-eight patients with NF1 and 14 healthy subjects were included in this study. All participants underwent a medical history collection, a complete ophthalmological examination including slit lamp exam and assessment of best-corrected visual acuity (BCVA), corneal sensitivity, and lacrimal function (Schirmer test and fluorescein tear break-up time test). Corneal nerves' morphology and endothelial cells density were evaluated by in vivo corneal confocal microscopy (IVCM). Tear and conjunctiva epithelium samples were collected to evaluate nerve growth factor (NGF) and brain-derived neurotrophic factor (BDNF) tear levels and conjunctival expression of their receptors TrkA and p75NTR.

RESULTS

Patients with NF1 showed a significant decrease of FTBUT when compared with healthy subjects (p < 0.001). Corneal sensitivity was ≤ 50 mm in 46% of NF1 patients. IVCM showed a significant increase of corneal nerve branching and of corneal endothelial cells density. No significant difference was observed between the two groups on NGF and BDNF tear levels and conjunctival expression of their receptors.

CONCLUSION

This study demonstrated the presence of ocular surface changes in NF-1 patients including decrease of tear stability and of corneal sensitivity. Patients with NF1 also showed changes of corneal endothelial cells' density.

Chiari type 1 malformation in Neurofibromatosis type 1: experience of a center and review of the literature

OBJECTIVE

To evaluate the possible correlation and the true incidence between Neurofibromatosis type 1 and Arnold-Chiari malformation type I.

MATERIALS AND METHODS

We reviewed all clinical charts, neurological consultations and MRI scans of 428 NF1 patients followed by 1994 to 2014 in our Department. NF1 patients in our clinic are seen usually every year by both the dermatologist and the neurologist. All patients also undergo a brain and spinal cord with the same 1.5 Tesla MRI scan.

RESULTS

We found a diagnosis of Arnold Chiari malformation type I in 9 of the 428 NF1 cases (2%).

CONCLUSION

This frequency is higher than that expected on the basis of a chance association. Therefore we underline the importance of serial MRI studies in patients with NF1 to assess the presence of cranio-cervical anomalies. Future studies should try to better understand what are the pathogenetic mechanisms underlying this close association.

Prognostic role of myocardial performance index on long-term survival after heart transplantation: a prospective study

The survival rate of heart transplant patients is increasing, underlying the need for accurate predictors of adverse events during clinical follow-up. Myocardial performance index (MPI) is a Doppler-derived index of combined systolic and diastolic function: we assessed the prognostic role of MPI in survival of patients >1 year after heart transplantation (HT). A total of 152 consecutive HT patients referred to our institution were enrolled in this prospective study. Primary endpoints were cardiac death and a composite of major adverse cardiac events (MACE). During follow-up (69 ± 22 months), 68 (44.7%) patients had an adverse event and 20 (13.15%) patients died. Patients with MACE during follow-up showed lower EF (57.3 ± 9.3 vs. 63 ± 6.1; P < 0.001) and higher MPI (0.45 ± 0.19 vs. 0.31 ± 0.13; P < 0.001) at enrolment. MPI and EF were independently related to MACE (OR = 2.2; 95% confidence interval [CI] = 1.01-5.1; and OR = 6.6; 95% CI = 3.5-11.2, respectively) and showed strong diagnostic power (MPI: receiver operating characteristic [ROC] area = 79%, with 79% sensitivity and 81% specificity; EF: ROC area = 77%, with 54% sensitivity and 91% specificity) in the subsequent year. Patients with EF > 50% and MPI < 0.45 at enrolment showed 75% event-free survival 5 years after HT. In HT patients, MPI combined with EF was an accurate means of predicting long-term adverse events.

Impact of multivessel stenting on top of percutaneous revascularization for unprotected left main disease in the drug-eluting stent era: insights from the Turin registry

OBJECTIVE

Drug-eluting stents (DESs) are commonly used in patients with unprotected left main (ULM) disease. Although multivessel disease and stenting are frequent in this population, pertinent details on short-term and long-term outcomes are lacking.

SETTING AND PATIENTS

We identified consecutive patients with DES treatment for ULM. We distinguished patients presenting isolated ULM stenting (group A) from those with additional treatment of at least another major vessel (group B). The primary end point was major adverse cardiovascular events (i.e. death, myocardial infarction or target vessel revascularization). We compared the impact of a DES-only versus a hybrid DES and bare metal stent strategy for non-ULM lesions.

RESULTS

A total of 189 patients were included, 25% in group A and 75% in group B. In-hospital events were similarly favorable (cardiac death in 0 and 2%, respectively, P = 0.58). A total of 99% patients were followed for a median of 25 months, yielding major adverse cardiovascular events in 17 and 37.5% (P = 0.011). Specifically, death occurred in 4 and 8.5% (P = 0.52), cardiac death in 0 and 7% (P = 0.12), myocardial infarction in 6.5 and 9% (P = 0.76) and target vessel revascularization in 4.3 and 22% (P = 0.006). Adoption of a systematic DES-only strategy for non-ULM lesions conferred significant benefits on major adverse cardiovascular events and repeat non-ULM revascularizations in comparison to a hybrid strategy (22 versus 45%, P < 0.001, and 9 versus 19%, P = 0.004, respectively), at both bivariate and multivariable analyses.

CONCLUSION

Multivessel stenting on top of DES implantation for ULM can be performed with favorable early results. Systematic DES implantation for both ULM and non-ULM lesions is pivotal to maximize clinical results and minimize long-term recurrences.

P304 CASE OF MYOCARDITIS AFTER COVID 19 VACCINATION

COVID 19 has so far found the only barrier in the use of mRNA and viral vector vaccines. Among the rare adverse effects related to mRNA vaccines is myocarditis (4.8 cases per million doses) a disease already found in COVID 19 infection but not in the safety studies of the vaccines. Males not older than 30 years (40% of the total), subjected to the second dose inoculation, are most affected. During our recent clinical practice there was a case of a patient with myocarditis, attributable to vaccination for COVID 19. It was a male, twenty–year–old, non–allergic smoker, subjected to second dose of Pfizer–BioNTech vaccine (BNT162b2). On the fifth day after the inoculation, the patient, already asthenic from the previous days, complained of an episode of oppressive chest pain, which lasted about 15 minutes, which returned, more intense the following night, associated with dyspnea, lasted for hours. When the patient went to the emergency room the pain was in regression and there was good hemodynamic compensation. EKG: sinus rhythm, slight diffuse ST segment elevation, more pronounced in the inferior–lateral leads, slight lowering of the P–R segment. Blood tests: troponin, CKMB and PCR increase, negativity of the molecular test for COVID 19. Echocardiography: normal left ventricle, non–dilated right sections, normokinetic right ventricle, normal valves, pericardial hyper–refraction without effusion, normal diastolic relaxation. In the suspicion of myocarditis, the patient was admitted to our intensive cardiological care. With the high–dose anti–inflammatory and beta–blocker therapy the pain gradually disappeared; never fever; EKG showed progressive ST segment improvement and T wave negativization. Never arrhythmic events. Negativity for all infections with common viral pathogens. MRI: hyperintensity (T2 STIR sequences and late enhancement) in the infero–lateral area. Patient discharged in therapy with lysine acetylsalicylate, to be reduced, associated with pantoprazole, and metoprolol and indicated for outpatient checks. In conclusion, the case presented reflects the scientific literature in the type of patient and in the favorable evolution of the disease.

Ultrastructure study of skin fibroblasts in patients with Ehlers-Danlos Syndrome (EDS): preliminary results

AIM OF THE STUDY

To investigate, in vivo and in vitro, the fibroblast-to-myofibroblast transition in patients with hypermobile Ehlers-Danlos Syndrome (EDS). To analyze the dermis of patients with classical form of EDS (cEDS) and with hEDS, to identify qualitative and/or quantitative differences in ECM component and ultrastructural changes in collagen.

MATERIALS AND METHODS

Seven subjects, aged over 18, two with cEDS and five with hEDS underwent two skin biopsy. One sample was prepared for transmission electron microscopy (TEM), the other for immunofluorescence. The diameter of collagen fibers was measured with TEM. Fibrils were analyzed in four patients: the two with cEDS and two with hEDS. For each patient, the diameter of n=250 collagen fibrils was measured. αSMA was used as specific marker for myofibroblast to highlight their presence in vivo in the skin of patients with hEDS.

RESULT

IF observation could not assess an increased expression of αSMA in hEDS patients, which showed no statistical difference compared to classic form patients. The major result from the analysis of TEM images is the clear difference in ECM composition between the two forms of EDS: ECM in hEDS is optically more dense and more prominently composed of elastic fibers.

CONCLUSION

Our study provides the following important evidence: 1) the absence in vivo of dermal fibroblasts in patients with hEDS, demonstrated by αSMA negativity; 2) the presence of statistically significant changes in the diameter of collagen fibrils between the classic and the hypermobile forms.

[Cardiac arrest caused by anomalous origin and course of the right coronary artery]

The anomalous origin of the right coronary artery from the left sinus with interarterial course is a rare but life-threatening coronary abnormality. Coronary computed tomography is crucial in identifying this disease whose treatment, based on coronary artery bypass grafting, is recommended in symptomatic patients but is more controversial in asymptomatic patients. The case report presented offers an opportunity to discuss the pathophysiological, diagnostic and therapeutic aspects of this congenital coronary artery disease.

P172 AN ACCESSORY PATHWAY WITHOUT REENTRANT TACHYCARDIA

A 65–year–old patient, hypertensive, dyslipidemic, strong smoker. He has heart disease with hypokinetic evolution EF 47%, mild MI. Negative Dipyridamole–stress echocardiography dated January 2008. Recently atrial fibrillation (AF) is found and anticoagulant therapy was started. Dyspnea and weight loss occurred in past two months. Detected keratinizing squamous pulmonary Ca with negative markers. This injury was judged to be inoperable, and the patient get indications for chemotherapy and radiotherapy. The patient also starts complaining of dyspnea and chest pain on exertion: Not serological modification, not ischemic ECG. Echocardiogram LVEF 47–50% highlights diffuse hypokinesia, regular valves. Ergometric test was not evaluable for ischemia. Coronary angiography shows stenosis of proximal and middle anterior interventricular coronary and non–critical lesions of circumflex and right coronary. Ecodobutamine test was positive for ischemia and arrhythmias (AF and wide QRS tachycardias in recovery phase), but negative for angor. The patient was treated with CT and IVA I – II. angioplasty Monitoring shows AF with high penetrance, wide QRS tachycardia runs and very short TVNS. ECG 1: During atrial tachycardia, show broad QRS conduction to BBSX alternating with narrow QRS with the same RR interval. ECG 2. show fusion between the wavefront conducted with narrow QRS and that with wide QRS. These are supraventricular arrhythmias that run along the atrioventricular nodal pathway (NAV) in the narrow QRS tracts and take an accessory pathway in the wide QRS run.

The Mahaim fibers have decremental conductivities like the AV node, therefore high ventricular frequencies does not occur AF appeared during ecodobutamine, but some beats were conducted by an anomalous path in a discontinuous way); they are generally directed from the atrium or the NAV, towards another part of the right ventricular conduction system, with atrium wave or NAV – RB, therefore the early activation of the RB generates a widened QRS, with a LBB morphology. ECG 3 Re–entry on Mahaim pathway, ventricular activation widened through Mahaim fiber, which generate LBB morphology with retrograde atrial depolarization. In this case there is no reentry, but we have an atrial tachycardia conducted alternately on an accessory pathway and across the NAV. Given the patient‘s clinical problems and the total absence of symptoms, the patient remains asymptomatic during therapy with amiodarone and beta–blocker.

Madelung's disease. Two case reports with pseudoathletic appearance

Abstract

Madelung's disease is a rare syndrome characterized by the pre-sence of multiple masses of unencapsulated adipose tissue, symme-trically distributed throughout different regions. It predominantly affects middle-aged men of Mediterranean origin with a history of alcoholism. The pathogenesis is still unknown. Diagnosis is essentially established through clinical history and physical examination. We report two cases for their unusual presentation and to emphasize the importance of early diagnosis.

Five year prognosis of an Italian cohort of juvenile acute myocardial infarction patients

AIM

The aim of this study was to describe the five-year prognosis of an Italian cohort of patients following acute myocardial infarction (AMI) occurred at age ≤ 45 years and to investigate the potential role of risk predictors for future cardiovascular events (CVE).

METHODS

The study enrolled 112 consecutive patients aged ≤ 45 years admitted to our Coronary Care Unit between March 1995 and January 2007 because of AMI. Clinical characteristics, extent of coronary vessel disease by angiogram and cardiovascular risk factors (including diet, physical activity, alcohol and coffee consumption) were registered.

RESULTS

Complete follow-up data was available for 104 (93%) patients with a duration of follow-up of 5.3 (2.9-7.6) years. Twenty-four (23%) patients presented with a new CVE: 16 (15%) angina pectoris, 6 (6%) recurrent AMI, one heart failure and one cardiac death. One in every five patients presented left ventricle systolic function below 50%. Multivariate analysis (Cox proportional regression model) proved physical activity as an independent predictor of new CVE occurrence (P=0.014). Patients who practised moderate aerobic physical activity for at least two hours per week following AMI had significantly higher event-free survival compared with inactive controls (P=0.029).

CONCLUSION

Five-year prognosis of juvenile AMI is poor, with one in every five patients presenting a new CVE. Based on the present cohort of patients physical activity following first event plays a relevant prognostic role, supporting the need of careful lifestyle counselling.

Tumors in patients with neurofibromatosis type 1: a single- center retrospective study

OBJECTIVE

To investigate the risk and pattern of tumors in italian neurofibromatosis type 1 (NF1) patients.

MATERIALS AND METHODS

A retrospective single institution case review of 711 patients (seen between March 1992 and February 2018) with NF1 was conducted to identify individuals with diagnoses of both NF1 and neoplasm. NF1-associated tumors have been collected and analyzed.

RESULTS

We identified 221 tumors in 191 subjects with a percentage of 26.9%, diagnosed at a median age of 32.5 years (range, 0.6-70.1 years); 111 of these patients were females (58%) and all were fol-lowed up for a median of 5.3 years. The cumulative risks for tumor in patients with NF1 by the ages of 30 and 60 years were 10% and 42.5%, respectively. In our patients with tumor, overall survival at 70 years was significantly shorter than in those without it (50% vs 95%, P<0.0001). We found an unequivocally increased incidence for breast cancer in females (33 cases observed).

CONCLUSIONS

Tumors that develop in patients with NF1 are heterogeneous, our data are consistent with other reports suggesting an increase in some cancers risk among these individuals, therefore systematic medical follow-up in people with NF1 is important.

Ectropion Uveae in neurofibromatosis type 1: a new manifestation

Abstract

Neurofibromatosis type 1 (NF1) is a rare genetic disorder with an autosomal dominant transmission and an estimated incidence of 1:2500-3500 live birth. Penetrance is virtually 100%, but the expression is highly variable and almost every organ can be affected. Diagnosis of NF1 is made with at least two of the following diagnostic criteria: six or more cafè-au-lait spots, two neurofibromas or one plexiform neurofibroma, axillary or groin freckling, optic glioma, two Lisch nodules, bone dysplasia and first-degree relative with NF1. Other ocular manifestations include orbital neurofibromas, cafè-au-lait spots on the eyelids, congenital dysplasia of the sphenoids wing and con-genital glaucoma and choroidal abnormalities. Congenital Ectropion Uveae (CEU) is a rare, non-progressive anomaly characterized by the presence of iris pigment epithelium on the anterior surface of the iris stroma, resulting from its proliferation. CEU probably depends on embryological disorders in neural cells and/or neuroectoderm of the optic cell. In this paper the authors describe three patients with CEU and NF1 found in 243 consecutive NF1 patients.