[Cutaneous polyarteritis nodosa in children: three cases]

INTRODUCTION

Polyarteritis nodosa is a necrotizing vasculitis of small and medium-size arteries. The cutaneous form of polyarteritis nodosa follows a chronic course, characterized by recurrent episodes limited to skin, muscles and joints. This entity differs from systemic polyarteritis nodosa in the absence of visceral involvement. This form is rare in children, we describe three cases.

CASE REPORTS

We describe three girls with a mean age of 11 years (range: 8-13). They presented painful subcutaneous edematous nodules, arthralgia and fever. Physical examination revealed livedo reticularis (2 cases) and pharyngeal infection (1 case). Laboratory findings showed an inflammatory syndrome. Skin biopsy supported diagnosis of polyarteritis nodosa. The course was characterized by periods of remission disrupted by exacerbations, well controlled by salicylotherapy, colchicine, dapsone or penicillin. Corticosteroid therapy was used only for invalidating symptoms. There was no systemic involvement after 2, 5 and 6 years of follow up.

DISCUSSION

Cutaneous polyarteritis nodosa in children must be suspected in presence of fever, subcutaneous nodules, livedo reticularis and arthralgia. Prognosis is usually benign, so we recommend no aggressive treatment. In view of the tendency to relapse, long-term follow-up is appropriate, before confirming diagnosis.

[Congenital generalized cutis laxa: 5 cases]

BACKGROUND

Congenital cutis laxa is an exceptional condition. No large scale series has been reported in the French literature. We report 5 cases observed between 1993 and 1997.

PATIENTS AND METHODS

Five children with a morphotype compatible with congenital generalized cutis laxa were examined. A family study, complete visceral workup and skin biopsy with standard histology, orceine coloration and histomorphometric analysis of the collagen and elastic fibers of the dermis were performed. Karyotype and copper metabolism (cupremia and ceruloplasminemia) were available in 3 children.

RESULTS

The diagnosis was clinical and proven histologically by orceine coloration of skin biopsies in all cases. There were discrete ultrastructure anomalies in the pure cutaneous form expressed in case n(o) 1 with possible autosomal dominant inheritance. Cupremia and ceruloplasminemia were normal in the 3 children explored; this corresponds to absence of the Elhers-Danlos type IX phenotype. The karyotype was normal in 3/3 children, in agreement with the absence in these three children of marfanoid cutis laxa phenotype. Patients n(o) 2, 3, 4 and 5 had common features: probable autosomal recessive inheritance and severe prognosis. Patient n(o) 2 died at the age of 3 weeks and had severe pulmonary emphysema. This child's sister also had cutis laxa but with no visceral component (autosomal recessive inheritance with variable expression). Patients n(o) 3, 4 and 5 had a severe multiple malformative syndrome with facial dysmorphism, growth retardation, unexplained digestive disorders and psychomotor retardation.

DISCUSSION

Our series of 5 patients and data in the literature confirm that primary cutis laxa is a heterogeneous group of conditions both clinically and genetically. The anomalies associated in patients n(o) 3, 4 and 5 were not directly related to anomalous elastic tissue as was also the case for the craniostenosis in patient n(o) 3 reported in other cases in the literature.

[Sporadic superficial pemphigus in the child: 2 cases]

INTRODUCTION

Excepting the endemic foliaceus form, childhood pemphigus is uncommon. We report two cases of pemphigus foliaceus in children with typical clinical manifestations.

CASE REPORTS

Case n(o) 1. A 5-year-old girl was seen for a vesiculobullous crusted dermatosis involving the trunk and the face which had developed over the last 5 months, predominantly in periorificial and fold localizations. Histology showed intragranulous acatholysis. Direct skin immunofluorescence was positive for anti-intercellular substance IgG and C3. Indirect immunofluorescence was positive for anti-intercellular substance antibodies at 1/500. The diagnosis of superficial pemphigus was retained and the child was given dapsone associated with systemic prednisone (1.5 then 2.5 mg/kg/d). Dapsone was stopped on day 15 due to poor hematological tolerance. Outcome was favorable allowing withdrawal of prednisone at 18 months. Case n(o) 2. A 6-year-old had developed since the age of 18 months a generalized and polycyclic pruriginous erythemato-squamous dermatosis with oozing discharge which started and predominated on the face (periorificial zones). Trace element (copper, selenium, zinc) and vitamin (A, E and B1) assays were within the normal range. Glucagon was normal. Histological examinations of several biopsies were non-contributive. Diagnosis of pemphigus foliaceus was finally obtained after repeated direct immunofluorescence tests which revealed anti-intercellular substance IgG. Indirect immunofluorescence was negative. The child was given prednisone (2 mg/kg/d).

DISCUSSION

In children, pemphigus foliaceus has an exceptional frequency and diagnosis is often made quite late (mean 8 months). The diagnosis should always be entertained in children who develop chronic extensive erythemato-squamous and crusted dermatosis, even if formation is absent. Direct skin immunofluorescence confirms the diagnosis and should be repeated if negative in cases with highly suggestive clinical presentations. It would be reasonable to attempt "minor" treatments as the first line approach. Systemic corticosteroids are however the treatment of choice despite the risk of classical side effects. Childhood pemphigus foliaceus is not an attenuated clinical form of adult pemphigus. Mortality is not negligible and is close to that in adults.

[Extensive Mongolian spot related to Hurler disease]

BACKGROUND

We report a case of a large blue mongolian spot which led to early diagnosis of Hurler's syndrome. This association is uncommon and should be recognized by dermatologists for early diagnosis and management.

CASE REPORT

A male infant from Guinea, born to first-cousin parents, was seen at the age of 4.5 months for multiple, particularly extensive blue mongolian spots. Growth was +2 SD for age and the infant's psychomotor development was normal. A slight thickening of the skin was noticed without real dysmorphism. The blue spots extended over the entire posterior aspect and part of the anterior aspect of the trunk and involved all four limbs and the eyelids. The elbow and knee joints were moderately stiff and liver enlargement was palpated. The skin biopsy showed fusiform cells with melanin pigment tattooing the cytoplasm. No vacuolized epidermal cells were observed. Blood cell counts and liver and kidney tests were normal. Tests were positive for vacuolized lymphocytes and Gasser lymphocytes. Urine was positive for mucopolysaccharides and the enzymology study showed an alpha-L-iduronidase deficiency in serum and leukocytes, confirming the diagnosis of Hurler's disease. As no HLA compatible donor was available, no bone marrow graft was attempted. The child is a candidate for organoid gene therapy.

DISCUSSION

Mongolian spots predominate in Asian, American Indian and black population (90% of the cases) compared with Caucasians (10%). The pathogenesis and pathogenic associations are unknown. The incidence of large widespread mongolian spots is also unknown and no precise criteria are available to define this entity. A few cases of extended mongolian spots associated with type 1 gangliosidosis and about 20 cases associated with Hurler's disease have been reported in the literature. The association with Hurler's disease is probably not fortuitous and several hypotheses have been put forward. Bone marrow transplantation can improve prognosis if performed early before onset of irreversible visceral disorders, emphasizing the importance of early diagnosis in children.

[Pilar dysplasia: an early marker of giant axonal neuropathy]

BACKGROUND

Giant axonal neuropathy is an autosomal recessive condition characterized by progressive degeneration of the central and peripheral nervous system. Sensoromotor neuropathy develops around 3 years of age. Children have particular faces with curly hair. Characteristic pilar anomalies occur early and have diagnostic value. CARE REPORT: An Algerian boy born to consanguineous parents (first cousins) had language retardation and gait disorders developed around 3 years of age. At 9 years, the child was in a cachetic state with valgus feet, amyotrophy and diminished muscle force predominating distally, ataxia, areflexia, sensoromotor neuropathy and nystagmus. Skin tropism was altered with pale, thin and dry skin, cold, cyanotic limbs and thick curly hair. Electrophysiology explorations showed signs of chronic sensoromotor polyneuropathy with axonal predominance. Brain and spinal MRI revealed cerebellar atropy and signs of leukodystrophy. The spinal tap was normal. A neuromuscular biopsy confirmed the diagnosis of giant axonal neuropathy. At examination the hair was thick with reduced refrangibility and a pseudo-pili torti aspect.

DISCUSSION

Giant axonal neurpathy is characterized by anomalous organization of the cytoskeleton of intermediary filaments in different types of cells. Hair anomalies occur early, before onset of neurological signs. At gross examination the hair is thick and curly, sometimes crimped and pale. Examination of the pilar shaft shows trichorrhexis nodosa, scalloped fringes and lack of internal structure. On the molecular level, there is a reduction in the number of bisulfur bridges which could be the cause of defective keratin filament alignement. Pathogenicaly, the pilar anomalies are considered as a direct manifestation of defective keratin organization characteristic of the disease.

[Lichen planus in children: 12 cases]

OBJECTIVE

Lichen planus is in children uncommon and poorly understood. The classical description is comparable to lichen planus in adults. We conducted a retrospective analysis of 12 cases in children.

PATIENTS AND METHODS

Twelve children with lichen planus consulted the Saint-Louis or Robert-Debré hospitals between February 1994 and March 1996. Data collected included: age, sex, ethnic origin, drug use, anti-hepatitis vaccination status, disease history, physical examination, skin histology, liver tests, hepatitis B and C serology, treatment and outcome. Histological proof was obtained in all cases but one (a child with isolated ungueal involvement whose sister had histologically proven ungueal lichen planus).

RESULTS AND DISCUSSION

The clinical features classically described in adults were atypical in all our childhood cases. A rapidly extensive eruption was the main sign in 6 cases. The localizations were unusual with lesions involving all four limbs and the trunk as well as the face in 5 cases and the scalp in 1. Mucosal involvement, observed in 65 p. 100 of adult cases was only found in one of our children. Unguel involvement also appears to be uncommon in children. The etiological pattern was also unusual since we did not observe a single case related to drugs or hepatitis B or C infection. Three children developed a lichen eruption after anti-hepatitis B infection. Four other cases of lichen planus after anti-hepatitis B vaccination have been reported in the literature. Mean delay between the booster vaccination and onset of eruption is reported to be 40 days. The increased incidence of childhood lichen planus in tropical zones suggests ethnic, genetic and climatic factors may be involved. Prognosis is poorly defined in the literature. Certain authors emphasize the long duration of the disease and resistance to treatment in cases of childhood lichen planus. Currently, there is no consensus on treatment. Dermocorticoids in combination with antihistaminics are usually prescribed. General corticosteroid therapy would appear to be warranted in extensive progressive forms with important functional and esthetic impact (scalp involvement with cicatricial alopecia, pigmentation sequellae). The role of other drugs, particularly retinoids, remains to be defined. This retrospective series was not statistically significant. Data in the literature are rather discordant, emphasizing the need for a prospective analysis to acquire a better understanding of the real incidence of childhood lichen planus and better define the therapeutic strategy.

[Scleroderma-like patch on the thigh in infants after vitamin K injection at birth: six observations]

INTRODUCTION

Texier's disease or pseudosclerodermatous reaction after intramuscular injection of vitamin K1 is well known in adults although only 1 report of a case in a newborn was found in the literature. We report 6 cases.

CASE REPORTS

Six infants (4 boys, 2 girls) developed "peau d'orange" skin lesions after the age of 6 months which was localized in the lower third of the medial aspect of the thigh. Initial rapid locoregional extension was followed by stabilization and then regression. In all 6 cases, histology showed lesions of the fascia and/or the deep hypoderma associated with variable mononuclear inflammatory infiltration and hyalin fibrosis. When performed, immunological studies (complement fixation, search for autoantibodies) were always negative or normal. No visceral involvement was found.

DISCUSSION

A pseudosclerodermatous lesion of the lower third of the thigh occurred in 6 infants at the site of an intramuscular injection of vitamin K1 administered at birth. The history, clinical manifestations, histology and outcome of these cases are compatible with the diagnosis of Texier's disease. We discuss the role of the solvent in the Roche vitamin K1 injection. The pathogenesis of this side effect remains unknown.

CONCLUSION

Texier's disease in infants after injection of vitamin K1 at birth is a stereotypic dermatosis. Diagnosis is based on history and clinical presentation. The causal effect of injectable vitamin K1 should be entertained whenever pseudosclerodermatous lesions are observed in a young child.

[Actinic prurigo of childhood. 3 familial cases associated with HLA-DR 0407]

BACKGROUND

Actinic prurigo, as idiopathic skin reaction involving light-exposed areas, was first described in American Indians. Actinic prurigo was early considered to be a particular form at polymorphous phototoxicity, but can be identified as a specific entity on the bases of clinical features and epidemiological characteristics.

CASE REPORTS

Three children in the same family developed photosensitive reactions early in childhood with characteristic polymorphous and persistent eczema-like or papulo-nodular pruriginous lesions which predominated in light-exposed areas and appeared several hours after exposure to sun. The lesions persisted during the winter season. The lesions followed a chronic course but tended to improve at puberty. Clinical laboratory tests, serum and urine porphyrin levels and antinuclear factors were normal. Histology and photobiology explorations gave non-specific results.

DISCUSSION

These observations have three points in common with actinic prurigo observed in American Indians. HLA typing showed that our three patients, as in white patients in Great Britain, had a significant association with a specific HLA DR1 subtype: DRB1*0407. This DRB1*0407 alleles could play a role in initiating the immune response to a light-induced peptide antigen. This particular genetic predisposition, if confirmed in other studies, would be an additional argument for distinguishing actinic prurigo as a specific polymorphous phototoxicity entity.

Omenn's reticulosis associated with the nephrotic syndrome

Omenn's reticulosis is an inherited severe combined immunodeficiency characterized by neonatal exfoliative erythroderma. A newborn baby who had minimal change nephrotic syndrome and Omenn's reticulosis is reported. Abnormalities in lymphocyte function could explain both the nephropathy and the cutaneous changes.

Late, painful, subungual hyperkeratosis in incontinentia pigmenti

The postpubertal appearance of subungual, painful keratotic tumors is a rare feature of incontinentia pigmenti. A patient affected by incontinentia pigmenti developed subungual, painful, nontumoral, hyperkeratotic lesions of the hands at 10 years of age. The mildness of the subungual lesions may be explained by the early stage of the disorder, but it is difficult to correlate the severity of the fingertip pain with the absence of true tumoral swelling. To our knowledge this is the youngest patient reported so far and the only one with a prepubertal expression of this puzzling disorder.

Paraquat poisoning by skin absorption: report of two cases

Two cases of paraquat poisoning resulting from skin absorption are reported. One patient died from respiratory failure 26 d after deliberate application of the herbicide onto his whole body as a treatment for scabies. The other patient developed extensive dermatitis (probably a complication of pre-existing psoriasis). Only a moderate and transitory impairment of this latter patient's renal and respiratory functions were observed after repeated exposure of his damaged skin to a dilute paraquat spray.