An atypical case of incontinentia pigmenti with a hypomorphic variant

Incontinentia pigmenti (IP) is a rare X-linked dominant genodermatosis that affects skin, hair, teeth, eyes and central nervous system. We present the case of a female patient with mild IP caused by a hypomorphic pathogenic variant of the inhibitor of the kappa light polypeptide gene enhancer in B cells, kinase gamma (IKBKG) gene. This is the first report of a female IP patient with the hypomorphic variant, NM_001099856.6: c.1423dup, which is causative of anhidrotic ectodermal dysplasia with immune deficiency in males.

Incontinentia pigmenti Stage 1 is not simply vesiculo-bullous but vesiculo-pustular

Incontinentia pigmenti (IP) is a rare X-linked dominant, male-lethal disorder characterized by pathognomic skin lesions. As described in the literature the typical cutaneous changes follow the pattern of Blaschko's lines and develop in four stages that usually start at birth. Stage 1 is called vesicular, bullous or inflammatory. The vesicles are rapidly filled with eosinophils and thus turn into pustules. Thus, the term "pustular" is relevant to the first phase of IP, and the stage can be considered as "vesiculopustular/inflammatory" to be more precise than "vesicular" or "bullous."

Incontinentia Pigmenti presenting as a newborn eruption: two case presentations

Linear vesicles or papules in a newborn can be a presenting sign of incontinentia pigmenti (IP). In this report, we present two cases of neonates with cutaneous manifestations of incontinentia pigmenti. In one case, mild peripheral eosinophilia was noted. No extra-cutaneous manifestations were noted otherwise in both cases after complete ophthalmological and neurological evaluations. These cases serve as a reminder for clinicians to consider IP in newborns presenting with linear vesicles or papules.

[THE CASE OF THE INCONTINENTIA PIGMENTI SYNDROME IN A NEWBORN]

The paper describes the case of a rare hereditary disease--Incontinentia Pigmenti syndrome incontinence of pigment in newborn.

Blaschko line analogies in the central nervous system: a hypothesis

In X-chromosome-linked skin disorders the pattern of involvement follows Blaschko lines. Patterns of changes analogous to cutaneous Blaschko lines in different X-linked diseases existed in other organs. There is no commonly accepted analogy to Blaschko lines in the central nervous system (CNS). The objective of this study was to consider a hypothesis of the existence of Blaschko lines in the CNS in the example of incontinentia pigmenti (IP). Articles were analyzed in which brain imaging methods were used in IP patients with CNS anomalies. In IP patients with neurological signs brain lesions usually were localized and extended radially. Affected areas did not correspond to territories vascularized by any determined artery. Radially distributed brain lesions morphologically match the radial unit model of cortical development. It can be proposed that in IP in CNS Blaschko line analogies, similar to those in the skin, represent the trace of development of the clone of neurons arising from the cell marked with IKBKG mutation. The hypothesis of the existence of Blaschko line analogies in CNS is supported by radially distributed CNS image findings in IP, the radial unit model of CNS development, and the common embryonic origin of skin, CNS, and eyes.

Incontinentia pigmenti (Bloch-Siemens syndrome)

Incontinentia pigmenti (IP) is an uncommon X-linked dominant genodermatosis. It affects predominantly females and is lethal in utero in male fetuses. We herein report a baby girl born with blisters on trunk and limbs. The diagnosis of IP was based on clinical findings and on histopathological analysis of biopsy specimen.

Incontinentia pigmenti and hypomelanosis of Ito

Incontinentia pigmenti (IP) is a rare X-linked dominant neurocutaneous disorder affecting ectodermal tissue: skin, eyes, central nervous system, hair, nails, and teeth. It is usually lethal for males in utero. The involved gene is NEMO, an essential component of the nuclear factor-kappa B (NF-κB) signaling pathway. Skin lesions are highly diagnostic, occurring in neonates, with a particular distribution on Blaschko lines. The severity of the disease is related to ocular and neurological impairment. The hallmark of ocular IP is retinal vasculopathy including peripheral retinal vascular nonperfusion, macular infarction and neovascularization, and preretinal neovascularization. CNS involvement consists of seizures, mental retardation, hemiparesis, spasticity, microcephaly, cerebellar ataxia, and coma. It often occurs in neonates. Some patients have persistent pharmacoresistant seizures throughout life. MRI findings consist essentially in: white-matter lesions; scattered cortical neuronal necrosis; multiple cerebral infarctions; cerebral atrophy, hypoplasia of the corpus callosum, encephalomalacia and neuronal heterotopia. A predominant role of vascular occlusive phenomena in small vessels is highly suspected. In fact several intricate mechanisms could be discussed: vascular, inflammatory, developmental mechanisms. Their role and predictive factors of IP CNS involvement in neonatal IP need to be better understood to identify effective innovative therapies. Hypomelanosis of Ito can occur in the neonate, infancy, or childhood, be isolated or diffuse, often following the Blaschko lines, and can fade in childhood or adulthood. It is due to reduced melanin in the epidermis. Eye, central nervous (mental retardation, epilepsy, language disabilities, motor system dysfunction, psychiatric symptoms including autism - with frequent cortical malformations including hemimegalencephaly and white matter involvement), and musculoskeletal systems can also be affected. Mosaicism with various chromosomal rearrangements has been reported.

Incontinentia pigmenti: case report

Incontinentia pigmenti or Bloch-Sulzberger syndrome is a rare X-linked dominant disorder with characteristic skin, hair, eye, dental and neurologic abnormalities mostly affecting females. We report a case of a female newborn exhibiting characteristic cutaneous and neurologic findings with one-year follow-up.

Incontinentia pigmenti: a newborn with characteristic skin lesions and bilateral optic atrophy: case report and review of literature

Incontinentia Pigmenti (IP) is a rare X-linked dominant disorder with skin, eye, central nervous system (CNS) and tooth abnormalities. According to the reported cases, it is estimated that there have been nearly 900-1200 affected individuals. In this article, the literature is reviewed and a case of IP with characteristic skin lesions and optic atrophy is presented.

Serial cytokine expressions in infants with incontinentia pigmenti

NF-κB dysfunction resulting from NEMO (NF-kappaB essential modulator) mutation can lead to significant alterations in cytokine production. However, little is known about changes in the expression of downstream molecules in patients with incontinentia pigmenti (IP). We aim to investigate serial cytokine expressions during the first 2 years of life in young infants with IP, the period in which skin inflammation and morphological changes are most significant. Gene analysis and X-inactivation test were performed for the two neonates with IP. Peripheral mononuclear cells were obtained after birth and successively at 6-month interval up to the age of two years. Levels of TNF-α and IL-6 were analyzed with ELISA before and after stimulating with Toll-like receptor ligands. The result showed the male IP patient had normal NEMO allele. His cytokine level, although initially lower, had returned to a level comparable with those of controls at 12 months of age. The female infant had mutated NEMO gene. Her baseline TNF-α level was significantly higher than those of the control subjects at birth and remained high by 6 months of age. All cytokine responses had decreased significantly by 2 years of age, the time in which all vesicular skin lesions had resolved. Both infants had normal serum immunoglobulin level and remained infection free during the follow up period. To our knowledge, this is the first report that demonstrates serial changes of cytokine profiles in humans with IP. This study showed that in the presence of NEMO mutation, alteration of cytokine production was remarkable during the first year of life, which may account for the prominent inflammatory changes in skin morphology.

Incontinentia pigmenti in a newborn with NEMO mutation

Incontinentia pigmenti (IP) (OMIM #308300) is a rare X-linked dominant neuroectodermal multisystemic syndrome due to mutations in the gene for NF-κB essential modulator (NEMO). A term newborn girl who was born with erythematous vesicular eruptions developed recurrent seizures during the first and second weeks of her life. The serial MRIs demonstrated diffuse, progressive brain infarctions and subsequent encephalomalacia as well as brain atrophy. Skin biopsy found it was consistent with the vesicular stage of IP. Genetic analysis revealed a deletion exon 4-10 in NEMO gene associated with IP. We hereby report a Korean female baby with IP confirmed by mutation analysis of NEMO gene.

Incontinentia pigmenti revisited. A novel nonsense mutation of the IKBKG gene

AIM

To describe and evaluate the clinical and molecular findings of patients with incontinentia pigmenti (IP) in Greece.

METHODS

We examined 12 female patients, initially aged 2 weeks to 7 months with clinical diagnosis of IP. Standard tests were performed including skin biopsies and ocular, dental and neurologic examinations. Molecular analysis was carried out on 8 out of 12 cases.

RESULTS

The initial clinical examination was stage 1 (vesicular lesions), stage 2 (verrucous lesions) or stage 3 (hyperpigmented linear lesions of the trunk/limbs). At the final clinical examination, 10 of our patients had typical vesicular, verrucous or mixed hyper-hypopigmented skin lesions which had persisted from the neonatal period; seven had delayed dentition or conical teeth; two had developmental delay; one had microcephaly and strabismus and two had scarring alopecia. In seven patients, deletion of exons 4-10 of the IKBKG gene was found. In one patient, skewed X-inactivation was demonstrated and a novel mutation p.Gln332X was found. The mothers' DNA analyses were all normal.

CONCLUSION

In our sample, all the cases were sporadic and the diagnosis of IP was based mainly on clinical features and confirmed with skin histology. Molecular analysis was used to find the mutations, in some cases to confirm diagnosis and to identify the carriers, which are crucial for prenatal and preimplantation diagnosis.

Incontinentia pigmenti

Incontinentia pigmenti is an X-linked dominant genodermatosis that can affect the teeth, eyes, and central nervous system as well as the skin. We describe an infant girl with characteristic cutaneous findings, which progressed through the vesicular, verrucous, and hyperpigmented stages in the first year of life. During the neonatal period, recognition of the linear distribution of vesicular lesions and associated peripheral eosinophilia as well as leukocytosis (which might suggest an infectious etiology) can help to establish the diagnosis. This enables early initiation of ophthalmologic care, which can help to prevent visual sequelae.

Incontinentia Pigmenti with vesicular stage in utero

Incontinentia pigmenti (IP) is a genodermatosis with a characteristic evolution of skin lesions. Most patients present with vesicles at birth or within the first weeks of life. We report a case of a female infant with genetically confirmed sporadic IP who presented with verrucous and hyperpigmented lesions with no previous vesicular stage.

The common NF-κB essential modulator (NEMO) gene rearrangement in Korean patients with incontinentia pigmenti

Incontinentia pigmenti (IP) is a rare X-linked dominant disorder characterized by highly variable abnormalities of the skin, eyes and central nervous system. A mutation of the nuclear factor-κB essential modulator (NEMO) located at Xq28 is believed to play a role in pathogenesis and the mutation occurs mostly in female patients due to fatal consequence of the mutation in males in utero. This study was designed to identify the common NEMO rearrangement in four Korean patients with IP. Deletion of exons 4 to 10 in the NEMO, the most common mutation in IP patients, was detected in all of the patients by the use of long-range PCR analysis. This method enabled us to discriminate between NEMO and pseudogene rearrangements. Furthermore, all of the patients showed skewed XCI patterns, indicating pathogenicity of IP was due to cells carrying the mutant X chromosome. This is the first report of genetically confirmed cases of IP in Korea.

Recurrent stroke in a child with incontinentia pigmenti

We report a child with genetically proven incontinentia pigmenti who had bilateral strokes at 5 days of age, and was subsequently found to have recurrent acute strokes on magnetic resonance imaging both at 10 days and 3 months of age. Brain magnetic resonance imaging at 5 days of age showed multiple areas of restricted diffusion throughout both hemispheres. The child was started on antiplatelet therapy after a second stroke was noted on magnetic resonance imaging at 10 days of age. Despite this treatment, she had a third punctate infarct on magnetic resonance imaging 3 months later. A magnetic resonance imaging at 10 months of age showed maturation of the old infarcts but no new strokes. The purpose of this article is to describe a unique presentation of recurrent stroke secondary to incontinentia pigmenti and to highlight the need for a better understanding of the pathophysiology of incontinentia pigmenti to develop appropriate treatment of stroke in incontinentia pigmenti.

Incontinentia pigmenti with encephalocele in a neonate: a rare association

Incontinentia pigmenti is a rare, X-linked dominant multisystem genodermatosis affecting ectodermal and mesodermal tissues. After the skin, the central nervous system is the second-most affected system. We report a neonate with incontinentia pigmenti and encephalocele, as a feature of the central nervous system involvement, to stress this uncommon association.

Preliminary ocular histopathological observations on heterozygous NEMO-deficient mice

The majority of patients with incontinentia pigmenti (IP) have a mutation in the nuclear factor-kappa-beta essential modulator (NEMO) gene, and mice with a targeted deletion of NEMO exhibit skin pathology remarkably similar to the human disease. This study characterizes the retinal vascular abnormalities of NEMO-deficient mice, and compares this phenotype to known features of human IP. Nineteen heterozygous NEMO-deficient female mice, ages ranging from post-natal day 8 (P-8) through 6.5 months of life, were studied. Eyes were sectioned and stained either whole or as retinal flat mounts after incubation for enzyme histochemical demonstration of ADPase, which labels the vasculature. With maturation, retinal arteriolar abnormalities became evident at 3 months of age. Global assessment of the retinal vasculature with ADPase staining showed increased vascular tortuosity. Microscopic examination of sections of ADPase-incubated retinas revealed arteriolar luminal narrowing due to endothelial cell hypertrophy and increased basement membrane deposition. Venous morphology was normal. This study characterized the histological retinal phenotype of heterozygous NEMO-deficient female mice. Most striking were retinal arteriolar abnormalities, including luminal narrowing, endothelial cell hypertrophy, and basement membrane thickening. Retinal flat mounts revealed arteriolar tortuosity without evidence of vaso-occlusion or neo-vascularization.

Serial changes in white matter lesions in a neonate with incontinentia pigmenti

CASE REPORT

We report an infant who presented with clinical manifestations of incontinentia pigmenti (IP). Despite experiencing seizures in the early neonatal period, the patient had normal growth and development until recently. However, follow-up magnetic resonance imaging revealed sequential changes in white matter lesions.

DISCUSSION

The pathogenesis of neurological involvement in IP has not been clearly elucidated and appears to be associated with various mechanisms, including developmental, destructive, and vascular processes. We have attempted to explain the pathogenesis of IP through these changes.

Clinical and molecular analysis of NF-?B essential modulator in Chinese incontinentia pigmenti patients

OBJECTIVE

To analyze clinical manifestation and gene of NF-kappaB essential modulator (NEMO) in 12 pediatric incontinentia pigmenti (IP) patients.

METHODS

Twelve pediatric probands with three of their mothers were enrolled in this study. Physical examinations were undertaken for all patients and questionnaires requesting additional medical and developmental data were sent to the patients' families. The deletion of exon 4-10 and all 10 exons of NEMO gene were analyzed in these cases. Skin biopsy was performed in one case.

RESULTS

All 15 patients had skin pigmentation abnormality and were diagnosed according to classic skin lesions. The prevalence of the dental, neurologic system, hair abnormality, and definite family history were 80.0%, 41.67%, 58.33%, and 25.0%, respectively. Histopathological examination was consistent with the diagnosis of IP with ectodermal dysplasia. In NEMO gene, deletion of exons 4-10 were noted in three cases and two of their mothers. A deletion of 19545 T in exon 6 was noted in one case and her mother. A 21690 T to C mutation in intron 8 of NEMO were found in another one case and her mother.

CONCLUSION

The results suggest that skin lesion are the most prominent findings in clinics and the traditional diagnosis of IP is based on classic melanin pigmentation. Nucleotide deletion of exons 4-10 and single nucleotide mutation/polymorphism were found in these patients, which might account for etiopathogenesis of IP.

[Bloch-Sulzberg syndrome in pathology]

The authors present some pathological findings in the skin and hair of the child affected by rather rare Bloch-Sulzberg syndrome manifested in incontinentia pigmenti, followed for 10 years. In this work are presented also some recent data about pathogenesis of the disease with X-chromosome dominant heredity, primary of neuroectodermal origincaused by mutation of nuclear factor kappa-B of essential modulator (NEMO) of the gene (chromosomal locus Xq28).

Incontinentia pigmenti (Bloch-Sulzberger syndrome): a systemic disorder

Incontinentia pigmenti (IP) is a rare inherited multisystem disorder characterized by a distinctive swirling pattern of the skin; defects of teeth, hair, and nails; and ophthalmic, central nervous system, and musculoskeletal abnormalities. It progresses through several well-defined stages. IP is transmitted as a dominant X-linked trait with variable expressivity, but many--if not most--cases are sporadic. IP has been shown to result from mutations in the NEMO gene that completely abolish expression of NF-kappaB essential modulator. The diagnosis of IP typically is made based on characteristic clinical findings. Molecular analysis of the NEMO gene is now possible, as is analysis of skewed X-chromosome inactivation, which can further reduce diagnostic confusion. A number of disorders, including hypomelanosis of Ito, should be considered in the differential diagnosis. The considerations vary according to the stage of IP. Careful head-to-toe clinical evaluation is critical in the evaluation of a child with suspected IP given the frequent multisystem involvement. A multidisciplinary approach including dermatology, ophthalmology, neurology, and dental consults is typically warranted. The skin manifestations of IP do not require specific treatment other than reassurance; spontaneous resolution of the lesions usually occurs.

Abnormal white matter in a neurologically intact child with incontinentia pigmenti

Incontinentia pigmenti is an X-linked neurocutaneous disorder which is often lethal in males. Ectodermal tissues are involved, and affected females often have abnormalities of skin, teeth, hair, eyes, and the central nervous system. Central nervous system involvement ranges from none to multiple strokes, seizures, and mental retardation. Deletions in the nuclear factor kappa beta essential modulator gene at Xq28 are present in 70-80% of patients with incontinentia pigmenti. White matter abnormalities have been reported in females with significant neurologic involvement. This report describes a neurologically intact child with deletion positive incontinentia pigmenti with significant white matter involvement, broadening the scope of this finding in incontinentia pigmenti.

[Incontinentia pigmenti: three new cases that demonstrate it is not only a matter of women]

Incontinentia pigmenti is a rare, dominantly X-linked genodermatosis characterized by multisystemic involvement that is lethal prenatally in the majority of affected males and shows great clinical variability when it is expressed in women. Recently it has been shown that mutations of the gene NEMO/IKK-g located in Xq28 cause the expression of the disease, being only one mutation responsible for approximately 80 % of the cases. The diagnosis of incontinentia pigmenti is performed based on clinical features and family history with the support of histological findings. Nevertheless, as the gene responsible for the phenotype of the disease has been identified, a genetic study may be employed for doubtful cases. We report three cases of this entity (two women and one man) in different clinical stages of development that show the broad clinical spectrum we may encounter in the clinic.

Incontinentia pigmenti in male patients

BACKGROUND

Incontinentia pigmenti (IP) is a rare X-linked dominant genodermatosis that is typified by distinctive cutaneous findings and often by abnormalities of teeth, hair, nails, eyes, musculoskeletal system, and central nervous system. The gene that is mutated in patients with IP has been mapped to Xq28 and encodes the NF-kappaB essential modulator, NEMO. Female patients with IP show functional mosaicism and cutaneous manifestations follow Blaschko's lines of ectodermal embryologic development. The condition is generally considered to be lethal in utero in male fetuses, suggesting that having some normal gene expression is critical for survival.

OBSERVATIONS

We observed 9 boys with IP. All had normal karotypes and no apparent family history of IP. In 8 of these 9 patients, lesions were localized to one extremity at presentation. The diagnosis was confirmed by histopathologic examination that showed eosinophils within intraepidermal, multiloculated vesicles. One of the boys later developed dental and neurologic abnormalities.

LIMITATIONS

The case series was small and the workup for these patients from different sites was not uniform.

CONCLUSIONS

Male individuals may show cutaneous and noncutaneous features of IP in a limited distribution that allows survival. Postzygotic mutation/somatic mosaicism is the likely mechanism. Given the potential sequelae associated with this condition, continuing follow-up of these patients is recommended.

Incontinentia pigmenti in a boy with XXY mosaicism detected by fluorescence in situ hybridization

We report the case of a male infant with incontinentia pigmenti (MIM 308310) and low-grade XXY mosaicism. Fluorescence in situ hybridization may reveal the underlying genetic alteration in male patients with incontinentia pigmenti and a normal karyotype.

Incontinentia pigmenti: clinical observation of 40 Korean cases

Incontinentia pigmenti (IP) is an uncommon genodermatosis that usually occurs in female infants. It is characterized by ectodermal, mesodermal, neurological, ocular, and dental manifestations. The aim of this study was to clarify clinical symptoms, accompanying diseases, and complications of IP. Forty cases of IP have been reviewed by their medical records, laboratory data, clinical photographs, and telephone survey. Male-to-female ratio was 1 to 19 and their onsets were mostly in utero. They were usually diagnosed during the neonatal period owing to their early expression of skin manifestation. Central nervous system anomalies were found in 46.7%. Ocular disorders and dental defects were detected in 66.7% and 72.7% respectively. The most commonly diagnosed anomalies were hypodontia, retinopathy, and seizure. For better understanding of IP, long term and close cooperation between dermatologists, pediatricians, neuroscientists, genetic counselors, and even dentists is crucial.

[Incontinentia pigmenti: clinical and neuroimaging findings in a series of 12 patients]

OBJECTIVE

To describe the clinical, neuroimaging 51 with magnetic resonance imaging (MRI) and evolutive findings in 12 patients with incontinentia pigmenti (IP). Five patients show cutaneous and neurological lesions and seven only show cutaneous lesions without neurologic or/ and ophthalmologic abnormalities.

MATERIAL AND METHODS

Five mothers and seven daughters from four families were studied and followed between 1965 and 2004. The studies consisted of detailed clinical history since birth, physical examination, family history, EEG recordings and MRI studies. In some patients, at least three MRI studies were performed during our follow-up. All patients were followed-up since their first visit until 2004. Including four patients since birth or early infancy. Skin biopsies were obtained from two infants for histological study.

RESULTS

MRI studies revealed brain abnormalities in five girls who had neurologic signs associated with the cutaneous lesions of IP. Brain lesions were bilateral in four and unilateral in one. Cerebellar changes were observed only in one case who also showed severe cerebral lesions. The lesions involved cortex, subcortical and deep white matter, ependymal and subependymal zones of one or both cerebral hemispheres. Lesions usually were localized and extended radially to involve all the cerebral parenchyma between ependyma and cortex. Affected areas did not correspond to territories vascularized by any determined artery. The corpus callosum showed generalized or localized atrophy in the five patients who had cerebral hemispheric lesions. Although parenchymal changes were seen in both the T1 and T2 weighted images, these were most evident in the latter. Parenchymal abnormalities were most severe in patients with neonatal severe cutaneous lesions, especially if these were located in the scalp. Cerebral lesions were present from birth or the first months of life and changed little thereafter. The acute appearance and distribution of cerebral lesions always during the neonatal period, associated with scalp lesions in stage 1, suggest an acute inflammatory origin of unknown etiology and of nonprogressive course. Ocular lesions were directly related with cerebral abnormalities. Patients who only had cutaneous lesions without neurologic symptoms showed no MRI abnormalities.

CONCLUSIONS

Neuroimaging studies reveals brain lesions only in patients with neurologic disease in this serie. The brain lesions may involve one or both cerebral hemispheres, corpus callosum, and cerebellum. The brain lesions correlate with the neonatal scalp lesions in stage 1, suggests an inflammatory process of unknown etiology and non-progressive course. The appearance and distribution of the cerebral lesions do not follow the territories vascularized by specific arteries. Ocular lesions are observed only in patients with severe cerebral changes. Early onset of cerebral lesions may be the most reasonable explanation for the progressive microcephaly within the first year of life in IP.

Skin lesion development in a mouse model of incontinentia pigmenti is triggered by NEMO deficiency in epidermal keratinocytes and requires TNF signaling

NF-kappaB essential modulator (NEMO), the regulatory subunit of the IkappaB kinase, is essential for NF-kappaB activation. Mutations disrupting the X-linked NEMO gene cause incontinentia pigmenti (IP), a human genetic disease characterized by male embryonic lethality and by a complex pathology affecting primarily the skin in heterozygous females. The cellular and molecular mechanisms leading to skin lesion pathogenesis in IP patients remain elusive. Here we used epidermis-specific deletion of NEMO in mice to investigate the mechanisms causing the skin pathology in IP. NEMO deletion completely inhibited NF-kappaB activation and sensitized keratinocytes to tumor necrosis factor (TNF)-induced death but did not affect epidermal development. Keratinocyte-restricted NEMO deletion, either constitutive or induced in adult skin, caused inflammatory skin lesions, identifying the NEMO-deficient keratinocyte as the initiating cell type that triggers the skin pathology in IP. Furthermore, genetic ablation of tumor necrosis factor receptor 1 (TNFRI) rescued the skin phenotype demonstrating that TNF signaling is essential for skin lesion pathogenesis in IP. These results identify the NEMO-deficient keratinocyte as a potent initiator of skin inflammation and provide novel insights into the mechanism leading to the pathogenesis of IP.

A new mutation in exon 7 of NEMO gene: late skewed X-chromosome inactivation in an incontinentia pigmenti female patient with immunodeficiency

Incontinentia pigmenti is an X-linked genodermatosis, lethal in males. Affected females survive because of X-chromosome dizygosity and negative selection of cells carrying the mutant X-chromosome, and for this reason the skewed X inactivation pattern is often used to confirm the diagnosis. The most frequent mutation is a deletion of part of the NEMO gene (NEMODelta4-10), although other mutations have been reported. Mutations of NEMO which do not abolish NF-kappaB activity totally permit male survival, causing an allelic variant of IP called hypohidrotic ectodermal dysplasia and immunodeficiency (HED-ID). We present a non-classical IP female patient who also suffered transient immunodeficiency because of a late and progressive selection against peripheral blood cells carrying an active mutated X-chromosome. This finding suggests that in the absence of known mutation the X-inactivation studies used in genetic counselling can induce mistakes with some female patients. At the age of 3 years and 6 months, all immunodeficiency signs disappeared, and the X-chromosome inactivation pattern was completely skewed. The low T cell proliferation and CD40L expression corroborate the important role of NEMO/ NF-kappaB pathway in T cell homeostasis. The decreased NEMO protein amount and the impaired IkBalpha degradation suggest that this new mutation, NM_003639: c.1049dupA, causes RNA or protein instability. To our knowledge, this is the first time that selection against the mutated X-chromosome in X-linked disease has been documented in vivo.

Incontinentia pigmenti case series: clinical spectrum of incontinentia pigmenti in 53 female patients and their relatives

A retrospective case series of 53 female patients with incontinentia pigmenti (IP) including 28 secondary cases (female relatives of probands) was reviewed and compared with other series in an attempt to estimate more accurately the true disease burden of patients with IP. We found that, while the frequency of the first three cutaneous stages of IP was comparable with previous studies, none of the secondary cases manifested any serious neurological complications but all displayed stage IV pale anhidrotic reticulate lines on their posterior calves. This important clinical feature of IP in secondary cases has previously been under-represented in studies that often involved only paediatric probands. Hence, mildly affected cases of IP are often undiagnosed and under-represented in case series to date, possibly leading to inappropriately high estimates of neurological and eye involvement. With the availability of genetic testing, it is now feasible to confirm the variability of the phenotype and the risk of complications in IP.

[From gene to disease; incontinentia pigmenti and the NEMO-gene]

Incontinentia pigmenti (IP; MIM308310) is a rare neurocutaneous X-dominant inherited disorder. Besides skin and neurological abnormalities, there is also ophthalmologic and dental involvement. The first stage is characterised by inflammation and apoptosis of the skin and central nervous system. The first stage consists of vesicles and the second of verrucous elements; the third stage is characterised by hyperpigmentation while the fourth is characterised by slightly atrophic hypopigmentations. The skin abnormalities follow the lines of Blaschko. The disorder is observed almost exclusively in girls, but diseased boys are more seriously affected. The IP gene is localised on chromosome Xq28. Mutations in the NEMO-gene are responsible for IP. This gene codes for the nuclear factor-KB essential modulator protein (NEMO; synonym: inhibitor kappaB kinase (IKK)y). In the absence of serious neurological symptoms, the prognosis is not poor.

Incontinentia pigmenti (IP2): familiar case report with affected men. Literature review

Incontinentia pigmenti is a genodermatosis described by Garrod and in 1920 by Bloch, Sulzberger, Siemens y Bardach. It is an ectodermic disorder that affects skin, teeth, eyes and may also have neurological problems. The IP2 name describes the histological characteristics, the incontinence of melanin into the melanocytes cells in the epidermal basal layer and its presence in superficial dermis. IP2 is an x-linked dominant condition but genetic heterogeneity may exist.

CASE REPORT

The patient was 4 yrs 5 months old when she came for the first time. In a physical exploration she presented sparse and thin hair, eyelashes and eyebrows, beaked nose, labial protrusion, the four central teeth have a conic crown and there was also a delayed eruption of other teeth, right eye strabismus, hipoacusia, language defects and a trunk, legs, feet, and face dermatosis characterized by grouped vesicles, hyperkeratotic and warty lesions and brownish-gray lesions in a lineal pattern. The patient s father had hypopigmented lesions in the posterior regions of both legs. The oral clinical and radiographic exams showed diverse anomalies. Both the patient's and the father's chromosomal studies were normal.

DISCUSSION

In the present case we can see that the father has IP2 without supernumeraries X, with the antecedent that his mother had something similar. It is possible that the inheritance was autosomic dominant or it is a different mutation of NEMO (NF-kappa-B essential modulator) gene to a classical one, which was found in some affected men. It is necessary to carry out a molecular study of these patients.

Dental anomalies in two patients with incontinentia pigmenti

Incontinentia pigmenti (IP) is a rare X-linked dominant inherited disorder which has a variety of ectodermal aberrations. Skin hyperpigmentation is the most characteristic feature of IP. However, extracutaneous anomalies involving dentition, hair, eyes, and central nervous system are also found. The dental anomalies reported include peg-shaped or malformed teeth, hypodontia, delayed eruption, and impacted tooth. This report describes the dental anomalies in 2 IP patients who had the characteristic features of skin hyperpigmentation. One was a 13-year-old girl who had slender cone-shaped permanent anterior teeth, hypodontia, and delayed eruption of teeth which are characteristic dental anomalies in an IP patient. The other was a 10-year-old girl who only had 2 tulip-shaped maxillary permanent central incisors with shorter tapering roots but no congenital missing teeth or delayed eruption of teeth. Our findings suggest that IP may present a broad variation of dental anomalies individually. However, the characteristic finding of permanent anterior teeth with a longer crown and a shorter root found in both of our IP patients may be worthy of consideration in the differential diagnosis of IP.