Cutis Laxa and the Value of Rhytidectomy: 4 Patients and Years of Follow-Up

The modalities of the esthetic treatment of cutis laxa (CL) patients have rarely been discussed. Here, the authors present 4 CL rhytidectomy cases. The surgery method was designed based on the traditional full-incision face-lift technique combined with lamellar superficial musculoaponeurotic system flap elevation and plication. Temporal, buccal, mandibular, and cervical regions were targeted. The shortest follow-up was 30 months, and the longest was 72. The results were assessed by subjective satisfaction and third-party photo evaluation. The subjective satisfaction was graded into worse than preoperation, no improvement, slight improvement, moderate improvement, and obvious improvement. The satisfaction rate was the sum of moderate and obvious improvement. Eighteen uncorrelated professionals participated in the third-party photo evaluation, in which the preoperative and follow-up photos were presented, and frontal, temporal, mid-face (including jowl), and cervical (including mandibular line) regions were evaluated as improved or nonimproved. The outcome of the subjective satisfaction was graded as no improvement (2/12, 16.7%), slight improvement (3/12, 25%), moderate improvement (4/12, 33.3%), and obvious improvement (3/12, 25%). The satisfaction rate was 58.3%, most investigators denied the frontal and temporal region improvement, 60% observed mid-face improvement, and 80% noticed cervical improvement. Most patients and their parents had positive attitudes towards the treatment results; however, the full expectation was not achieved. The cervical region maintained the best improvement after our treatment and the mid-face ranked second. This surgery method conduces to the esthetic requirement of CL patients; however, skin laxity remains a challenge.

Bi-allelic premature truncating variants in LTBP1 cause cutis laxa syndrome

Latent transforming growth factor β (TGFβ)-binding proteins (LTBPs) are microfibril-associated proteins essential for anchoring TGFβ in the extracellular matrix (ECM) as well as for correct assembly of ECM components. Variants in LTBP2, LTBP3, and LTBP4 have been identified in several autosomal recessive Mendelian disorders with skeletal abnormalities with or without impaired development of elastin-rich tissues. Thus far, the human phenotype associated with LTBP1 deficiency has remained enigmatic. In this study, we report homozygous premature truncating LTBP1 variants in eight affected individuals from four unrelated consanguineous families. Affected individuals present with connective tissue features (cutis laxa and inguinal hernia), craniofacial dysmorphology, variable heart defects, and prominent skeletal features (craniosynostosis, short stature, brachydactyly, and syndactyly). In vitro studies on proband-derived dermal fibroblasts indicate distinct molecular mechanisms depending on the position of the variant in LTBP1. C-terminal variants lead to an altered LTBP1 loosely anchored in the microfibrillar network and cause increased ECM deposition in cultured fibroblasts associated with excessive TGFβ growth factor activation and signaling. In contrast, N-terminal truncation results in a loss of LTBP1 that does not alter TGFβ levels or ECM assembly. In vivo validation with two independent zebrafish lines carrying mutations in ltbp1 induce abnormal collagen fibrillogenesis in skin and intervertebral ligaments and ectopic bone formation on the vertebrae. In addition, one of the mutant zebrafish lines shows voluminous and hypo-mineralized vertebrae. Overall, our findings in humans and zebrafish show that LTBP1 function is crucial for skin and bone ECM assembly and homeostasis.

Effect of the R119G mutation on human P5CR structure and its interactions with NAD: Insights derived from molecular dynamics simulation and free energy analysis

Pyrroline-5-carboxylate reductase (P5CR), an enzyme with conserved housekeeping roles, is involved in the etiology of cutis laxa. While previous work has shown that the R119G point mutation in the P5CR protein is involved, the structural mechanism behind the pathology remains to be elucidated. In order to probe the role of the R119G mutation in cutis laxa, we performed molecular dynamics (MD) simulations, essential dynamics (ED) analysis, and Molecular mechanics Poisson-Boltzmann surface area (MM-PBSA) binding free energy calculations on wild type (WT) and mutant P5CR-NAD complex. These MD simulations and ED analyses suggest that the R119G mutation decreases the flexibility of P5CR, specifically in the substrate binding pocket, which could decrease the kinetics of the cofactor entrance and egress. Furthermore, the MM-PBSA calculations suggest the R119G mutant has a lower cofactor binding affinity for NAD than WT. Our study provides insight into the possible role of the R119G mutation during interactions between P5CR and NAD, thus bettering our understanding of how the mutation promotes cutis laxa.

Metabolic cutis laxa syndromes

Cutis laxa is a rare skin disorder characterized by wrinkled, redundant, inelastic and sagging skin due to defective synthesis of elastic fibers and other proteins of the extracellular matrix. Wrinkled, inelastic skin occurs in many cases as an acquired condition. Syndromic forms of cutis laxa, however, are caused by diverse genetic defects, mostly coding for structural extracellular matrix proteins. Surprisingly a number of metabolic disorders have been also found to be associated with inherited cutis laxa. Menkes disease was the first metabolic disease reported with old-looking, wrinkled skin. Cutis laxa has recently been found in patients with abnormal glycosylation. The discovery of the COG7 defect in patients with wrinkled, inelastic skin was the first genetic link with the Congenital Disorders of Glycosylation (CDG). Since then several inborn errors of metabolism with cutis laxa have been described with variable severity. These include P5CS, ATP6V0A2-CDG and PYCR1 defects. In spite of the evolving number of cutis laxa-related diseases a large part of the cases remain genetically unsolved. In metabolic cutis laxa syndromes the clinical and laboratory features might partially overlap, however there are some distinct, discriminative features. In this review on metabolic diseases causing cutis laxa we offer a practical approach for the differential diagnosis of metabolic cutis laxa syndromes.

Cutis laxa: a case report and an update

Very few cases of Cutis Laxa are reported worldwide. This is the first case report of its kind from Bangladesh. A 10 year-old girl looking very aged was admitted in the paediatric ward of Dhaka Medical College with most striking skin feature. There was loosely hanging skin over the face which was inelastic, hyper extensible and which recoils slowly after stretching. She had downward slanting palpebral fissures, periorbital oedema, a broad flat nose with everted nostril, sagging cheeks, and large and soft ears. Skin biopsy showed fragmentation of the elastic tissue with collagen tissue in the dermis, which was suggestive of Cutis Laxa. Her chest x-ray showed hypertranslucent lung fields, prominence of pulmonary conus area and some ring like opacity near the lower zone with cardiomegaly, which is suggestive of corpulmonale with bronchiectasis. Her echocardiography showed dilated right atrium, ventricle and pulmonary artery which were suggestive of corpulmonale. All these confirmed the diagnosis.

Mutations in PYCR1 cause cutis laxa with progeroid features

Autosomal recessive cutis laxa (ARCL) describes a group of syndromal disorders that are often associated with a progeroid appearance, lax and wrinkled skin, osteopenia and mental retardation. Homozygosity mapping in several kindreds with ARCL identified a candidate region on chromosome 17q25. By high-throughput sequencing of the entire candidate region, we detected disease-causing mutations in the gene PYCR1. We found that the gene product, an enzyme involved in proline metabolism, localizes to mitochondria. Altered mitochondrial morphology, membrane potential and increased apoptosis rate upon oxidative stress were evident in fibroblasts from affected individuals. Knockdown of the orthologous genes in Xenopus and zebrafish led to epidermal hypoplasia and blistering that was accompanied by a massive increase of apoptosis. Our findings link mutations in PYCR1 to altered mitochondrial function and progeroid changes in connective tissues.

Acquired cutis laxa following urticarial vasculitis associated with IgA myeloma

Cutis laxa (CL) is an inherited or acquired connective tissue disorder characterized clinically by loosely hanging skin folds. There is often preceding cutaneous inflammatory eruption (ie, urticaria, eczema, erythema multiforme), and there is frequently internal organ involvement of the gastrointestinal, urogenital, pulmonary, and cardiovascular systems. Histologically, there are degenerative changes in the dermal elastic fibers. Of the few reports on this rare disorder, authors have speculated about an immune-mediated destruction of elastic fibers, and monoclonal gammopathies, such as multiple myeloma or heavy chain deposition disease, have a recognized association with CL. We report an unusual case of rapidly progressing acquired CL associated with leukocytoclastic vasculitis, IgA myeloma, and an immune complex-mediated glomerulonephritis. Light microscopy of the lax skin revealed complete absence of elastic fibers in areas of vasculitis.

Functional rescue of elastin insufficiency in mice by the human elastin gene: implications for mouse models of human disease

Diseases linked to the elastin gene arise from loss-of-function mutations leading to protein insufficiency (supravalvular aortic stenosis) or from missense mutations that alter the properties of the elastin protein (dominant cutis laxa). Modeling these diseases in mice is problematic because of structural differences between the human and mouse genes. To address this problem, we developed a humanized elastin mouse with elastin production being controlled by the human elastin gene in a bacterial artificial chromosome. The temporal and spatial expression pattern of the human transgene mirrors the endogenous murine gene, and the human gene accurately recapitulates the alternative-splicing pattern found in humans. Human elastin protein interacts with mouse elastin to form functional elastic fibers and when expressed in the elastin haploinsufficient background reverses the hypertension and cardiovascular changes associated with that phenotype. Elastin from the human transgene also rescues the perinatal lethality associated with the null phenotype. The results of this study confirm that reestablishing normal elastin levels is a logical objective for treating diseases of elastin insufficiency such as supravalvular aortic stenosis. This study also illustrates how differences in gene structure and alternative splicing present unique problems for modeling human diseases in mice.

Plastisch-chirurgische Korrekturen der Körperform – Rekonstruktion und Ästhetik

Body contouring surgery is traditionally part of plastic surgery training. Reconstructive techniques are needed most in trauma cases, tumor reconstructions, treatment of degenerative diseases and metabolic diseases such as Madelung's deformity, body contouring after massive weight loss, and all aesthetic plastic surgery. With various surgical techniques, liposuction became an important option in the overall treatment plan. Body contouring surgery in the massive weight loss patient is a rapidly expanding field of plastic surgery. Its challenge is the management of excess skin remaining after bariatric surgery. To achieve an aesthetic body contour, patients must accept numerous long scars. They must understand that recurrent laxity and scar migration is not necessarily a failure of the operation but rather an expected outcome. Body contouring surgery is challenging, time-consuming, and not without complications. The patient population has very real aesthetic and appearance concerns that must be addressed in an effective, definite, and safe manner.

Collagen dysregulation in the dermis of the Sagg/+ mouse: a loose skin model

The Sagg/+ mouse is an ethylnitrosourea-derived mutant with a dermal phenotype similar to some of the subtypes of Ehlers-Danlos syndrome (EDS) and cutis laxa. The dermis of the Sagg/+ mouse has less dense and more disorganized collagen fibers compared to controls. The size of extracted Type I dermal collagen was the same as that observed in normal skin; however, more collagen could be extracted from Sagg/+ skin, which also showed decreased collagen content and decreased steady-state levels of alpha1(I), alpha2(I), alpha1(V), and alpha2(V) procollagen mRNAs. The biomechanical properties of Sagg/+ skin were significantly decreased relative to normal skin. However, there were no significant differences in the quantities of the major collagen cross-links, that is, dehydrohydroxylysinonorleucine and dehydrohistidinohydroxymerodesmosine between Sagg/+ and normal skin. Electron microscopic evaluation of Sagg/+ skin indicated that the mutation interferes with the proper formation of collagen fibrils and the data are consistent with a mutation in Type V collagen leading to haploinsufficiency with the formation of two sub-populations of collagen fibrils, one normal and one with irregular shape and a larger diameter. Further study of this novel mutation will allow the identification of new mechanisms involved in the regulation of normal and pathologic collagen gene expression.

Cutis laxa in hereditary gelsolin amyloidosis

BACKGROUND

Hereditary gelsolin amyloidosis (AGel amyloidosis) is an age-associated systemic disease with global distribution, caused by a G654A or G654T gelsolin gene mutation. Cutis laxa is a principal clinical manifestation of this disease. However, only few data on the dermatological involvement are available, and the pathogenesis of this amyloidosis-associated form of cutis laxa has remained unknown.

OBJECTIVES

To elucidate the pathomechanism of this less well-known genodermatosis.

METHODS

We performed systematic clinical, histological, immunohistochemical and ultrastructural skin biopsy studies in 12 patients with a G654A gelsolin gene mutation. For comparison, skin specimens from 10 control subjects were analysed.

RESULTS

All patients had clinically characteristic cutis laxa, and frequently other signs of symptomatic skin disease such as increased fragility and risk for intracutaneous bleeding. All patients showed cutaneous deposition of gelsolin amyloid (AGel), mainly attached to basement membranes or basal laminae of various cutaneous structures, dermal nerves and blood vessel walls, and elastic fibres, particularly in the lower reticular dermis. AGel often encircled the elastic fibres, and colocalized with amyloid P component (AP), an elastic fibre microfibrillar sheath-associated protein. Fragmentation and loss of elastic fibres, epidermal atrophy, and reduction of dermal appendages were also common. Antibodies to wild-type gelsolin bound to S-100-positive epidermal dendritic cells, a previously unrecognized immunoreaction. Patients had fewer gelsolin-positive dendritic cells than controls.

CONCLUSIONS

Widespread skin involvement with AGel deposition and elastic fibre involvement are essential pathological features in AGel amyloidosis, and contribute to the characteristic cutis laxa, dramatic in old age. Codistribution of AGel and AP, with demonstrated specific binding affinity for amyloid fibrils, suggests that elastic fibre-associated AP acts as a matrix for cutaneous amyloid deposition in AGel amyloidosis.

[Post-inflammatory cutis laxa. A case report]

Cutis laxa (CL) is a rare disorder in which the skin hangs in loose fields, so that affected individuals appear to be prematurely aged. The changes are more evident when effect the face with a prematurely-aged appearance. The acute form follows an inflammatory skin lesions. Its aetiology is not well known. We report a case of a head acute CL of a 17 years patient, secondary to a generalized skin eruption. The prematurely-aged appearance concern especially forehead, ear lobes and nasolabial folds. A two stages surgical treatment has associated: a forehead lifting associated to a Coleman lipofilling and an ear lobe reduction, a secondary Coleman lipofilling of the nasolabial folds. The skin biopsy confirm the diagnosis. The correction is stable and satisfactory after one year. The confrontation of our findings to those previously described confirm complexity of diagnosis and histological observations of this rare disorder.

Acquired cutis laxa associated with multiple myeloma

Cutis laxa is an uncommon condition characterized by loose and redundant skin. Biopsy results are positive for a reduction in or an absence of elastic fibers in the dermis. Cutis laxa is acquired or congenital. The acquired form is either a generalized insidious form (type I) or a form associated with prior inflammation (type II). Cardiovascular, pulmonary, gastrointestinal, and urologic complications may occur. In the past, cutis laxa was associated with plasma cell dyscrasia. We report on a characteristic cause of cutis laxa to alert clinicians to this uncommon manifestation of multiple myeloma.

Fibulin-5/DANCE is essential for elastogenesis in vivo

The elastic fibre system has a principal role in the structure and function of various types of organs that require elasticity, such as large arteries, lung and skin. Although elastic fibres are known to be composed of microfibril proteins (for example, fibrillins and latent transforming growth factor (TGF)-beta-binding proteins) and polymerized elastin, the mechanism of their assembly and development is not well understood. Here we report that fibulin-5 (also known as DANCE), a recently discovered integrin ligand, is an essential determinant of elastic fibre organization. fibulin-5-/- mice generated by gene targeting exhibit a severely disorganized elastic fibre system throughout the body. fibulin-5-/- mice survive to adulthood, but have a tortuous aorta with loss of compliance, severe emphysema, and loose skin (cutis laxa). These tissues contain fragmented elastin without an increase of elastase activity, indicating defective development of elastic fibres. Fibulin-5 interacts directly with elastic fibres in vitro, and serves as a ligand for cell surface integrins alphavbeta3, alphavbeta5 and alpha9beta1 through its amino-terminal domain. Thus, fibulin-5 may provide anchorage of elastic fibres to cells, thereby acting to stabilize and organize elastic fibres in the skin, lung and vasculature.

Middermal elastolysis in two patients with lupus erythematosus

Despite lupus erythematosus (LE) being considered a "connective tissue disease," little has been written about the elastic fiber changes in the skin of affected patients. We report our histologic findings in two patients with unusual cutaneous lesions. Elastic fiber loss was noted, and scattered giant cells with elastic fiber phagocytosis were prominent in one patient. The findings are similar to those described for middermal elastolysis. Other authors have reported patients with LE and elastic fiber loss resembling anetoderma. We believe that a spectrum of elastic fiber changes can occur in patients with LE and may be induced by infiltrating lymphocytes and/or circulating antibodies.

Anetoderma arising in cutaneous B-cell lymphoproliferative disease

Anetoderma is circumscribed atrophy of the skin due to a localized deficiency in elastic tissue. It can follow inflammatory skin diseases of several types, and occasionally is present in the skin around neoplasms. There are a few reports of anetoderma in the lesional skin of cutaneous lymphoma. We report on two patients who presented with multiple lesions of anetoderma and who later proved to have low-grade cutaneous B-cell lymphomas. One patient (Patient 1) is a 39-year-old man and the other patient is a 26-year-old woman who is a renal transplant recipient (Patient 2). Some biopsy specimens from the anetodermic skin of Patient 1 appeared to show an urticarial reaction, although plasma cells were present. A large nodule showed lymphoid follicles surrounded by plasmacytoid lymphocytes, with loss of elastic tissue in the adjacent dermis. The plasmacytoid cells stained overwhelmingly for lambda light chain, and staining of the urticarial lesions from this patient also showed a marked majority of lambda positive cells. Immunoglobulin heavy chain gene (IgH) rearrangements showed a dominant clonal pattern in the nodular lesion. We classified the disease in Patient 1 as marginal zone lymphoma and the disease in Patient 2 as a post-transplant lymphoproliferative disorder. Because of the intimate association of anetoderma and cutaneous B-cell lymphoproliferative disorders in these two patients, it seems possible that anetoderma could result from either a local effect of the neoplastic cells or associated inflammatory cells, especially neutrophils as in Case 1. The infiltrates of Case 1 had many interstitial neutrophils and only a few clonal plasmacytoid lymphocytes, indicating that this presentation of B-cell lymphoma can be a diagnostic pitfall. Given these two cases and similar ones in the literature, biopsy of lesional skin in anetoderma should be performed to ensure that lymphomatous infiltrates are not present. Even if plasma cells are sparse, studies to detect clonality are appropriate. Cutaneous B-cell lymphoma can be added to the list of associations of elastolysis and cutaneous lymphoma, which includes granulomatous slack skin (T-cell lymphoma) and cutis laxa (myeloma).

Bilateral eyelid edema: cutis laxa or blepharochalasis?

A 59-year-old woman with massive bilateral edema of the upper and lower eyelids is presented. The edema occurred suddenly and without provocation. No cause could be identified despite a multitude of examinations. Initially the patient was diagnosed as having blepharochalasis, but later skin biopsy suggested an acquired form of cutis laxa. Most likely the cutis laxa was a result of angio-edema. Pharmacological treatment was not successful, but surgical intervention provided an acceptable result. The differential diagnosis of periorbital edema is discussed with special attention to cutis laxa, angio-edema, and blepharochalasis.

Congenital hypopituitarism in a 48-year old adult. Natural course, hormonal study and MRI evidence

A case of Congenital Hypopituitarism (CH) in an untreated 48 yr-old-man is reported. The hormonal studies demonstrated a panhypopituitarism and MR imaging revealed absence of pituitary stalk, small anterior pituitary remnant on the sella floor and ectopic neurohypophysis at the tuber cinereum. The pattern of hormonal responsiveness suggests that CH encompasses findings typical of primary anterior pituitary disease and those of hypothalamic dysfunction.

Mid-dermal elastolysis in an adolescent subsequent to lesions resembling granuloma annulare

First described by Shelley and Wood in 1977, mid-dermal elastolysis (MDE) is a rare acquired disorder in which there is a bandlike absence of elastic tissue limited to the mid-dermis. In their patient, MDE developed in an area previously involved with recurrent episodes of urticaria. We describe a 15-year-old white girl with well-circumscribed, minimally palpable yellow-white plaques and wrinkling diagnosed histologically as MDE in areas clinically diagnosed 5 years previously as granuloma annulare. As in the first described patient, five years elapsed between clearance of the original skin lesions and the clinical appearance of MDE. To our knowledge, we report the first adolescent case of MDE localized to previous sites of lesions clinically consistent with granuloma annulare and propose that MDE represents an abnormal end-stage reaction to multiple processes.

Acquired cutis laxa associated with a plasma cell dyscrasia

Acquired cutis laxa (generalized acquired elastolysis) is characterized by skin laxity often with systemic involvement of the lungs, aorta, gastrointestinal tract, and pelvic organs. Although there have been many speculations regarding its pathogenesis, the etiology of this condition is still unclear. We describe a patient with generalized acquired cutis laxa associated with a plasma cell dyscrasia. Immunofluorescence studies were used to evaluate the pathogenesis of the elastolysis. Lesional skin was examined by direct and indirect immunofluorescence techniques for evidence of deposition of immunoglobulins on elastic fibers in the dermis. Direct immunofluorescence revealed deposition of IgG on elastic fibers in the dermis. Some patients with acquired cutis laxa have underlying lymphoreticular disorders such as plasma cell dyscrasia and may have immunoglobulins deposited on dermal elastic fibers. Immune-mediated mechanisms may play a major role in the pathogenesis of acquired cutis laxa in at least some cases.

Acquired cutis laxa associated with chronic urticaria

A 31-year-old man had cutis laxa after an urticarial eruption. He had no systemic manifestations. In urticarial lesions, elastolysis occurred only within the inflammatory infiltrate of neutrophils around the vessels and between the collagen bundles. In lax skin, elastolysis occurred throughout the entire dermis. Electron microscopic study showed a markedly decreased number of elastic fibers, with elastolysis most predominant near the inflammatory cells. These findings suggest that the neutrophil plays a significant role in the destruction of elastic fibers and subsequent development of cutis laxa.

Sweet's syndrome leading to acquired cutis laxa (Marshall's syndrome) in an infant with alpha 1-antitrypsin deficiency

BACKGROUND

Marshall's syndrome is a rare pediatric skin disease that is characterized by acquired, localized neutrophilic dermatitis (Sweet's disease), followed by loss of elastic tissue in the dermis and cutis laxa. The cause of this syndrome is unknown. alpha 1-Antitrypsin (alpha 1-AT) deficiency is a codominantly inherited disorder of alpha 1-AT, the major serum antiprotease active against a number of serine-type proteases.

OBSERVATIONS

The first patient with classic Marshall's syndrome who had coexisting alpha 1-AT deficiency and a review of other cases of Marshall's syndrome are presented, and pathogenic mechanisms are discussed.

CONCLUSIONS

A deficiency of alpha 1-AT may allow proteases such as neutrophil elastase to destroy dermal elastin and, thus, produce cutis laxa in Marshall's syndrome. Other cases of acquired cutis laxa should be screened for alpha 1-AT deficiency to further evaluate this association and to enable patients and their families to be counseled about possible systemic complications of alpha 1-AT deficiency.

Cutis laxa: etiology, pathophysiology, characteristics, and management

Cutis laxa causes premature aging of the skin, which results in an abnormal appearance. Corrective, not aesthetic, surgery is one treatment option. A blepharoplasty and facelift would be two procedures that can be performed.

Acquired cutis laxa with dermatitis herpetiformis and sarcoidosis

Cutis laxa is a rare condition characterized by loss of elastic tissue. We describe a patient with dermatitis herpetiformis and pulmonary and articular sarcoidosis in whom acquired cutis laxa developed. We believe this association is unique.

Elastolytic cutaneous lesions in myeloma-associated amyloidosis

Elastolytic cutaneous lesions were the initial manifestation of amyloidosis in two patients with multiple myeloma. The skin of the fingertip was noticeably soft, loose, and redundant. The skin of the fingers was depressed with pressure and remained depressed for an abnormally long period of time. Amyloid deposition in the dermis was demonstrated in both cases. In addition, fragmentation and a decrease of elastic fibers in the dermis were observed. Possible explanations for the pathogenesis of such skin lesions were also discussed.

Michelin-tire baby syndrome resulting from diffuse smooth muscle hamartoma

We cared for an infant who was born with the Michelin-tire baby syndrome characterized by dermatomegaly and hypertrichosis. Histology revealed a diffuse smooth muscle hamartoma.

[Cutis laxa syndrome associated with articular calcification punctata]

One case of congenital cutis laxa with delayed development, ligamentous and articular laxity, multiple diverticulum and articular punctuated calcifications, with ultrastructural study, is presented. Literature is reviewed, reporting the known data about pathogenesis and inheritance.

Ptosis and dermatochalasis as presenting signs in a case of occult primary systemic amyloidosis (AL)

Amyloidosis (AL) is a disease characterized by the extracellular deposition of a complex glycoprotein, part of which is derived from light chains of immunoglobulins. The ocular adnexa can be involved in both systemic primary amyloidosis (AL), usually associated with multiple myeloma or other immunologic disorders, or in a localized form without such systemic implications. We present the case report of a 65-year-old man in whom occult primary systemic amyloidosis (AL), associated with a monoclonal IgG-kappa gammopathy, occurred with presenting signs of ptosis and dermatochalasis secondary to infiltration of the extraocular and orbicularis oculi muscles with amyloid.

[Acquired cutis laxa (elastolysis generalisata)]

Following glomerulonephritis with subsequent anasarca and repeated penicillin treatments, generalized cutis laxa developed in a forty-year-old patient. Progressive signs of pulmonary emphysema appeared in the same period. Additionally, a monoclonal gammopathy was detected during extensive examination.

Acquired cutis laxa: case report and review of disorders of elastolysis

A 10-year-old boy developed cutis laxa while receiving isoniazid therapy; no systemic manifestations occurred. There are several well-documented cases of acquired cutis laxa. We propose a classification of the elastolysis syndromes, including inherited, neonatal, and acquired forms of cutis laxa.

Elastin: relation of protein and gene structure to disease

The elastic properties of many tissues such as the lung, dermis, and large blood vessels are due to the presence of elastic fibers in the extracellular space. These fibers have been shown by biochemical and ultrastructural analysis to be comprised of two distinct components, a more abundant amorphous component and the microfibrillar component. The microfibrillar component is found in 10- to 12-nm fibrils which are located primarily around the periphery of the amorphous component but, to some extent, interspersed within it. The protein, elastin, makes up the highly insoluble amorphous component and is responsible for the elastic properties. Elastin is found throughout the vertebrate kingdom except for very primitive fish and possesses an unusual chemical composition consonant with its characteristic physical properties. Elastin is composed largely of glycine, proline, and other hydrophobic residues and contains multiple lysine-derived cross-links, such as the desmosines, which link the individual polypeptide chains into a rubber-like network. The intervening, hydrophobic regions of the polypeptide chains between the cross-links are highly mobile, and the elastic properties of the fibers can be described in terms of the theory of rubber elasticity. Recent application of recombinant DNA techniques has led to further understanding of the structure of elastin. Analyses of the bovine and human elastin genes have demonstrated that the hydrophobic and cross-linking domains are encoded in separate exons. These exons tend to be small, varying from 27 to 114 base pairs, and are separated by large intervening sequences. Furthermore, DNA sequence analysis has demonstrated that the elastin molecule contains two cysteine residues which were not previously identified near the carboxy terminus and which may be important in the interaction of elastin with other extracellular matrix proteins. Further DNA sequencing should determine the complete amino acid sequence of elastin. Biosynthetic studies and in vitro translation of elastin mRNA have demonstrated that a 72,000-dalton polypeptide, designated tropoelastin, is the initial translation product. Analysis of several developing systems has demonstrated that elastin synthesis is controlled by the level of elastin mRNA. After packaging into membrane-bound vesicles in the Golgi apparatus, tropoelastin is secreted by exocytosis into the extracellular space where it is cross-linked by a copper-requiring extracellular enzyme, lysyl oxidase. Elastin can be solubilized only by proteases that have consequently been designated elastases, although these are general, powerful proteases that can hydrolyze numerous proteins.(ABSTRACT TRUNCATED AT 400 WORDS)

Postinflammatory elastolysis and cutis laxa: report of a case with aortitis

A 17-month-old black female manifested an acute febrile dermatosis followed by the development of cutis laxa and aortitis. The neutrophilic, acute inflammatory nature of the disease is emphasized. Pathologically, both the skin and the aorta were affected by a lesional process that shared common morphologic attributes and resulted in extensive elastolysis. However, the disease appears to differ from other entities characterized by generalized degradation of elastic fibers.

[Juvenile atrophying erythema multiforme]

This is a case report of an Atrophic Juvenile Erythema Multiform that has occurred in a ten year old white girl. She has been having symptoms since age three, presenting severe flares of lesions that looked like multiform erythema. When the lesions healed a loose scar was left involving the whole skin. Some of the histological and pathogenic mechanisms of the disease are discussed.

[Syntropy of dermatochalasis and urticaria pigmentosa as sequelae of dermatosparaxis endoplasmatica]

A 44 years old male is reported who had aquired dermatochalasis and urticaria pigmentosa at the same time. This is interpreted as a subsequent phenomenon of a dermatosparaxis endoplasmatica. Clinic, histology and electron microscopy are elaborated. Systemic involvement is verified by x-rays. Histologically, predominant is the severe atrophy of the elastica, the collagenous degeneration, the presence of mastocytes, the subepidermal blister formation and the secondary xanthomatosis. The picture deviates from the common dermatosparaxis occuring in calves by the paracrystalline content of the procollagene in the endoplasmatic reticulum as verified by electron microscopy. A severe disturbance of the synthesis of collagene exists in the state of procollagene for which here the term "dermatosparaxis endoplasmatica" is suggested.