Cutaneous and neurologic manifestations of biotinidase deficiency

Rare Treatable Cause of Demyelinating Leukoencephalopathy That One Cannot Afford to Miss

Biotinidase deficiency is a treatable neurometabolic disorder. It usually presents during the first year of life with seizures, ataxia, hypotonia, vision and hearing disturbance, alopecia, and skin rashes. It can have various neuroimaging findings but demyelinating leukoencephalopathy is an unusual finding in children with biotinidase deficiency that can cause diagnostic challenge as it can radiologically mimic perinatal hypoxic–ischemic encephalopathy or other leukodystrophies. It reverses with early diagnosis and treatment with biotin supplementation and the outcome is rewarding.

Interference From High-Dose Biotin Intake in Immunoassays for Potentially Time-Critical Analytes by Roche

CONTEXT.—

Immunoassays using the interaction between streptavidin and biotin are used for clinical chemical analytes on platforms by many different manufacturers. The design can be susceptible to interference from high-dose biotin intake in patients, which remains an often-overlooked confounder despite recently increased awareness.

OBJECTIVE.—

To evaluate an easily implementable method of in vitro biotin depletion for the removal of biotin interference in immunoassays for potentially time-critical analytes.

DESIGN.—

A biotin stock solution was made and de-identified patient samples were spiked to reach a biotin concentration of 1.126 × 106 pg/mL, the maximum reported biotin concentration 1 to 2 hours after a single oral dose of 300 mg biotin. Then, the resulting interference in Elecsys immunoassays for cortisol, cyclosporine A, tacrolimus, digitoxin, thyroid-stimulating hormone, free triiodothyronine, free thyroxine, C-peptide, insulin, N-terminal pro-B-type natriuretic peptide, troponin T high sensitive, human immunodeficiency virus, procalcitonin, β human chorionic gonadotropin, toxoplasma immunoglobulin M, and toxoplasma immunoglobulin G was evaluated before and after biotin depletion using streptavidin particles.

RESULTS.—

All tested immunoassays, with the exception of toxoplasma immunoglobulin M and toxoplasma immunoglobulin G, suffered from significant biotin interference. The depletion protocol removed assay interference due to biotin and produced results that were close or identical to initial prespike measurements.

CONCLUSIONS.—

Despite an increase in turnaround times, biotin adsorption is a feasible countermeasure for biotin interference in Elecsys immunoassays. Until test kits with an increased resistance to the interference from high-dose biotin intake are distributed, the evaluated protocol can provide results properly reflecting the patient's clinical condition.

Cutaneous manifestations of nutritional deficiency

PURPOSE OF REVIEW

Childhood malnutrition is a major global health issue. It is often thought of as a developing world problem and therefore, underdiagnosed or misdiagnosed in developed countries. The delay in diagnosis and treatment can lead to increased morbidity and mortality. Cutaneous manifestations are often the initial presenting signs of nutritional deficiency. Early recognition is essential in timely initiation of the necessary interventions. This article will review pertinent cutaneous findings and systemic manifestations associated with common nutritional deficiencies.

RECENT FINDINGS

Malnutrition has historically been associated with poverty in developing countries. However, recent literatures suggest that the incidence of nutritional deficiencies continuous to rise among infants from developed countries, as a result of dietary restrictions because of perceived food allergies or intolerance. It is also an emerging finding in children with complicated medical problems.

SUMMARY

It is very important to raise awareness about cutaneous manifestations of nutritional deficiency as early and appropriate treatment results in excellent prognosis.

Vitamin-responsive epileptic encephalopathies in children

Untreated epileptic encephalopathies in children may potentially have disastrous outcomes. Treatment with antiepileptic drugs (AEDs) often may not control the seizures, and even if they do, this measure is only symptomatic and not specific. It is especially valuable to identify potential underlying conditions that have specific treatments. Only a few conditions have definitive treatments that can potentially modify the natural course of disease. In this paper, we discuss the few such conditions that are responsive to vitamin or vitamin derivatives.

Ohtahara syndrome with biotinidase deficiency

Ohtahara syndrome is a rare epileptic encephalopathy in infants; the underlying etiology is generally thought to be structural brain malformations. The authors present a rare case of this type of epileptic encephalopathy in which a treatable metabolic condition such as biotinidase deficiency was suspected and diagnosed, and early institution of appropriate therapy led to a good clinical outcome.

Acrodermatitis due to nutritional deficiency

PURPOSE OF REVIEW

Nutritional deficiency is prevalent in developing countries but should also be considered in developed countries in the setting of genetic or acquired disease states. The skin is commonly involved and is often one of the first organs affected in nutritional deficiency, providing a key to the diagnosis. This article will review the most common nutritional deficiencies causing a periorificial and/or acrodermatitis: zinc deficiency, biotin deficiency, kwashiorkor, and essential fatty acid deficiency.

RECENT FINDINGS

Whereas older literature has focused on the relationship among nutritional deficiency, malnutrition and poverty, recent research has identified additional patient populations that are at risk for developing nutritional deficiencies. These populations include premature infants, patients with long-term total parenteral nutrition, Crohn's disease, cystic fibrosis, intestinal bypass procedures, chronic alcoholics, anorexia nervosa, and restrictive diets. Recent studies have also focused on further understanding the genetic basis of inherited nutritional deficiencies such as acrodermatitis enteropathica.

SUMMARY

Skin manifestations can lead a provider to the diagnosis of a nutritional deficiency. In a child with a periorificial or acral dermatitis, the diagnosis of zinc, biotin, protein, or essential fatty acid deficiency should be considered, especially if accompanied by systemic signs of failure to thrive.

Eruptive pseudoangiomatosis: report of an adult case and unifying hypothesis of the pathogenesis of paediatric and adult cases

One month after the onset of immunosuppressive treatment with corticosteroids and mycophenolate mofetil for a newly diagnosed pemphigus vulgaris, a 50-year-old female patient developed a new eruption clinically and histomorphologically consistent with eruptive pseudoangiomatosis (EP). Its self-limited course further confirmed this diagnosis. Although initially described as a paediatric eruption, meanwhile more adult cases of EP (30 out of a total of 53 cases identified by a Medline search) are reported in the literature. The review of adult cases of EP disclosed some common clinical and epidemiological characteristics: adult EP cases tend to cluster in the Mediterranean region of Europe, develop during the summer months, sometimes in the form of limited micro-epidemics, affect immunocompromised individuals and have lesions confined to the exposed skin sites. These characteristics, together with the exanthematic nature of the disease in children, point to some vector-transmitted infectious agent as the cause of this probably underdiagnosed disease.

Eruptive pseudoangiomatosis

Eruptive pseudoangiomatosis (EPA) is a rare, self-limiting exanthem, which is known to occur primarily in children. It is characterized by an eruption of distinctive erythematous angioma-like papules often surrounded by a pale halo, with histological findings distinct from that of true angiomas. We describe three women with angioma-like papules. The biopsy specimens from them showed a unique histological appearance consisting of dilated dermal blood vessels with plump endothelial cell and perivascular lymphocytes. On the basis of the clinical and histological findings, we present the adult cases of eruptive pseudoangiomatosis and their etiology.