Cutaneous Disorders Masking Celiac Disease: Case Report and Mini Review with Proposal for a Practical Clinical Approach

Celiac disease (CD) is an immune-mediated systemic gluten-related disorder characterized by a wide spectrum of intestinal and extra-intestinal manifestations, including damage to cutaneous and connective tissue. We report a rare case of chronic severe dermatitis involving connective tissue and cutaneous vascular vessels as the main clinical presentation of undiagnosed seronegative gluten disorder. A gluten-free diet dramatically improved the intestinal and cutaneous clinical damage in the patient. Pitfalls and the steps of differential diagnosis are described. We also review the literature regarding studies of CD and connective tissue diseases to extend the knowledge of these rare associations. We propose a practical diagnostic approach in suspected CD in autoimmune cutaneous disorders.

Skin manifestations help identifying different phenotypes of paediatric SAPHO syndrome

OBJECTIVES

to evaluate whether the heterogeneous skin manifestations might influence the disease presentation and outcome of a cohort of SAPHO children.

METHODS

the clinical, serological, imaging and therapeutic data of 14 SAPHO patients, followed between 2001 and 2022 at the Unit for Autoinflammatory diseases at the Gaslini Hospital, were reviewed. According to their cutaneous manifestations, patients were divided into 2 groups: the acne-hidradenitis suppurativa (HS) and the Palmo-Plantar Pustulosis (PPP) group. Data were retrieved from the Eurofever database.

RESULTS

all patients presented bone involvement characterized by Chronic Recurrent multifocal Osteomyelitis (CRMO): 8 patients presented acne-HS while 6 patients had PPP. In the PPP group, all patients were female, characterized by a prepuberal disease onset with osteoarticular manifestations, followed by the appearance of PPP in the following 6 months. This group responded well to the treatments. In the acne-HS group, 7/8 patients were male: the disease onset was characterized by skin manifestations in pubertal age, followed by osteoarticular manifestations in the following year. This group presented a severe refractory skin disease that required in most cases the addition of biological therapies. A literature review confirmed our data highlighting the association males-acne-puberal age and female-PPP-prepuberal age.

CONCLUSION

paediatric SAPHO patients should be mainly stratified according to their skin involvement. In fact, our data suggest that two different skin phenotypes may be identified in SAPHO: the first is constituted by prepuberal females with PPP and a prevalent osteoarticular involvement, while the second by puberal males with a difficult-to-treat acne-HS.

Corticophobia among Parents of Children with Atopic Dermatitis: Assessing Major and Minor Risk Factors for High TOPICOP Scores

Corticophobia, fear of applying topical corticosteroids (TCSs), is a rising issue in industrialized countries, despite the actual safety of TCSs for atopic dermatitis (AD). Patients attending the Pediatric Dermatology Unit for skin examination were screened for AD. AD patients were included, and data were collected. Parental corticophobia was evaluated through the Topical Corticosteroid Phobia (TOPICOP) questionnaire. The χ2 test and logistic regression were used to analyze statistical associations between parental corticophobia (mild/moderate vs. severe) and patients' and parents' characteristics. Overall, 100 patients were included (53 females; 47 males; mean age 5.9 years): 44 had mild/moderate AD (EASI ≤ 21), and 56 had severe AD (EASI > 21) (mean EASI 19.7). Of the patients, 33 never consulted healthcare providers for AD, and 67 did. Parental education was low/intermediate in 60 cases and high (gymnasium/university degree) in 40. Mean parental DLQI was 10.7. Mean parental TOPICOP was 39.1%: 51 had mild/moderate corticophobia (TOPICOP ≤ 50%), and 49 had severe corticophobia (TOPICOP > 50%). At the χ2 test, corticophobia was associated with mild/moderate AD (OR 20.9487; 95% CI 7.2489-60.5402; p < 0.001), older age of patients (OR 4.1176; 95% CI 1.7880 to 9.4828; p < 0.001), early disease onset (OR 9.8925; 95% CI 2.7064-36.1596; p < 0.001), and previous healthcare professional consultations (OR 4.9279; 95% CI 1.9335-12.5597; p < 0.001). Also, severe parental corticophobia was very significantly associated with severe parental involvement of life quality (OR 33.3333; 95% CI 10.9046-101.8937; p < 0.001) and with high education of parents (gymnasium or university degree) (29/49) (OR 5.2727; 95% CI 2.1927-12.6790; p < 0.001). At logistic regression, high parental DLQI (p < 0.0001), high parental education (p < 0.0338), older age of patients (p = 0.0015), and early disease onset (p < 0.0513) accounted for major risk factors influencing severe parental corticophobia. Assessing risk factors for corticophobia is essential for addressing groups of parents at higher risk for corticophobia using educational programs, to overcome unfounded fears and augment treatment adherence.

Pediatric spitzoid lesions of the ear: a single-center experience and review of the literature

Spitzoid lesions are challenging melanocytic lesions comprising benign, intermediate, and malignant lesions. In this study, we aimed to analyze the diagnostic accuracy of clinical and dermatoscopical evaluations of pediatric spitzoid ear lesions. We collected and analyzed, clinically, dermatoscopically, and histologically, pediatric spitzoid ear lesions. We also conducted a systematic review of the literature. At the Pediatric Hospital Gaslini, excision and histopathological evaluation were performed on eight cases: 87.5% of the lesions were consistent with Spitz nevus (SN), and 12.5% with atypical Spitz tumor (AST). Notably, multiple (≥2) dermatoscopical irregularities were present in 5 of 7 SN (71%), yet none were found in AST (0%, 0/1) (Fisher's exact test, P=0.375). From systematic research in the literature, 9 patients were included in this review. At histology, 88.9% were SN and 11% AST. Remarkably, also in the literature, multiple dermatoscopical irregularities were present in most SN (75%, 6/8), but not in the identified AST (0%, 0/1) (P=0.3333). We present a monocentric study on pediatric spitzoid ear lesions. Importantly, dermatoscopical irregularities were not significantly associated with AST, neither in our series nor in the reviewed literature (respectively P=0.375 and P=0.3333), supporting the fact that relying only on the dermatoscopical aspect of spitzoid lesions is not accurate enough for the special site of the ear, where dermatoscopy could actually be misleading.

Childhood vitiligo developing after COVID-19 infection

Both COVID-19 and vaccinations against it have been related to immune cutaneous manifestations. Here, we present a case of childhood vitiligo, developed after a COVID-19 infection.

Facial pruritic skin rash in a Nigerian boy with atopic dermatitis

We present the case of a 4-year-old boy with annular, pruritic macules on the face who did not respond to the application of topical immunosuppressive therapy for atopic dermatitis. In this case report, we emphasize how pruritic annular macules that are not responsive to immunosuppressants should always be suspected of being tinea incognita.

Paediatric Spitzoid Neoplasms: 10-Year Retrospective Study Characterizing Histological, Clinical, Dermoscopic Presentation and FISH Test Results

INTRODUCTION

Spitzoid lesions are a wide tumour class comprising Spitz nevus (SN), atypical Spitz tumour (AST) and Spitz melanoma (SM).

MATERIALS AND METHODS

We conducted a single-centre-based retrospective survey on all histologically diagnosed spitzoid lesions of paediatric patients (1-18 years) of the last 10 years (2012-2022). Histopathological reports and electronic records of patients were used to retrieve relevant data regarding patients' features, clinical and dermatoscopical aspects of lesions when recorded, and FISH tests when present.

RESULTS

Of 255 lesions, 82% were histologically benign, 17% atypical, 1% malignant. Clinically, 100% of SM were large (≥6 mm) and raised; AST were mainly large (63%), raised (98%), pink (95%). Small (≤5 mm), pigmented, flat lesions correlated with benign histology (respectively 90%, 97%, 98% SN) (p < 0.0001). Dermatoscopical patterns were analysed in 100 patients: starburst pattern correlated with benign histology (26% SN (p = 0.004)), while multicomponent pattern correlated with atypical/malignant lesions (56% AST, 50% SM (p = 0.0052)). Eighty-five lesions were subjected to fluorescence in situ hybridization (FISH): 34 (71% AST; 29% SN) were FISH-positive; 51 (63% SN; 37% AST) were FISH-negative (p = 0.0038).

DISCUSSION

This study confirmed predominant benign histology (82%) of paediatric spitzoid lesions, thus detecting 17% AST and 1% SM, highlighting the need for caution in handling spitzoid lesions.

CONCLUSION

Until AST are considered potentially malignant proliferations and no reliable criteria are identified to distinguish them, the authors suggest a prudent approach, especially in children.

Treatment of Pediatric Anogenital Warts in the Era of HPV-Vaccine: A Literature Review

Anogenital warts (AWs) represent a therapeutic challenge, especially in infants, due to sensitive skin and frequent disease recurrence. Though the initial wait-and-see approach is often adopted in asymptomatic immunocompetent children, with spontaneous clearing in almost 90% of cases within two years, persistent or symptomatic lesions can be reasonably treated. However, few studies have been conducted on children. Consequently, most treatments on patients under age 12 are not approved by the Food and Drug Administration. Herein, we review possible therapies for pediatric use in AW and report an illustrative case of a two-year-old boy with atopic skin and symptomatic, persistent AWs who was successfully treated with topical podophyllotoxin, without adverse effects or recurrence. Among available therapies for AWs, topical therapies, such as immunomodulating-agents (topical imiquimod 5% and 3.75% cream, sinecatechins 15% ointment) and cytotoxic agents (podophyllotoxin and cidofovir) are considered manageable in children because of their low aggressiveness. In particular, podofillotoxin gel 5% and imiquimod 5% cream have been reported to be safe and efficacious in children. Currently, HPV vaccination is not recommended as a treatment for established HPV infection and AWs, yet a possible therapeutic role of HPV vaccination was recently suggested in the literature and deserves mention.

Disseminated life-threatening viral skin rash in a child with atopic dermatitis

We report the case of a toddler, with a history of mild atopic dermatitis (AD) since early infancy, presented to the Giannina Gaslini, a pediatric polyclinic hospital, 14 days after measles-mumps-rubella (MMR) vaccination, for the occurrence of a disseminated vesico-pustular rash, accompanied by general malaise, fever, restlessness, and anorexia. Eczema herpeticum (EH) was diagnosed clinically and confirmed by laboratory examinations. The exact pathogenesis of EH in AD is still debated and possibly involves an inter-play between altered cell-mediated and humoral immunity, failure to up-regulate antiviral proteins, and exposure of viral binding sites through the dermatitis and an epidermal barrier failure. We hypothesize that in this particular case, MMR vaccination might have played an additional important role in the alteration of innate immune response, facilitating the manifestation of herpes simplex virus type 1 in the form of EH.

POS1305 PEDIATRIC SAPHO SYNDROME: SINGLE ENTITY OR COMBINATION OF DIFFERENT DISEASES?

Background

SAPHO is a heterogeneous autoinflammatory disease, characterized by bone and joint involvement and by a wide variety of dermatologic manifestations, including palmo-plantar pustulosis (PPP), acne, hidradenitis suppurativa (HS), pyoderma gangrenosum (PG), psoriasis, Snedd-Wilkinson disease and Sweet syndrome. In children, the osteo-articular manifestations are characterized by chronic recurrent multifocal osteomyelitis (CRMO), involving the metaepiphysis of the long bones and the axial skeleton, as in the adult form. The SAPHO treatment still today is a challenge, and no therapeutic guidelines are available in children: NSAIDs are frequently used as first line treatment for CRMO lesions, followed by bisphosphonates, methotrexate and biologic therapies. In the literature there are many case reports but only a few case series1-3, of which this is the largest in Europe (29 cases reported in China4).

Objectives

to report the clinical and radiological features and the response to therapy of SAPHO children.

Methods

the clinical data (serological, imaging and therapy) of 13 SAPHO patients, followed between 2001 and 2021 at the Unit for Autoinflammatory diseases at the Gaslini Hospital were reviewed.

Results

7/13 patients were male. At disease onset, acne-HS was present as the only manifestation in 8/13 patients while PPP was concomitant or subsequent to bone manifestations. The skin involvement was characterised by acne (comedonic in 3 cases, nodulo-cystic in 4 cases), PPP (5), HS (3), PG (1). Multifocal inflammatory bone lesions with axial or long bone involvement were both present in 92% of patients, whereas sternoclavicolar involvement was observed in 85% of patients.

At disease onset all patients were treated with NSAIDS but only 4, with also PPP, achieved remission. In 7/13 patients, Methotrexate or salazopirin were used, and in 2/13 with severe painful bone lesions bisphosphonates were successfully employed. In the 5 PPP patients, the cutaneous involvement was mild and did not need treatment. In 9/13 patients, the skin manifestations required a therapeutic upgrade with biologics: Etanercept in 5 with partial result, Adalimumab in 6 had an optimal response, in 1 a partial response, even if requiring an increased dose (80 mg per week) and 1 was swapped to dapsone. Anakinra (3), ustekinumab and secukinumab (2) were not efficacious. It is to note that the 3 patients with comedonic acne were refractory to all treatments and needed multiple therapy cycling to achieve a partial remission only.

Conclusion

Our patients were characterised by well known SAPHO clinical manifestations. Despite the optimal therapeutic response of CRMO, comedonic acne was refractory to any treatment while PPP and nodulo-cystic acne achieved remission. This may suggest that the skin involvement in SAPHO may identify clinical phenotypes with a different response to treatments.

References

[1]Luzzati M, Ital J Pediatr. 2020;46(1):169.

[2]Tlougan BE, Pediatr Dermatol. 2009;26(5):497

[3]Beretta-Piccoli BC, Eur J Pediatr. 2000;159(8):594

[4]Wu N, Clin Rheumatol. 2021;40(4):1487

Disclosure of Interests

Caterina Matucci-Cerinic: None declared, Gianmaria Viglizzo: None declared, Roberta Caorsi Speakers bureau: Sobi, Consultant of: Novartis, Eli Lilly, Stefano Volpi: None declared, Clara Malattia: None declared, Marco Gattorno Speakers bureau: Novartis, SOBI

Genotype-Phenotype Correlations in Neurofibromatosis Type 1: A Single-Center Cohort Study

Simple Summary

Neurofibromatosis type 1 (NF1) is a complex disorder characterized by a multisystem involvement and cancer predisposition. It is caused by genetic variants in NF1, a large tumor suppressor gene encoding a cytoplasmatic protein (neurofibromin) with a regulatory role in essential cellular processes. Genotype–phenotype correlations in NF1 patients are so far elusive. We retrospectively reviewed clinical, radiological, and genetic data of 583 individuals with at least 1 National Institutes of Health (NIH) criterion for NF1 diagnosis, including 365 subjects fulfilling criteria for the diagnosis. Novel genotype–phenotype correlations were identified through uni- and multivariate statistical analysis. Missense variants negatively correlated with neurofibromas. Skeletal abnormalities were associated with frameshift variants and whole gene deletions. The c.3721C>T; p.(R1241*) variant positively correlated with structural brain alterations, whereas the c.6855C>A; p.(Y2285*) variant was associated with a higher prevalence of Lisch nodules and endocrinological disorders. These novel NF1 genotype–phenotype correlations may have a relevant role in the implementation of patients’ care.

Abstract

Neurofibromatosis type 1 (NF1) is a proteiform genetic condition caused by pathogenic variants in NF1 and characterized by a heterogeneous phenotypic presentation. Relevant genotype–phenotype correlations have recently emerged, but only few pertinent studies are available. We retrospectively reviewed clinical, instrumental, and genetic data from a cohort of 583 individuals meeting at least 1 diagnostic National Institutes of Health (NIH) criterion for NF1. Of these, 365 subjects fulfilled ≥2 NIH criteria, including 235 pediatric patients. Genetic testing was performed through cDNA-based sequencing, Next Generation Sequencing (NGS), and Multiplex Ligation-dependent Probe Amplification (MLPA). Uni- and multivariate statistical analysis was used to investigate genotype–phenotype correlations. Among patients fulfilling ≥ 2 NIH criteria, causative single nucleotide variants (SNVs) and copy number variations (CNVs) were detected in 267/365 (73.2%) and 20/365 (5.5%) cases. Missense variants negatively correlated with neurofibromas (p = 0.005). Skeletal abnormalities were associated with whole gene deletions (p = 0.05) and frameshift variants (p = 0.006). The c.3721C>T; p.(R1241*) variant positively correlated with structural brain alterations (p = 0.031), whereas Lisch nodules (p = 0.05) and endocrinological disorders (p = 0.043) were associated with the c.6855C>A; p.(Y2285*) variant. We identified novel NF1 genotype–phenotype correlations and provided an overview of known associations, supporting their potential relevance in the implementation of patient management.

Medulloblastoma variants: age-dependent occurrence and relation to Gorlin syndrome--a new clinical perspective

PURPOSE

We aimed to test the hypothesis that medulloblastoma (MB) variants show a different age distribution and clinical behavior reflecting their specific biology, and that MB occurring at very young age is associated with cancer predisposition syndromes such as Gorlin syndrome (GS).

EXPERIMENTAL DESIGN

We investigated the frequency, age distribution, location, response to treatment, outcome, and association with familial cancer predisposition syndromes in a series of 82 cases of MB in patients ages <14 years diagnosed at the Giannina Gaslini Children's Hospital, Genoa, between 1987 and 2004.

RESULTS

Desmoplastic MB and MB with extensive nodularity (MBEN), were present in 22 of 82 cases (27%) and were more frequent in children ages <or=3 years (13 of 25; 52%). In this age group, MBEN was significantly more frequent than desmoplastic MB and classic MB (P < 0.001) and had a good prognosis. MBEN was associated with GS in 5 of 12 cases. Overall, 8 cases occurred in the context of familial tumor predisposition syndromes (5 GS, 1 each NF1, Li-Fraumeni, and Fragile X) and 7 of these patients were ages <or=3 years at diagnosis. Desmoplastic histology and a more intensive treatment represented independent favorable prognostic factors in multivariate analysis (P = 0.003 and P = 0.0139, respectively). Metastasis was a predictor of bad outcome (P = 0.0001).

CONCLUSIONS

Our data indicate that biologically different MB entities warrant risk-adapted treatment and that MBEN is strongly associated with GS. Patients, ages <or=3 years, with MB and their families should be investigated for tumor predisposition syndromes such as GS.

A unique case of multiple dermatomyofibromas

We report on a case of multiple dermatomyofibromas on the posterior neck of a 10-year-old boy. Dermatomyofibroma is a benign proliferation of myofibroblasts of the skin. It is more common in adolescents and young adults, with a female preponderance. It usually appears as a single plaque or nodule. To our knowledge, this is the first case of multiple dermatomyofibromas reported in the literature.

A case of linear IgA disease in a child with IgA and IgG circulating antibodies directed to BPAg2

A 7-year-old Caucasian girl had multiple bullae on the trunk, upper and lower limbs (Fig. 1a,b) for 10 days. The lesions were large, tense, and asymptomatic, and mucosae were not involved. Laboratory findings were all normal. Histopathology revealed a subepidermal blister containing numerous neutrophils, eosinophils, and fibrin. Direct immunofluorescence of perilesional skin disclosed linear deposition of IgA and slight linear deposits of IgM at the basement membrane zone (Fig. 2). Indirect immunofluorescence on monkey esophagus and on human salt-split skin was negative. Immunoblot assay (IB), performed with an epidermal extract, revealed IgA and IgG antibodies directed to BPAg2 antigen (Fig. 3), while it was negative when performed on dermal extract. Enzyme-linked immunosorbent serologic assay using a commercial kit (MBL, Naka-Ku Nagoya, Japan) with the noncollagenous domain (NC16A) of the BPAg2 antigen was negative for both IgA and IgG. A diagnosis of linear IgA disease (LAD) was made and a treatment with dapsone (50 mg/day) and prednisolone (30 mg/day) was initiated. One month later, lesions had cleared.

Familial Lassueur-Graham-Little-Piccardi Syndrome

Lassueur-Graham-Little-Piccardi syndrome (LGLPS) is a rare lichenoid dermatosis characterized by progressive cicatricial alopecia of the scalp, loss of pubic and axillary hairs and keratosis pilaris. The syndrome is considered a form of follicular lichen planus (LP). Although the familial occurrence of LP is a well-described phenomenon, no familial case of LGLPS has ever been reported. We describe the occurrence of LGLPS in a mother and her daughter. HLA typing revealed HLA-DR1 in both patients. Topical tacrolimus was of partial benefit in the daughter.