1
|
Ai W, Liang Z, Li F, Yu H. Degos disease with multiple intestinal perforations: A missed-opportunity case report and literature review. Front Cardiovasc Med 2022; 9:910288. [PMID: 36324742 PMCID: PMC9618646 DOI: 10.3389/fcvm.2022.910288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 09/30/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction Degos disease, also known as malignant atrophic papulosis (MAP), is a rare systemic obstructive vascular disease with unknown pathophysiology, which can affect multiple systems, especially gastrointestinal tract and central nervous system. Intestinal perforations with MAP is associated with high mortality rate and ambiguous treatment outcomes. Case presentation Here we report a missed-opportunity case of Degos disease characterized by generalized skin eruption and multiple intestinal perforations. Definite diagnosis of Degos disease was finally concluded after two exploratory laparotomy operations and skin biopsies. Due to the delayed diagnosis and treatment, the patient died after being discharged automatically in spite of application of aspirin and low-dose subcutaneous heparin. In view of such circumstances, we searched the Pubmed using “Degos [Title] OR Malignant Atrophic Papulosis [Title]” AND “perforation [Title] OR perforations [Title]” and make a detailed analysis of the result. Conclusions Degos disease is a rare systemic obstructive vascular disease with unknown pathologic mechanism and unavailable treatment methods. Diagnosis is usually based on the presence of pathognomonic skin lesions and tissue biopsy. Gastrointestinal involvement can cause serious and lethal conditions with high mortality. Currently, how to achieve a satisfying prognosis of MAP with intestinal perforations becomes the most urgent problem in front of medical staff.
Collapse
|
2
|
Sattler SS, Magro CM, Shapiro L, Merves JF, Levy R, Veenstra J, Patel P. Gastrointestinal Kohlmeier-Degos disease: a narrative review. Orphanet J Rare Dis 2022; 17:172. [PMID: 35443671 PMCID: PMC9022239 DOI: 10.1186/s13023-022-02322-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Accepted: 04/09/2022] [Indexed: 11/10/2022] Open
Abstract
Introduction Kohlmeier-Degos (K-D) disease is a rare obliterative vasculopathy that can present as a benign cutaneous form or with potentially malignant systemic involvement. The gastrointestinal tract is most frequently involved in systemic disease and mortality is often related to bowel perforations. Herein, we provide information to providers and patients regarding gastrointestinal K-D symptomology, pathology, treatment, and diagnosis, with a focus on the importance of timely diagnostic laparoscopy. We present three new cases of gastrointestinal K-D to highlight varying disease presentations and outcomes. Body Based on reviewed reports, perforation is preceded by at least one gastrointestinal symptom: abdominal pain/cramping, anorexia/weight loss, vomiting, diarrhea, nausea, gastrointestinal bleeding, obstipation, constipation, and abdominal fullness. Perforation most commonly occurs in the small intestine and often results in sepsis and death. Although underutilized, laparoscopy is the most sensitive and specific diagnostic technique, demonstrating serosal porcelain plaques similar to those on the skin and characteristic for K–D. The combination of eculizumab and treprostinil is presently the most effective treatment option for gastrointestinal K–D. The pathology of gastrointestinal K-D is characterized by an obliterative intimal arteriopathy eventuating in occlusive acellular deposits of mucin and collagen along with an extravascular pauci-cellular sclerosing process resembling scleroderma confined to the subserosal fat. C5b-9 and interferon-alpha are both expressed in all caliber of vessels in the affected intestine. While C5b-9 blockade does not prevent the intimal expansion, enhanced type I interferon signaling is likely a key determinant to intimal expansion by, causing an influx of monocytes which transdifferentiate into procollagen-producing myofibroblast-like cells. Conclusion Prompt laparoscopic evaluation is necessary in any K–D patient with an abdominal symptom to facilitate diagnosis and treatment initiation, as well as to hopefully decrease mortality. Those with gastrointestinal K–D should start on eculizumab as soon as possible, as onset of action is immediate. Supplementary Information The online version contains supplementary material available at 10.1186/s13023-022-02322-9.
Collapse
Affiliation(s)
| | - Cynthia M Magro
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Lee Shapiro
- Division of Rheumatology, Albany Medical College, 6 Medical Park Drive, Malta, NY, 12020, USA.
| | - Jamie F Merves
- Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Rebecca Levy
- Division of Dermatology, Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada
| | - Jesse Veenstra
- Department of Dermatology, Henry Ford Health System, Detroit, MI, USA
| | - Puraj Patel
- Department of Surgery, Henry Ford Health System, Detroit, MI, USA
| |
Collapse
|
3
|
Lu JD, Sachdeva M, Silverberg OM, Shapiro L, Croitoru D, Levy R. Clinical and laboratory prognosticators of atrophic papulosis (Degos disease): a systematic review. Orphanet J Rare Dis 2021; 16:203. [PMID: 33957947 PMCID: PMC8101154 DOI: 10.1186/s13023-021-01819-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 04/06/2021] [Indexed: 12/14/2022] Open
Abstract
Background Degos disease is a rare vascular disorder with a cutaneous-limited form, benign atrophic papulosis (BAP), and a systemic variant, malignant atrophic papulosis (MAP). Despite the poor prognosis of MAP, no study has established features associated with systemic disease. Objectives The aims of this systematic review were to: (1) summarize clinical features and treatments implemented for patients with MAP and BAP (2) identify clinical and laboratory factors associated with the development of MAP, compared to BAP. Methods We systematically searched MEDLINE and Embase from inception to April 2020. Demographic and clinical features of Degos patients were presented descriptively; multivariable logistic regression was performed to identify associations with MAP. Results We identified 99 case studies, comprising 105 patients. MAP (64%) had a 2.15 year median survival time from cutaneous onset, most often with gastrointestinal or central nervous system involvement. We found that elevations in either of erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) were associated with systemic involvement (OR 2.27, p = 0.023). Degos secondary to an autoimmune connective tissue disease was found to be inversely associated with MAP (OR 0.08, p = 0.048). Conclusions Elevated ESR or CRP is associated with MAP and may be a predictor of systemic involvement for patients with Degos disease. In addition, secondary Degos disease is associated with a favourable prognosis. Clinicians should be aware of the differences between primary and secondary Degos and the utility of ESR or CRP in identifying disease evolution to systemic involvement. The utility of ESR and CRP to identify systemic involvement should be further explored. Supplementary Information The online version contains supplementary material available at 10.1186/s13023-021-01819-z.
Collapse
Affiliation(s)
- Justin D Lu
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | | | | | - Lee Shapiro
- Department of Medicine, Division of Rheumatology, Albany Medical College, Albany, NY, USA
| | - David Croitoru
- Division of Dermatology, Department of Medicine, Women's College Hospital, 76 Grenville St, 3rd Floor, Toronto, ON, M5S 1B2, Canada.
| | - Rebecca Levy
- Department of Dermatology, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
4
|
Toledo AE, Shapiro LS, Farrell JF, Magro CM, Polito J. Laparoscopy shows superiority over endoscopy for early detection of malignant atrophic papulosis gastrointestinal complications: a case report and review of literature. BMC Gastroenterol 2015; 15:156. [PMID: 26527039 PMCID: PMC4630896 DOI: 10.1186/s12876-015-0387-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Accepted: 10/22/2015] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND The malignant form of atrophic papulosis (Köhlmeier-Degos disease) is a rare thrombo-occlusive vasculopathy that can affect multiple organ systems. Patients typically present with distinctive skin lesions reflective of vascular drop out. The small bowel is the most common internal organ involved, resulting in considerable morbidity and mortality attributable to ischemic microperforations. Determination of the presence of gastrointestinal lesions is critical in distinguishing systemic from the benign, cutaneous only disease and in identifying candidates for treatment. CASE PRESENTATION We describe an 18 year old male who first presented with cutaneous atrophic papulosis but became critically ill from small bowel microperforations. He had an almost immediate and dramatic response to treatment. Prior to his presentation with acute abdomen he had upper and lower endoscopy showing areas of nonspecific patchy erythema. At laparotomy, innumerable characteristic lesions with central pearly hue and erythematous border were seen. PubMed was used for a literature search using the keywords malignant atrophic papulosis, Degos disease, endoscopy, laparoscopy and laparotomy. This search yielded 200 articles which were further analyzed for diagnostic procedures and findings. Among the 200 articles we identified only 11 cases in which endoscopy was performed. Results of endoscopy and laparotomy in our patient with malignant atrophic papulosis were compared to those in the literature. Endoscopy of the gastrointestinal tract has shown gastritis and non-specific inflammation whereas laparoscopy shows white plaques with red borders on the serosal surface of the small bowel and the peritoneum. From personal communications with other physicians worldwide, we identified three additional unpublished cases in which endoscopy revealed only minimal changes while laparoscopy showed dramatic lesions. From our experience the endoscopic findings are often subtle and nonspecific, whereas laparascopy or laparotomy will reveal pathognomic lesions on the serosal surface of the intestine. CONCLUSION Our report contrasts the endoscopic and laparoscopic findings in malignant atrophic papulosis which suggest laparoscopy is the more powerful means of detecting gastrointestinal involvement. Imaging studies may serve as a key indicator of systemic progression. Based on our experience, laparoscopy should be performed when there is a high index of suspicion for gastrointestinal malignant atrophic papulosis, even if endoscopic examination is non-diagnostic or normal.
Collapse
Affiliation(s)
- A E Toledo
- Steffens Scleroderma Center, Saratoga Springs, NY, USA. .,The Center for Rheumatology, Albany and Saratoga Springs, NY, USA.
| | - L S Shapiro
- Steffens Scleroderma Center, Saratoga Springs, NY, USA. .,The Center for Rheumatology, Albany and Saratoga Springs, NY, USA. .,Albany College of Pharmacy and Health Sciences, Albany, NY, USA.
| | - J F Farrell
- Steffens Scleroderma Center, Saratoga Springs, NY, USA. .,The Center for Rheumatology, Albany and Saratoga Springs, NY, USA. .,Albany College of Pharmacy and Health Sciences, Albany, NY, USA.
| | - C M Magro
- Weill Cornell College of Cornell University, New York, NY, USA.
| | - J Polito
- Gastroenterology Consultants, Albany, NY, USA.
| |
Collapse
|
5
|
Pirolla E, Fregni F, Miura IK, Misiara AC, Almeida F, Zanoni E. Degos disease - malignant atrophic papulosis or cutaneointestinal lethal syndrome: rarity of the disease. Clin Exp Gastroenterol 2015; 8:141-7. [PMID: 25926751 PMCID: PMC4403817 DOI: 10.2147/ceg.s59794] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Degos disease is a very rare syndrome with a rare type of multisystem vasculopathy of unknown cause that affects the skin, gastrointestinal tract, and central nervous system. Other organs such as the kidneys, lungs, pleura, liver, heart, and eyes, can also be involved. OBJECTIVE To highlight the incidence of Degos disease with regard to age and sex, discuss the necessity of its accurate and early diagnosis, and demonstrate the most current techniques for its diagnosis; to discuss whether early therapeutic intervention can impact patient prognosis; and to present a literature review about this disease. DESIGN With a retrospective, observational, nonrandomized trial, we described the evolution of the different forms of Degos disease and referenced the literature. DATA SOURCES Research on rare documented cases in the literature, including two cases of potentially lethal form of the disease involving the skin and gastrointestinal system and, possibly, the lungs, kidneys, and central nervous system. A case of the benign form of the disease involving the skin was observed by the authors. MAIN OUTCOME MEASURES Differences between outcomes in patients with the cutaneointestinal form and skin-only form of the disease. There was one fatal outcome. We reviewed possible new approaches to diagnosis and treatment. RESULTS The study demonstrated the rapid evolution of the aggressive and malignant form of the disease. It also described newly accessible Phase I diagnostic tools being currently researched as well as new therapeutic approaches. LIMITATION The rarity of the disease, with only eleven cases throughout the literature. CONCLUSION The gastrointestinal form of Degos disease can be lethal. Its vascular etiology has finally been confirmed; however, new and more accurate early diagnostic modalities need to be developed. There are new therapeutic possibilities, but the studies of them are still in the early stages and have not yet shown the full effectiveness of these new therapies.
Collapse
Affiliation(s)
- Eduardo Pirolla
- Spaulding Rehabilitation Network Research Laboratory, Harvard Medical School, Boston, MA, USA
| | - Felipe Fregni
- Spaulding Rehabilitation Network Research Laboratory, Harvard Medical School, Boston, MA, USA
| | - Irene K Miura
- University of São Paulo, Sirio Libanes Hospital, São Paulo, Brazil
| | | | | | | |
Collapse
|
6
|
Ali YN, Hamed M, Azita N. Lethal systemic degos disease with prominent cardio-pulmonary involvement. Indian J Dermatol 2012; 56:564-7. [PMID: 22121280 PMCID: PMC3221225 DOI: 10.4103/0019-5154.87157] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
A 48-year-old man presented with acute abdominal pain underwent laparotomy that revealed two perforated ulcers in jejunum. He had skin lesions with porcelain white atrophic scar which were ignored for 3 years, whereas the disease revealed own malignant nature and progressed to nervous, gastrointestinal, and cardiopulmonary systems. The diagnosis of Degos disease was established on the basis of clinical and histopathological features. He expired due to cardio-pulmonary insufficiency after 5 months from the onset of systemic involvement. Autopsy showed diffuse fibrotic changes in serosal membranes and internal organs. Distribution of skin lesions that involved palmoplantar surfaces, genitalia and scalp and, furthermore, course of disease as rapid progressive cardio-polmunary involvement are remarkable point in this patient. On the other hand, this case highlights importance of clinicopathologic correlation, specially in the dermatologic field.
Collapse
|
7
|
Surgery for small bowel perforation in an Asian population: predictors of morbidity and mortality. J Gastrointest Surg 2010; 14:493-9. [PMID: 19997984 DOI: 10.1007/s11605-009-1097-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2009] [Accepted: 11/02/2009] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Peritonitis from small bowel perforation is associated with prohibitive morbidity and mortality rates. The aims of our study were to review our institution's experience in the surgical management of small bowel perforation and to identify factors that could predict morbidity and mortality. METHODS A retrospective review of all patients who underwent operative intervention for peritonitis from small bowel perforation from January 2003 to May 2008 was performed. Patients were identified from the hospital's diagnostic index and operating records. The severity of abdominal sepsis for all patients was graded using the Mannheim peritonitis index (MPI). All the complications were graded according to the classification proposed by Clavien and group. RESULTS Forty-seven patients, of median age 68 years (18-95 years), formed the study group. Pneumoperitoneum on chest radiographs was seen in only 11 (23.4%) patients. Foreign body ingestion (17.0%), adhesions (14.9%), and malignancy (12.8%) accounted for majority of the pathologies. There was one patient who had several small bowel perforations from Degos disease. Small bowel resection was performed in the majority of the patients (74.5%). The mortality rate in our series was 19.1%, while another 57.4% patients had perioperative complications. On univariate analysis, American Society of Anesthesiologists score >or= 3, MPI > 26, hypotension, stoma creation, abnormal electrolyte level, and renal impairment were related to worse outcome, while the three independent variables that were related to worse outcome after multivariate analysis were MPI > 26, hypotension, and abnormal serum potassium level. CONCLUSION Surgery for small bowel perforation is associated with significant morbidity and mortality rates. Patients with more severe peritonitis and physiological derangement were more likely to fare worse.
Collapse
|
8
|
Slaviero F, Annes RD, Frighetto L, Schirmer LM, Vanzin JR, Fröhlich AC, Ferraz J, Azambuja Jr ND. Köhlmeier-Degos Disease (malignant atrophic papulosis) and Neurologic Involvement. ARQUIVOS DE NEURO-PSIQUIATRIA 2009; 67:692-4. [DOI: 10.1590/s0004-282x2009000400022] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
|
9
|
Caviness VS, Sagar P, Israel EJ, Mackool BT, Grabowski EF, Frosch MP. Case records of the Massachusetts General Hospital. Case 38-2006. A 5-year-old boy with headache and abdominal pain. N Engl J Med 2006; 355:2575-84. [PMID: 17167141 DOI: 10.1056/nejmcpc069029] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
|
10
|
Aydogan K, Alkan G, Karadogan Koran S, Adim SB, Kiyici M, Tokgoz N. Painful penile ulceration in a patient with malignant atrophic papulosis. J Eur Acad Dermatol Venereol 2006; 19:612-6. [PMID: 16164721 DOI: 10.1111/j.1468-3083.2005.01227.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Malignant atrophic papulosis (MAP) is a rare, obliterating vasculopathy affecting multiple systems, frequently with a poor prognosis. Although cutaneous lesions are often the initial presentation, systemic involvement is also common, usually with a fatal outcome. Involvement of the genitalia is very rare. We describe a 45-year-old male patient with multisytemic manifestation of MAP accompanied by painful penile ulceration. The pathogenesis of MAP is not yet fully understood and effective treatment choices are limited. In our case, the combination of pentoxifylline and dipyridamole failed to provide a beneficial effect on the progression of the disease and the patient died due to intestinal and intrathoracic manifestation of MAP. In the present case, attention should be drawn to the following clinical course and therapeutic properties: (i) we describe the second patient in the literature diagnosed with MAP and painful penile ulceration; (ii) to our knowledge, this is the first reported case with oesophageal fistula due to MAP; (iii) we could not confirm the efficacy of pentoxifylline, the recently reported treatment modality, in our patient.
Collapse
Affiliation(s)
- K Aydogan
- Department of Dermatology, Uludag University School of Medicine, Bursa, Turkey
| | | | | | | | | | | |
Collapse
|