Mitral annuloplasty in endomyocardial fibrosis: an alternative to valve replacement

Phänotypisches und genetisches Spektrum von Incontinentia pigmenti – eine große Fallserie

HINTERGRUND

Incontinentia pigmenti ist eine seltene X-chromosomal dominant vererbte Systemerkrankung, die vor allem die Haut, aber auch andere neuroektodermale Gewebe wie Zähne, Haare, Augen und das zentrale Nervensystem betrifft.

PATIENTEN UND METHODIK

Diese multizentrische Fallserienstudie wurde an drei europäischen Hautkliniken durchgeführt und umfasste 30 Patienten mit Incontinentia pigmenti. Zwanzig Patienten wurden klinisch und genetisch untersucht, weitere zehn nur genetisch.

ERGEBNISSE

Die Studie umfasste 28 Frauen und zwei Männer mit einem medianen Alter von drei Jahren. Kutane Manifestationen zeigten sich bei allen 20 Patienten mit klinischen Daten. Stadium I wurde in 90 % dieser Patienten beobachtet. Stadium IV wurde bereits im Alter von einem Jahr beobachtet. Zahn- (81 %), Haar- (78 %) und neurologische Anomalien (53 %) waren häufiger als in bisherigen Berichten. Vierzehn Hautbiopsien zeigten typische Merkmale des entsprechenden Stadiums. Genetische Tests wurden bei 24 Patienten durchgeführt, von denen 14 die häufige Exon 4-10-Deletion und sieben andere pathogene Varianten aufwiesen, darunter drei unveröffentlichte Mutationen. In drei weiteren Fällen wurden keine genetischen Veränderungen gefunden.

SCHLUSSFOLGERUNGEN

In dieser Studie reichte der Phänotyp von lediglich subtil ausgeprägter Hautbeteiligung bis hin zu schweren Multisystemerkrankungen. Die extrakutane Beteiligung sollte zum Zeitpunkt der Diagnose und in regelmäßigen Abständen evaluiert werden, da sich einige Manifestationen erst mit der Zeit entwickeln.

SUMMARY

Background and objectives Incontinentia pigmenti is a rare X-linked dominantly inherited systemic disease affecting primarily the skin but also other neuroectodermal tissues such as teeth, hair, eyes, and the central nervous system. Patients and methods This multicenter case series study was conducted at three European departments of Dermatology including 30 patients with incontinentia pigmenti. Twenty patients were evaluated clinically and genetically, another ten only genetically. Results The study included 28 females and two males with a median age of three years. Cutaneous manifestations were present in all 20 patients with clinical data. Stage I was observed in 90 % of those patients. Stage IV was observed as early as one year of age. Dental (81 %), hair (78 %) and neurological anomalies (53 %) were more frequent than previously reported. Fourteen skin biopsies showed typical features of the corresponding stage. Genetic testing of 24 patients revealed the common exon 4-10 deletion in 14 cases and seven other pathogenic variants, including three unpublished mutations. In another three cases, no genetic alterations were found. Conclusions In this study, the phenotype ranged from only subtle cutaneous involvement to severe multisystemic disorders. Extracutaneous involvement should be evaluated at the time of diagnosis and in regular intervals, as some manifestations may develop over time.

Phenotypic and genetic spectrum of incontinentia pigmenti - a large case series

BACKGROUND AND OBJECTIVES

Incontinentia pigmenti is a rare X-linked dominantly inherited systemic disease affecting primarily the skin but also other neuroectodermal tissues such as teeth, hair, eyes, and the central nervous system.

PATIENTS AND METHODS

This multicenter case series study was conducted at three European departments of Dermatology including 30 patients with incontinentia pigmenti. Twenty patients were evaluated clinically and genetically, another ten only genetically.

RESULTS

The study included 28 females and two males with a median age of three years. Cutaneous manifestations were present in all 20 patients with clinical data. Stage I was observed in 90 % of those patients. Stage IV was observed as early as one year of age. Dental (81 %), hair (78 %) and neurological anomalies (53 %) were more frequent than previously reported. Fourteen skin biopsies showed typical features of the corresponding stage. Genetic testing of 24 patients revealed the common exon 4-10 deletion in 14 cases and seven other pathogenic variants, including three unpublished mutations. In another three cases, no genetic alterations were found.

CONCLUSIONS

In this study, the phenotype ranged from only subtle cutaneous involvement to severe multisystemic disorders. Extracutaneous involvement should be evaluated at the time of diagnosis and in regular intervals, as some manifestations may develop over time.

Cardiopulmonary anomalies in incontinentia pigmenti patients

BACKGROUND

Incontinentia pigmenti (IP) is a rare inherited genodermatosis that usually involves the skin, and also teeth, oral cavity, central nervous system, eyes, blood with eosinophilia, and rarely skeletal system, breast, heart, and lungs. Skin lesions usually appear early, at birth or within the first 2 weeks of life, with four different phases tending to follow Blaschko lines that may overlap.

CASE REPORT

We report a rare case of a neonate with transient reversible pulmonary hypertension that presented at day 9 of life. She manifested increasing dyspnea and deterioration of respiratory dynamics with a serious pulmonary hypertension without a primary pulmonary disease. Hence, oxygen therapy at high flows and nitric oxide have been administered with an initial response, but, subsequently, because of the worsening of the respiratory activity, she underwent sildenafil and bosentan treatment with respiratory dynamics improvement and progressive decrease of the pulmonary pressures.

CONCLUSION

In literature only a few cases of cardiopulmonary anomalies in IP have been described with different outcomes, and these rare complications are probably underestimated by physicians. We could suppose that microangiopathic damages may have a critical role in endothelial alterations, and these processes are probably shared by multiple organs involved in IP and rarely by lungs and heart.

Unusual neonatal presentation of incontinentia pigmenti with persistent pulmonary hypertension of the newborn: a case report

Incontinentia pigmenti (Bloch-Sulzberger syndrome) is a multisystem disorder with classical changing skin lesions. The other systems that are involved include the central nervous system, eye, hair, teeth, musculoskeletal system and, occasionally, the cardiovascular system. We report a neonate with a diagnosis of incontinentia pigmenti who presented at birth with pulmonary hypertension. This presentation has not been described in the literature.

Incontinentia pigmenti: a case associated with cardiovascular anomalies

Various cutaneous and developmental defects of the eyes, teeth, skeleton, and central nervous system have been detected in infants with incontinentia pigmenti. We report an isolated case of incontinentia pigmenti in a 6-month-old girl in association with tricuspid insufficiency, an abnormal shunt of the right pulmonary vein into the superior vena cava, and pulmonary hypertension. We believe that our findings will help to confirm the association of cardiovascular anomalies in IP.

Mitral valve repair in patients with endomyocardial fibrosis

Between 1987 and 1990, 12 patients were operated on for endomyocardial fibrosis at our institution. Nine were treated by endocardectomy and mitral valve repair and constitute the material of this study. Ages ranged from 9 to 58 years (mean age, 32.5 years). Biventricular involvement was present in 3 cases, and 6 patients had predominantly left ventricular endomyocardial fibrosis. Six patients were in New York Heart Association class III/IV. Six patients had severe mitral insufficiency (3 to 4/4) and 3 patients had moderate mitral insufficiency (2/4). The operation consisted of left ventricular endocardectomy with complete detachment and mobilization of the posterior leaflet of the mitral valve in all cases. An autologous pericardial patch was used to reconstruct posterior leaflet continuity in 4 patients. In 7 patients a prosthetic mitral ring was used. In 3 patients right ventricular endocardectomy and tricuspid valve repair were also performed. All patients survived and none required early reoperation. Follow-up was complete and ranged from 9 to 38 months. No late deaths occurred, and 1 patient required mitral valve replacement for recurrent mitral regurgitation. Doppler echocardiographic studies were performed in 7 patients and revealed no or mild mitral insufficiency. In conclusion, mitral valve repair is safe and offers good early and late results in patients with endomyocardial fibrosis.

Endomyocardial fibrosis. Preoperative diagnosis and surgical therapy

The case of a Nigerian student with biventricular endomyocardial fibrosis is presented. Diagnosis was suggested by cardiac catheterization and histologically confirmed by a percutaneous endomyocardial biopsy. Successful surgical repair including mitral valve replacement, tricuspid valve reconstruction, and left ventricular endomyocardial resection was performed through a biatrial approach. The pathologic and surgical considerations are reviewed. This is one of the few cases of endomyocardial fibrosis reported from the United States and the first in which a percutaneous endomyocardial biopsy was used to provide a definitive preoperative histologic diagnosis.