Pediatric Voice Disorders from the Perspective of Rare Diseases

OBJECTIVE

This study aims to present rare pediatric voice disorders, which are usually reported as case reports in the literature, with their clinical features, treatment options, and prognosis, and to emphasize clinical findings that may be associated with rare diseases.

METHODS

The clinical records of the pediatric patients presented with dysphonia were reviewed between 2014 and 2019. The terminology "rare disease" is used to describe diseases where the average prevalence thresholds are between 40 to 50 cases/100,000 people. Age, gender, symptoms, laryngeal examination findings, histopathological results, treatment modalities and follow-up results of rare laryngeal pathologies were reviewed.

RESULTS

274 children were diagnosed with and treated for voice disorders at our institution. Seven patients were identified with rare laryngeal pathologies. Four patients diagnosed with lipoid proteinosis, two patients with neurofibroma and one patient with amyloidosis. One patient was known to have neurofibromatosis type-1, while the others did not have any previously diagnosed diseases, dysphonia was the initial clinical presentation.

CONCLUSION

There are some clues that bring to mind rare entities. Firstly, these patients generally present with various systemic manifestations. Secondly, if there is any discrepancy between voice quality and endoscopic laryngeal examination, the diagnosis should be reconsidered. Thirdly, in the case of the prolonged dysphonia recalcitrant to treatment, the clinician should reassess the treatment or the diagnosis.

[An atypical case of lipoid proteinosis]

The lipoid proteinosis is a rare autosomic recessive genodermatosis characterized histologically by deposits of hyaline-like eosinophilic material of characteristic distribution. We herein report the case of a 56-year-old man admitted for progressive aggravated dementia associated with a late-onset dysphonia. Histologic examination of cutaneous and laryngeal biopsies showed deposits of an amorphous and eosinophilic material arranged around vessels, and adnexal structures, stained by PAS and congo red negative. The detection of a mutation in the ECM1 gene confirmed the diagnosis of lipoid proteinosis of atypical clinical presentation.

Urbach-Wiethe disease in a young woman: A case report

Urbach-Wiethe disease (lipoid proteinosis) is an autosomal recessive disorder that is characterized by a general thickening of the skin and mucous membranes. We report the case of a 22-year-old woman with lipoid proteinosis who presented with hoarseness, poor dentition, and skin lesions, and we discuss the management of this rare disease.

The eye and the skin in nonendocrine metabolic disorders

As metabolism is controlled by the input of genes and the environment, metabolic disorders result from some disturbance in the interaction between genes and environmental factors. Many metabolic disorders consist in congenital enzyme deficiencies, also known as "inborn errors of metabolism," that may be disabling or cause severe illness and death and are predominantly inherited in an autosomal recessive fashion. The deposit in cells and tissues of storage substances from errors in metabolic processes may produce a wide variety of disorders affecting different organs and functions, with different degrees of severity, and often present around the time of birth or early childhood. Distinctive ocular and skin manifestations accompany many metabolic diseases and may provide clues for their diagnosis and evolution.

Vocal fold hyalinosis in Urbach-Wiethe disease, a rare cause of hoarseness

BACKGROUND

Lipoid proteinosis is an autosomal recessive disorder characterized by hyalin deposits in the skin and mucosa of the upper aerodigestive tract; currently, no treatment exists. Nearly all patients experience hoarseness and speech difficulties, due to hyalin deposition in the vocal folds and diminished mobility in infiltrated lips, tongue, and palate.

METHODS

We describe a patient with extensive hyalin plaques on the vocal folds, which resulted in near-aphonic hoarseness. Hyalin deposits in the vocal folds and skin were treated with laser resection.

RESULTS

Both the vocal folds and skin improved in appearance, with smoother surface epithelium. However, the patient's speech remained impaired, due to extensive hyalin plaques in the mouth, tongue, and lips. The voice improved only temporarily.

CONCLUSIONS

Laser resection of hyalin plaques in the vocal folds and skin is a feasible treatment for lipoid proteinosis. However, speech may remain severely limited, due to impaired tongue and lip movement.

Lipoid Proteinosis: An Unusual Presentation with Verruca Vulgaris

Lipoid proteinosis (LP) is a very rare, autosomally recessive, inherited disease. It is also known as Urbach Wiethe disease or Hyalinosis cutis et mucosa. LP usually runs a benign, stable, and slowly progressing course. We present one LP case with additional unusual dermatologic involvement; verruca vulgaris was superimposed on papular lesions of LP. To our knowledge, this case is the first and only one described in the literature. In this presentation, we discuss the possibility of predisposition to Human Papilloma Virus (HPV) infections in LP.

[Hyalinosis cutis et mucosae : 5 cases from Tabarka (Tunisia)]

BACKGROUND

Hyalinosis cutis et mucosae (HCM), is a rare autosomal recessive genodermatosis. Cutaneous features are characteristic and allow to suspect diagnosis.

AIM

To report a series of HCM.

METHODS

A retrospective study of all cases of HCM, diagnosed in a dermatology department over a period of 25 years (1983-2007).

RESULTS

Over the considered period, 5 new cases of HCM were diagnosed. Patients were aged between 14 and 41 years. They were 3 females and 2 males. All patients were native of Tabarka (northwestern Tunisia). The age of the onset of the disease varied from neonatal period to 5 years. Hoarseness was the first clinical manifestation in all cases. Skin lesions developed between the ages of 3 and 8 years. Vesiculobullous lesions were observed in 2 patients. Moniliform blepharosis was seen in all patients. Warty and hyperkeratotic papules were observed in 3 patients. Diffuse thickening of the skin was seen in 3 patients. Lesions were primarily distributed on the face. All patients presented diffuse scars. Linear palmoplantar keratoderma was seen in one patient. Asymptomatic endocranial calcifications were noted in 4 patients. A pituitary adenoma was noted in one patient. Histopathological examination of a skin lesion revealed a typical pattern of HCM. Two patients were treated with systemic retinoids without improvement.

CONCLUSION

We reported five new cases of HCM. All patients were native from Tabarka. We report also one case of linear palmar keratoderma associated with HCM. This association was not reported in the literature. Finally, the association HCM-pituitary adenoma, seen in one patient, may be fortuitous.

Otolaryngological manifestations and genetic characteristics of lipoid proteinosis

OBJECTIVES

We investigated the otolaryngological manifestations and genetic characteristics of lipoid proteinosis (LP).

METHODS

Twenty-two cases of LP were included. Multisystem manifestations, pharyngolaryngeal behaviors, and histopathologic and genetic characteristics were evaluated.

RESULTS

All patients presented with hoarseness as the first sign. The onset was in the newborn period in 14 cases. Video-laryngoscopy revealed irregularities along the edges and the surface of the vocal folds with diffuse yellowish deposits. In 18 cases, the oral and pharyngeal mucosa showed yellow-white infiltrates. In all cases, whitish moniliform papules were observed on the upper eyelids. In 18 cases, pocklike scars were present on the face and limbs. Histologically, there were diffuse depositions of hyaline material in the submucosa and dermis that were positive on periodic acid-Schiff staining and negative on Congo red staining. Two patients had homozygous mutations in ECM1 exon 6 and exon 8, and 13 patients had heterozygous mutations in ECM1 exons. Nine patients underwent microlaryngosurgery for excision of deposits in the vocal folds. The voice function was significantly improved after operation.

CONCLUSIONS

Persistent hoarseness from early infancy with laryngeal involvement is the most common feature of LP. Histopathologic characteristics and skin and mucosa changes aid in the diagnosis. Microlaryngosurgery may improve the voice function. Compound heterozygote mutations may be frequent in LP in nonconsanguineous Chinese families.

Niemann-Pick disease type C2 presenting as fatal pulmonary alveolar lipoproteinosis: morphological findings in lung and nervous tissue

BACKGROUND

Niemann-Pick disease type C1 (NPC1) and type C2 (NPC2) display the same pattern of neurovisceral storage due to deficiencies within lysosomes. NPC2 is a much rarer condition, and as reports on the pathological changes are scarce, the morphological findings in the lungs and brain in two siblings who died at an early age from pulmonary involvement are described. The diagnosis of NPC2 was confirmed at postmortem mutational analysis.

CASE REPORTS

Both siblings presented with postnatal conjugated hyperbilirubinemia. They subsequently developed progressive respiratory insufficiency with opacification of the lungs on X-ray examination and died at the ages of 8 and 13 months. The lungs contained intra-alveolar accumulation of periodic acid-Schiff positive material, foamy macrophages, and hyperplasia of the alveolar cells, consistent with pulmonary alveolar lipoproteinosis. On neuropathological examination, storage material in swollen perikarya in the deep cerebellar nuclei, thalamus, medulla oblongata, and in the paravertebral ganglion cells was found. Meganeurites were present in the cerebral cortex. A few axonal spheroids were also observed. There seemed to be a reduced number of Purkinje cells in the cerebellum.

CONCLUSIONS

Evidence that NPC2 is associated with severe pulmonary alveolar lipoproteinosis is supported. There were extensive neuropathological changes with storage material in swollen perikarya and a few axonal spheroids.

Lipoid proteinosis: a case series from Istanbul

BACKGROUND

Lipoid proteinosis (LP) is a very rare genodermatosis. The literature on LP consists of case reports only. As we have observed 14 LP patients belonging to nine different families in the last 15 years in our practice, we decided to review all reported Turkish LP patients in this 15-year period, and noted 37 diagnosed cases. The reasons for this relatively large number of cases, the clinical features of the patients, and the associations of LP with other clinical conditions are described in this article.

METHODS

Fourteen LP patients followed in our university clinic in Istanbul were scrutinized with regard to their demographic and clinical features. Diagnoses were established using clinical features, with histopathologic confirmation in 13 cases.

RESULTS

All but one of the patients had a history of consanguinity, or at least a marriage of parents from the same village. Typical cutaneous signs of LP and hoarseness of the voice were observed in all patients. Two patients of the same pedigree had insulin-dependent diabetes mellitus (IDDM), two patients from two different pedigrees had short stature, one patient had multinodular toxic goiter, and one patient had celiac disease.

CONCLUSION

LP is not rare in Turkey as consanguineous marriage is still a social problem, especially in some rural areas. The disease is not limited to a particular geographic region in Turkey. Short stature was observed in two cases from two different families, an association not reported previously; the association of LP with IDDM in one pedigree was thought to be coincidental.

Bilateral lens subluxation in a case of lipoid proteinosis

We report a patient who presented with pain, redness, and diminution of vision in the right eye and low vision in the left eye. Ophthalmologic examination showed characteristic eyelid lesions, anterior dislocation of the crystalline lens in the right eye, and nasal subluxation in the left eye. The patient's voice was hoarse, and he had skin lesions. After histopathologic examination of the skin biopsy, lipoid proteinosis (LP) was diagnosed. Bilateral pars plana lensectomy was performed. The ophthalmic manifestations of LP are discussed.

Nasolacrimal duct obstruction with Urbach-Wiethe syndrome

An 80-year-old woman presented with signs and symptoms consistent with bilateral nasolacrimal duct obstruction. She also was noted to have multiple eyelid margin lesions. She underwent bilateral dacryocystorhinostomy with biopsy of the nasolacrimal ducts and eyelid lesions. Her tearing resolved. Histopathology of the eyelid lesions was consistent with lipoid proteinosis. Nasolacrimal duct obstruction may occur in patients with lipoid proteinosis (Urbach-Wiethe syndrome).

Epilepsy and migraine in a patient with Urbach-Wiethe disease

We report the clinical, neuroradiological, and molecular genetic findings in a patient with lipoid proteinosis or Urbach-Wiethe disease. Interestingly, in this patient epilepsy and migraine were the symptoms leading to the diagnosis of the disease, contrary to most patients in whom skin abnormalities are the first recognized symptoms.

[Urbach-Wiethe disease (lipoid proteinosis) with neurological involvement]

INTRODUCTION

Lipoid proteinosis is a rare autosomal recessive disease that has recently been shown to result from mutations in the ECM1 gene. Some cases are associated with a more severe mucocutaneous phenotype.

OBSERVATION

We report the case of a 38-year-old woman who had clinical and histological skin features typical of Urbach-Wiethe disease. Physical examination revealed neurological abnormalities including dizziness, ataxia, slight psychomotor retardation and amnesic impairment. The patient reported sudden left brachiofacial paralysis one month earlier that regressed spontaneously after one week. CT scan and MRI were normal. Cerebral scintigraphy displayed bilateral hypoperfusion of the frontal areas, of the anterior and internal right temporal lobe (which includes amygdala), and of the left thalamic core.

DISCUSSION

We considered these abnormalities as neurological features of lipoid proteinosis in the absence of evidence of any other cause. Our observation as well as other recent reports suggests the need for neurological and neuropsychological investigations in patients with Urbach-Wiethe disease.

[Lipoid proteinosis in the mouth and laryngeal structures: a case report]

Lipoidproteinosis is an uncommon autosomal recessive disorder characterized by accumulation of hyaline material in the skin, oral and laryngeal mucosa. A 23-year-old woman presented with complaints of hoarseness and dryness of the mouth. Yellowish papular deposits were noted in the oral and laryngeal mucosa on physical examination, and in vocal cords and laryngeal structures during laryngoscopy. The lesions were removed and histopathologic diagnosis was made as lipoidproteinosis. A slight improvement was obtained in hoarseness. A control examination after two years showed an increase in the extent of hoarseness and new deposits in the vocal cords. The lesions were removed by microlaryngeal surgery.

Manifestations ophtalmologiques de la hyalinose cutanéo-muqueuse

INTRODUCTION

Lipoid proteinosis (LP), also known as hyalinosis (or lipoidosis) cutis et mucosae or Urbach-Wiethe disease, is a rare autosomal recessive disorder. It is associated with deposits of protein-lipid complexes in various tissues including the skin and mucous membranes. Ophthalmologic manifestations are frequent and can affect visual prognosis.

CASE

This 28-year-old patient presented vesiculobullous lesions of the face that developed into varioloid scars associated with hoarseness. Ophthalmologic examination revealed unilateral lesions including hyaline deposits on the palpebral margins, iris, and trabecular zone, complicated by uveitis, cataract, and glaucoma, which caused the functional loss of the left eye. Histological examination of a cutaneous biopsy confirmed the diagnosis.

DISCUSSION

Involvement of the eyelids is characteristic, and moniliform blepharosis is pathognomonic and frequent. This case featured a rare intraocular form (uveitis). Deposits may be found on the conjunctiva, cornea, trabecula and Bruch membrane. Conjunctival or cutaneous biopsy confirms the diagnosis. Available treatment is quite limited.

Lipoid proteinosis: A case with ophthalmological and psychiatric findings

Lipoid proteinosis (LP) is an uncommon, recessively inherited disorder. The disease usually has its onset in the newborn period and is manifested by hoarseness. The skin and mucous membrane involvement arises between the first and second year of age. A 14-year-old male presented with the complaint of blistering on various sites of his skin, from the age of 12 months, resulting in scarring. Ophthalmological and psychiatric findings also appeared during the clinical course. The histological findings of skin biopsy included extensive deposits of amorphous eosinophilic material in the papillary dermis. No known therapy exists for LP.

Lipoid proteinosis: report of three familial cases

Lipoid proteinosis is a rare autosomal recessive disorder; it presents in early childhood with hoarseness, skin infiltration and thickening with beaded papules on eyelid margins, and facial acneiform or pock-like scars. Although 250 cases have been reported until now, the occurrence of disease in siblings is very rare. We report three familial cases of lipoid proteinosis involving a brother and sister and their nephew.

Lipoid proteinosis in a 12-year-old child: a report from west India

A 12-year-old male child born of non-consanguineous parents presented with multiple skin lesions, hoarseness of voice, and episodes of epilepsy since early childhood. The findings of characteristic beaded eyelid margins, patchy alopecia of the scalp, hoarseness of voice, and epilepsy were consistent with a rare clinical diagnosis, lipoid proteinosis. Skin biopsies obtained from representative skin lesions were subjected to histology and electron microscopy. Light microscopy demonstrated PAS-positive diastase-resistant material in the papillary dermis of skin. Ultrastructure revealed granulo-filamentary aspect of the accumulated material. Although this rare autosomal recessive disorder has been described in the literature, its occurrence is rare in India.

Generalized dystonia and striatal calcifications with lipoid proteinosis

Lipoid proteinosis (LP) is an autosomal recessive disease that typically presents with papular, verrucous, poxlike, or acneiform scars and lesions and hoarseness. LP was recently mapped to the 1q21 locus and shown to result from mutations in the extracellular matrix protein 1 gene (ECM1). Epilepsy, mental retardation, and hippocampal calcifications can occur. The authors describe a patient with generalized dystonia caused by striatal calcifications.

Clinical and molecular characterization of lipoid proteinosis in Namaqualand, South Africa

BACKGROUND

Lipoid proteinosis (LiP) is a rare autosomal recessive disorder characterized by a hoarse voice, warty skin infiltration and scarring. Mutations within the extracellular matrix protein 1 (ECM1) gene cause LiP. Since the early 1970s it has been recognized that South Africa has one of the largest groups of LiP patients worldwide, suggesting a probable founder effect. As LiP patients present with considerable clinical variability, this group of patients offers a unique opportunity for genotype-phenotype correlation.

OBJECTIVES

To assess the clinical features and the molecular basis of LiP in patients from the Namaqualand area of the Northern Cape province of South Africa and to examine molecular evidence for a founder effect.

SUBJECTS AND METHODS

The LiP patient cohort consisted of 29 Coloured patients from Namaqualand and a further seven Caucasoid patients from other areas of South Africa. The control group included 100 healthy geographically and ethnically matched individuals from Namaqualand. Samples were collected after informed consent and with ethics committee approval from the University of the Witwatersrand. LiP patients were examined clinically and a structured recording sheet was completed. A brief neurological evaluation was also performed. The LiP founder effect was investigated at the molecular level by ECM1 mutation detection and haplotype analysis.

RESULTS

The most consistent clinical signs for a diagnosis of LiP in this group were a hoarse voice and thickened sublingual frenulum leading to restricted tongue movement. Homozygosity for a nonsense mutation in exon 7 of the ECM1 gene, Q276X, was identified in all patients (Coloured and Caucasoid). Despite this genetic homogeneity, considerable clinical variability in skin presentation and psychiatric involvement was observed. Haplotype analysis using markers from a 9.98-Mb region around the ECM1 locus confirmed the founder effect with a founder core haplotype, 19-Q276X-12 (ND1-ECM1-D1S2343), in all but four LiP-associated alleles (n = 58). A LiP carrier rate of 1 in 9 was observed among the 100 Namaqualand controls, predicting a LiP incidence of 1 in 324 in this community.

CONCLUSIONS

Although several consistent clinical features in LiP patients homozygous for the Q276X mutation in the ECM1 gene were observed, there remains considerable clinical variability. This suggests the action of genetic and environmental modifiers of disease severity. Strong molecular evidence supports a single founder effect for the high prevalence of LiP in South Africans, both Coloured and Caucasoid.

The role of lipoid proteinosis in gingival hypertrophy

Hyalinosis cutis et mucosae (lipoid proteinosis, Urbach-Wiethe disease) is a rare syndrome with autosomal recessive inheritance. The disease is characterized by diffuse deposition of a hyalinelike substance in the dermis, submucosal connective tissue, and various internal organs. In this study, the patient demonstrated classic signs and symptoms of lipoid proteinosis except for gingival infiltration. Gingival infiltration is still an unexplainable feature of this disease. In the context of this case, the diagnostic significance of the microscopic findings of the gingival tissues and the possible factors playing a role in gingival hypertrophy, are discussed.

Vesicular lesions in a patient with lipoid proteinosis: a probable acantholytic dermatosis

Lipoid proteinosis is a rare genodermatosis with characteristic clinical and histologic findings later in life. We present a case of lipoid proteinosis in which the diagnosis was originally missed because the patient presented in childhood with vesicles and a hoarse voice and lacked any other manifestations. Microscopic examination of a vesicle revealed extensive non-dyskeratotic acantholysis. Vesiculo-bullous lesions have been described clinically in lipoid proteinosis, but we are unaware of any histopathologic description regarding bullae formation. Although only a single patient is herein described, it seems unlikely that this type of acantholysis is purely coincidental. It is proposed that lipoid proteinosis should be in the differential of acantholytic vesiculo-bullous lesions in a child.

Alveolar lipoproteinosis in an acid sphingomyelinase-deficient mouse model of Niemann-Pick disease

Types A and B Niemann-Pick disease (NPD) are lipid storage disorders caused by the deficient activity of acid sphingomyelinase (ASM). In humans, NPD is associated with the dysfunction of numerous organs including the lung. Gene targeting of the ASM gene in transgenic mice produced an animal model with features typical of NPD, including pulmonary inflammation. To assess mechanisms by which ASM perturbed lung function, we studied lung morphology, surfactant content, and metabolism in ASM-deficient mice in vivo. Pulmonary inflammation, with increased cellular infiltrates and the accumulation of alveolar material, was associated with alterations in surfactant content. Saturated phosphatidylcholine (SatPC) content was increased twofold, and sphingomyelin content was increased 5.5-fold in lungs of the ASM knockout (ASMKO) mice. Additional sphingomyelin enhanced the sensitivity of surfactant inhibition by plasma proteins. Clearance of SatPC from the lungs of ASMKO mice was decreased. Catabolism of SatPC by alveolar macrophages from the ASMKO mouse was significantly decreased, likely accounting for decreased pulmonary SatPC in vivo. In summary, ASM is required for normal surfactant catabolism by alveolar macrophages in vivo. Alterations in surfactant composition, including increased sphingomyelin content, contributed to the abnormal surfactant function observed in the ASM-deficient mouse.

Lipoid proteinosis of the larynx

Lipoid proteinosis is a rare disease that presents with hyaline deposits in many tissues. It involves predominantly the skin and upper aerodigestive tract, presenting with small yellowish papules and hoarseness. It may involve the central nervous system and cause intracerebral calcifications. Laryngeal lesions may resemble singer's nodule or chronic laryngitis. The pathogenesis of the disease is not clear although several studies suggest a defective collagen production and/or lysosomal storage disease. In this article two cases with skin and larynx involvement are reported.

Periodontal lesions in lipoid proteinosis

Lipoid proteinosis is a rare autosomal recessive heritable disease. Clinical features are hoarseness starting in infancy and the formation of yellowish papules and plaques on the skin and mucous membranes of the nose, oral cavity, pharynx and larynx. Light and electron microscopy demonstrates a subepithelial accumulation of PAS-positive (hyaline) material around blood vessels and in the dermis. This case is unusual in that the gingiva is also involved in the lipoid proteinosis.

Protean manifestations of lipoid proteinosis in a 16-year-old boy

We report a 16-year-old Japanese male with lipoid proteinosis showing various skin manifestations. The patient was born to nonconsanguineous parents and none of his relatives was similarly affected. The patient suffered from a hoarse voice and refractory temporal epilepsy from early childhood. Computed tomography scanning of the brain showed bilateral calcification in the temporal lobes, a characteristic feature of lipoid proteinosis. On physical examination, various skin manifestations, including papules and haemorrhagic blisters, acne-like scars at sites of minor trauma or friction, and beads of small papules along the free margins of the eyelids were noted. A skin biopsy showed deposits of homogeneous hyaline-like material, positive on periodic acid-Schiff staining, throughout the dermis, particularly around small blood vessels. It is noteworthy that a range of characteristic skin lesions can be present in a patient with lipoid proteinosis even with mild systemic involvement.

Hemorheology and tissue oxygenation in hypertensives with lipoidoproteinosis and peripheral occlusive arterial disease (POAD) treated with sulodexide and pravastatine and evaluated with laser assisted optical rotational red cell analyzer (LORCA) and transcutaneous oxymetry

BACKGROUND

During arterial hypertension it is often possible to find other factors like lipoidoproteinosis and peripheral arterial disease (POAD), which can accentuate blood rheological abnormalities in hypertensive subjects. A group of hypertensives with lipoidoproteinosis (LP) and POAD were therefore examined to evaluate the relationship between these factors and blood rheological disorders and, if possible, to correct it.

METHODS

We studied a group of 27 hypertensives with LP and POAD (15 males and 12 females in menopause for at least 1 year, aged 48 +/- 4 years), with WHO stage I hypertension, obesity (BMI = 30 +/- 2), stage II type "a" POAD, class 2 type "b" lipoidoproteinosis (acc. to Fredrick-son's classification) and hyperfibrinogenemia. All patients received oral medication with 500 lipidic units (ULS) sulodexide a day, 20 mg pravastatin o.d. orally, and were put on a low-salt and low-calorie diet (1400 kcal/day) during a follow-up of 60 days. Blood rheology status was evaluated before and after treatment (red blood cell--RBC--deformability and aggregability) using a new computerized instrument, which uses laser rays: the laser assisted optical rotational red cell analyzer (LORCA) (acc. to Hardeman) and RBC deformability using optical microscopy under immersion (acc. to Zipursky and Forconi). Transcutaneous oxymetry was also used to evaluate tissue oxygenation.

RESULTS AND CONCLUSIONS

At the end of the study a significant improvement (p < 0.01) was noted in the blood rheological patterns of peripheral perfusion and tissue oxygenation. This underlined the positive influence of sulodexide with pravastatin in improving hemorheological patterns and modulating hypercholesterolemia and hyperfibrogenemia in hypertensives with POAD II "a" and LP 2 "b" and blood rheology disorders.

Oral lipoid proteinosis

This literature review of oral lipoid proteinosis and a case report of an infant with this condition describe an uncommon condition inherited as an autosomal recessive trait, but one which is more likely to occur in this country than elsewhere. The article discusses other lesions which could be mistaken for oral lipoid proteinosis, and offers some pertinent aspects of its diagnosis and management.

[Lymphocytic alveolitis, chronic viral hepatitis C, lipoproteinosis and cryoglobulinemia in a patient]

Chronic hepatitis C virus (HCV) infection, lipoproteinosis and cryoglobulinemia may all be associated with lymphocyte alveolitis. The pathogenic mechanisms involved would suggest a compromised immune system. We report the first observation of a patient with lipoproteinosis, cryoglobulinemia and hepatitis C virus infection who developed lymphocyte alveolitis. Taken individually, each of these three disease states could explain cellular modifications observed in the lung, but their association aggravated the clinical course.

Lipoid proteinosis in three children

We report on three children with lipoid proteinosis, an autosomal recessive disorder characterized by the deposition of hyaline-like material in the skin, mucous membranes and other tissues. All cases had characteristic hoarseness. Other symptoms observed were infiltrated whitish plaques and pock-like scars on the face, papules on the palpebral margins, and infiltrates in the mucous membranes of the lower lip and tongue. Two of the children were siblings whose parents were first cousins.

The amygdala's contribution to memory--a study on two patients with Urbach-Wiethe disease

The consequences of primary amygdaloid damage on memory performance are described in terms of neuropsychological, CT, MRI and PET results of two patients, a brother and a sister. Both had circumscribed, bilaterally symmetrical damage confined to the amygdaloid region, while the hippocampal formation and other brain structures were intact. PET-imaging furthermore revealed an overall decrease in glucose metabolism which was particularly apparent at the cingular and thalamic levels. Although neither patient was amnesic, both showed memory impairments in selective tests. In one patient these impairments were more pronounced and they were accompanied by marked affective-emotional fluctuations. Our results suggest that the amygdaloid region is a bottle-neck structure that confers an affective flavour to memories, thereby enhancing the probability of their long term storage.

Lipoid proteinosis of the small bowel

We describe a 65-year-old-man who presented with acute gastrointestinal bleeding secondary to massive submucosal deposits of hyaline material in the small bowel. The histochemical and ultrastructural features of the hyaline substance were typical of lipoid proteinosis, a rare cutaneous disorder in which, to our knowledge, symptomatic compromise of internal organs has not been described previously. The patient was later found to have mild but characteristic mucocutaneous lesions of lipoid proteinosis, as well as asymptomatic deposits in other gastrointestinal sites. Our case documents that severe visceral involvement may occur in lipoid proteinosis, even in previously undiagnosed patients with mild cutaneous manifestations of the disease.

Specific xerostomia during Urbach-Wiethe disease

We describe the case of a 59-year-old woman who had suffered from a typical Urbach-Wiethe disease since childhood and who complains of progressive mouth and ocular dryness since the age of 54 years. Xerostomia was severe with very poor salivation and was associated with a slight keratoconjunctivitis sicca. A specific lipoid proteinosis was evidenced in salivary glands (lower lip biopsy) with a PAS-positive hyalin-like deposit around vessels, capillaries and salivary gland canaliculi. An ultrastructural study showed the typical aspect of multilamination of the basal lamina of capillary vessels. Dysphonia and hoarseness are commonly found in Urbach-Wiethe disease, but, to our knowledge, a specific xerostomia has never been reported.

Clinical, histologic, and ultrastructural findings in two cases of infantile systemic hyalinosis

Two unrelated infants had stiff skin and painful joint contractures in the first few months of life. Other features included gingival hyperplasia, small papules on the face and trunk, perianal nodules, and bloody diarrhea. Hyaline material was evident in the papillary dermis and gut mucosa in both patients. Ultrastructural examination revealed a distinctive fibrillogranular appearance. These infants have the same clinical, histologic, and ultrastructural features as four infants we reported previously with infantile systemic hyalinosis. One of the patients described here demonstrated some features that overlap with those of juvenile hyaline fibromatosis.

Lipoid proteinosis: case report

A 20-month-old Kuwaiti girl had manifestations of lipoid proteinosis, a rare autosomal recessive disorder seen more commonly in Caucasians. This condition is diagnosed based on clinical, histopathologic, and ultrastructural criteria. Its biochemical and genetic aspects are still poorly understood.

Gingival lesions in lipoid proteinosis

Lipoid proteinosis is a rare heritable disease of the skin and mucous membranes characterized by subepithelial deposits of hyaline material. The morbid factors include disfiguring papulo-nodular lesions particularly of exposed skin, hoarseness of voice due to vocal cord infiltration, nodular deformation of the eyelids, and board-like rigidity of the tongue. Infiltration of the gingiva is usually unreported, and when mentioned has been equivocally related to the overall disease process. This patient demonstrates striking ulceration and hypertrophy with histologic evidence of heavy deposition of amorphous material confirming a gingival component to the lipoid proteinosis entity.

Neuropsychological correlates of bilateral amygdala damage

We conducted an extensive neuropsychological investigation in a patient with bilateral amygdala damage due to Urbach-Wiethe disease. The patient had significant defects in nonverbal visual memory, in social behavior, and in "executive control" functions, findings consistent with the proposal, based on experimental animal work, that the amygdala plays important roles in memory and in the modulation of social and emotional behavior. General intellect and language were normal. A psychophysiological study showed that she had normal electrodermal activity (skin conductance responses), an important finding in view of the role that has been attributed to the amygdala in the central control of autonomic responses.

Lipoid proteinosis: Urbach-Wiethe disease

An otherwise healthy patient with Urbach-Wiethe disease required surgical removal of two 3rd molar teeth. In this multisystem disorder infiltration of the buccal, pharyngeal and laryngeal mucosa may cause difficulties with tracheal intubation and increase the likelihood of trauma. The anaesthetic implications and management are described.

Corectopia and lipoid proteinosis

Lipoid proteinosis (Urbach-Wiethe disease) is a rare autosomal recessive disorder associated with deposition of hyalinised material in the skin, mucous membrane, and brain. Corectopia has not been described in this disorder. A case is presented of lipoid proteinosis with bilateral corectopia.

Pulmonary alveolar lipoproteinosis complicating juvenile dermatomyositis

A 9 year old boy with juvenile dermatomyositis developed pulmonary alveolar lipoproteinosis. This previously unreported association was treated successfully by bronchoalveolar lavage.