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Minnaganti D, Gampala AR, Khanna YP, Haury E. Eschar Formation Following Coma Bullae: A Case Report. Cureus 2024; 16:e58646. [PMID: 38770478 PMCID: PMC11103451 DOI: 10.7759/cureus.58646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/20/2024] [Indexed: 05/22/2024] Open
Abstract
Coma blisters, or coma bullae, are lesions often seen in the setting of impaired consciousness. Most commonly associated with drug-induced comas, coma bullae have been repeatedly linked to central nervous system (CNS) depressing agents, such as opiates. These lesions are believed to develop due to a complex multifactorial process involving external pressure on the skin, which leads to hypoxia and eventual death of eccrine sweat glands. In addition, the vasoactive and inflammatory properties of CNS depressing agents may play a role in this process. Come bullae usually develop on pressure points 48-72 hours after the onset of impaired consciousness and are self-limiting. We present the case of a 68-year-old male who was brought to the emergency department after being found unresponsive on the street. The urine drug screen was positive for cocaine and fentanyl. The initial examination showed several large, non-tender bullae on his scalp that continued to expand over two days. He subsequently developed similar lesions on his thighs, right shoulder, and knuckles. Dermatology was consulted and clinically diagnosed the patient with coma bullae, likely attributed to his altered consciousness and opiate use. Notably, more violaceous bullae were found on the bilateral lower extremities, with dermatology suspecting additional vasculitic features related to concurrent opiate and cocaine use. Skin biopsy and aspiration were deferred to avoid the risk of infection, and the patient was discharged per dermatology's recommendations for no immediate intervention. He continued to follow with wound care for the next six months, with most of the bullae healing. However, eschars developed over the scalp and left lower extremity, requiring debridement by general surgery. This case report underscores a unique manifestation of coma bullae. Unlike typical presentations localized to pressure-dependent areas and appearing after two to three days of unconsciousness, our patient exhibited blisters in atypical sites with associated vasculitic features. Moreover, the development of eschars over time may be linked to ongoing vasoactive drug use, reperfusion injury, and social determinants of health. This case highlights the complex and multifactorial nature of coma bullae, emphasizing the challenges in wound care and management despite their expected self-resolution.
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Affiliation(s)
- Divya Minnaganti
- Internal Medicine, University of Missouri Kansas City School of Medicine, Kansas City, USA
| | - Arjun R Gampala
- Internal Medicine, University of Missouri Kansas City School of Medicine, Kansas City, USA
| | - Yash P Khanna
- Internal Medicine, University of Missouri Kansas City School of Medicine, Kansas City, USA
| | - Emily Haury
- Internal Medicine and Pediatrics, University of Missouri Kansas City School of Medicine, Kansas City, USA
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Liu L, Lu Q, Luo H, Yu C. Identification of novel KRT5 gene variants in two Chinese patients with sporadic form of epidermolysis bullosa simplex: A case report. Exp Ther Med 2024; 27:132. [PMID: 38414793 PMCID: PMC10895618 DOI: 10.3892/etm.2024.12420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 01/24/2024] [Indexed: 02/29/2024] Open
Abstract
Epidermolysis bullosa simplex (EBS), a rare genetic disorder characterized by fragile skin that is prone to blistering and tearing, is primarily caused by mutations in genes encoding keratin proteins, such as KRT5 and KRT14. This study aimed to identify the pathogenic gene variants responsible for the sporadic form of EBS in two Chinese patients. Blood samples were collected from patients and their parents, and next-generation sequencing (NGS) was performed for variant screening. Two novel gene variants were identified within the KRT5 gene: c.1399A>T (p.Ile467Phe) in patient 1 and c.1412G>A (p.Arg471His) in patient 2. These variants were absent in the unaffected parents and a control group of 100 healthy individuals. These two novel gene variants within the KRT5 gene may be responsible for EBS, thus improving understanding of the genetic basis of EBS.
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Affiliation(s)
- Linli Liu
- Department of Dermatology, Suining Central Hospital, Suining, Sichuan 629000, P.R. China
| | - Qinglian Lu
- Department of Dermatology, Suining Central Hospital, Suining, Sichuan 629000, P.R. China
| | - Hui Luo
- Department of Dermatology, Suining Central Hospital, Suining, Sichuan 629000, P.R. China
| | - Chunshui Yu
- Department of Dermatology, Suining Central Hospital, Suining, Sichuan 629000, P.R. China
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Yoshida K, Yoshida S, Hori Y, Tsubota H, Mochizuki R, Nagano T, Koyama T. Totally endoscopic concomitant aortic and mitral valve surgery in junctional epidermolysis bullosa: a case report. J Cardiothorac Surg 2024; 19:102. [PMID: 38378631 PMCID: PMC10877881 DOI: 10.1186/s13019-024-02567-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 01/30/2024] [Indexed: 02/22/2024] Open
Abstract
BACKGROUND Junctional epidermolysis bullosa is a rare skin and mucosal disorder characterized by blister formation in response to minor trauma and extracutaneous manifestations. There have been no reports of cardiac surgery and prognostication in patients with epidermolysis bullosa due to skin and mucosal fragility. CASE PRESENTATION A 55-year-old man presented with congenital junctional epidermolysis bullosa, hypertension, and vasospastic angina. He complained of dyspnea on exertion, and transthoracic echocardiography revealed severe aortic valve regurgitation, moderate aortic valve stenosis (tricuspid valve), and severe mitral valve regurgitation. Considering that the skin condition in the right chest wall was relatively healthy, the right thoracotomy approach was preferred and totally endoscopic concomitant mitral valve repair and aortic valve replacement were performed using a sutureless bioprosthetic valve (Perceval™ (Corcym, Group, Milan, Italy)). Polyurethane and silicon dressing foams were used to protect the skin at the site of contact with the bag valve mask, arterial pressure catheter, intravenous catheter, and the tracheal intubation tube. Vertical mattress sutures were used for the skin sutures. The postoperative course was uneventful, and the patient was discharged nine days after the operation. There was no indication for reoperation until three years follow-up period. CONCLUSIONS The totally endoscopic concomitant aortic and mitral valve surgery using Perceval™ prosthesis can be performed safely in patients with junctional epidermolysis bullosa by adequate protection of the skin and mucosa.
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Affiliation(s)
- Kazufumi Yoshida
- Department of Cardiovascular Surgery, Kobe City Medical Center General Hospital, 2-1-1 Minatojimaminamimachi, Chuo-ku, Kobe, 650-0047, Japan.
| | - Soshi Yoshida
- Department of Cardiovascular Surgery, Kobe City Medical Center General Hospital, 2-1-1 Minatojimaminamimachi, Chuo-ku, Kobe, 650-0047, Japan
| | - Yoshimasa Hori
- Department of Cardiovascular Surgery, Kobe City Medical Center General Hospital, 2-1-1 Minatojimaminamimachi, Chuo-ku, Kobe, 650-0047, Japan
| | - Hideki Tsubota
- Department of Cardiovascular Surgery, Kobe City Medical Center General Hospital, 2-1-1 Minatojimaminamimachi, Chuo-ku, Kobe, 650-0047, Japan
| | - Ryosuke Mochizuki
- Department of Dermatology, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Tohru Nagano
- Department of Dermatology, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Tadaaki Koyama
- Department of Cardiovascular Surgery, Kobe City Medical Center General Hospital, 2-1-1 Minatojimaminamimachi, Chuo-ku, Kobe, 650-0047, Japan
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Tabor A, LeQuang JAK, Pergolizzi J. Epidermolysis Bullosa: Practical Clinical Tips From the Field. Cureus 2024; 16:e53774. [PMID: 38465068 PMCID: PMC10921121 DOI: 10.7759/cureus.53774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Accepted: 02/05/2024] [Indexed: 03/12/2024] Open
Abstract
Epidermolysis bullosa (EB) is a rare genetic condition characterized by fragile skin caused by impaired adhesion between the dermis and epidermis. EB is present at or near birth. There is no cure and treatments are supportive. Children with EB are at elevated risk of squamous cell cancer. Under ideal circumstances, EB patients benefit from interdisciplinary care teams who can offer state-of-the-art treatments. In reality and particularly in less-developed nations, care can be limited. In all cases, families dealing with a member with EB face great challenges in caregiving, much of which is managed at home, and incur great financial expenses for dressings, equipment, transportation, and out-of-pocket expenses. While research groups are working to find a cure for EB, clinicians working with EB patients around the world have found practical and relatively inexpensive tips to make life easier for people with EB. NoBabyBlisters.org, a nonprofit organization actively supplying monthly medical supplies for EB children on five continents and working on EB research, has innovated, developed, collected, and now offers here seven such practical and actionable items learned from its experience in the real world assisting children in less-developed nations, typically with hot climates. These are based on real-world clinical experience dealing with a complex disorder under challenging circumstances. The goal of this short paper is to provide advice to EB caregivers and their loved ones that may make things easier and enhance quality of life, including blister and pain reduction.
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Affiliation(s)
- Aaron Tabor
- Research, No Baby Blisters, Colorado Springs, USA
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Torres Pradilla M, Álvarez E, Novoa M, Lozano I, Trujillo M. Oleogel-S10 in Dystrophic Epidermolysis Bullosa: A Case Series Evaluating the Impact on Wound Burden Over Two Years. Adv Ther 2024; 41:867-877. [PMID: 38170434 PMCID: PMC10838820 DOI: 10.1007/s12325-023-02749-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 11/23/2023] [Indexed: 01/05/2024]
Abstract
Epidermolysis bullosa (EB) is a group of rare, difficult-to-treat, inherited multisystem diseases affecting epithelial integrity. Impaired wound healing is central and can lead to serious clinical complications, deformities, and symptoms with a devastating impact on quality of life (QoL). Dressing changes and wound care are central to the management of EB. Recently Oleogel-S10 (also known as birch bark extract or birch triterpenes) was approved in Europe and the UK for treating EB wounds. This approval was based on data from the EASE phase 3 study, which demonstrated Oleogel-S10 accelerated wound healing, reduced total wound burden, and decreased the frequency of dressing changes in patients with EB. A retrospective analysis of medical records was conducted for up to 24 months in 13 patients with EB treated with Oleogel-S10 through an early access programme in Colombia. Effectiveness was assessed by measuring body surface area percentage (BSAP) and total body wound burden (EBDASI). Tolerability and safety were monitored throughout. This is the first report to evaluate the effectiveness of Oleogel-S10 in clinical practice. The results showed a reduction in percentage of BSA affected, from a mean of 27.3% at baseline to 10.4% at 24-month follow-up, despite treatment interruptions. A reduction in EBDASI skin activity score of - 16.2 (24 months) together with a reduced skin damage index score of - 15.4 (18 months) was also observed. Physicians, patients, and caregivers perceived faster wound closure. Adherence with therapy by patients was good, and patients expressed satisfaction with treatment and reported improvements in self-esteem, productivity, and social interaction. Oleogel-S10 was well tolerated; however, two patients reported worsening wounds related to gauze adherence. Two deaths during treatment interruption were reported and was not considered related to Oleogel-S10. This study supports the effectiveness of Oleogel-S10 in a real-world scenario in a country with scarce resources for the treatment of EB.
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Affiliation(s)
- Mauricio Torres Pradilla
- Fundación Universitaria de Ciencias de la Salud and Hospital Infantil de San José, Bogotá, Colombia.
| | - Erick Álvarez
- Universidad De Cartagena, Hospital Infantil Napoleón Franco Pareja, Cartagena, Colombia
| | - Mónica Novoa
- Fundación Universitaria de Ciencias de la Salud and Hospital Infantil de San José, Bogotá, Colombia
| | - Ivonne Lozano
- Fundación Hospital Pediátrico de la Misericordia, Bogotá, Colombia
| | - Maribel Trujillo
- Fundación Hospital Pediátrico de la Misericordia, Bogotá, Colombia
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Wu R, Li X, Guo J, Mu Q. Pseudosyndactyly and musculoskeletal contractures caused by epidermolysis bullosa in a young man: A challenge for dermatologists and surgeons. Asian J Surg 2023; 46:3839-3840. [PMID: 37031085 DOI: 10.1016/j.asjsur.2023.03.130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 03/21/2023] [Indexed: 04/10/2023] Open
Affiliation(s)
- Rina Wu
- Department of Dermatology, International Mongolian Hospital of Inner Mongolia, Hohhot, 010020, China
| | - Xu Li
- Department of Dermatology, The First Hospital of Hohhot, Hohhot, 010030, China; Department of Allergy, The First Hospital of Hohhot, Hohhot, 010030, China
| | - Jingxue Guo
- Inner Mongolia Medical University, Hohhot, 010110, China
| | - Qiri Mu
- Department of Dermatology, International Mongolian Hospital of Inner Mongolia, Hohhot, 010020, China.
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Ball K, Camilleri S, Kiefel S, Schulz I, Weston L, Sacks B. Epidermolysis Bullosa in Pediatric Palliative Care: A Case Series. J Palliat Med 2023; 26:1159-1164. [PMID: 36888536 DOI: 10.1089/jpm.2022.0559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023] Open
Abstract
Background: Epidermolysis bullosa (EB) comprises a group of rare genetic conditions that are characterized by fragility of the skin and mucous membranes and formation of blisters with minor trauma. Severe forms can be life limiting. The palliative care needs of children with severe EB are poorly described. Aim: The aim of this case series was to examine the contribution of a pediatric palliative care service to the complex health care needs of children with severe EB. Methods: We present a case series of five children with severe forms of EB who were known to the state-wide Victorian Paediatric Palliative Care Service, with a discussion of our learnings in caring for these children and their families. Results: Medical treatment decision making in EB provokes complex ethical, psychological, personal, and professional dilemmas. This case series highlights the diversity of management approaches that may be considered, each tailored to the unique context of the child and family.
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Affiliation(s)
- Kirsten Ball
- Department of Pediatrics, The Women's and Children's Hospital, South Australia, Australia
| | - Sonya Camilleri
- Department of Paediatric Palliative Care, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Simone Kiefel
- Department of Paediatric Palliative Care, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Ingrid Schulz
- Department of Paediatric Palliative Care, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Lauren Weston
- Department of Dermatology, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Bronwyn Sacks
- Department of Paediatric Palliative Care, The Royal Children's Hospital, Melbourne, Victoria, Australia
- Murdoch Children's Research Institute, Monash Health, Parkville, Victoria, Australia
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