Malignant atrophic papulosis (Degos disease) with central nervous system involvement

A 49-year-old man presented with a 2-year history of weakness and sensory disturbances in the bilateral lower extremities, vesicorectal dysfunction, and progressive gait disturbances. Brain MRI revealed multiple ischemic and hemorrhagic cortical/subcortical lesions with patchy enhancement involving the frontal and parietal lobes, suggesting the possibility of distal perforating arteries injury. Spine MRI revealed lesions of the cervical and thoracic spinal cord with associated enhancement. The diagnosis of malignant atrophic papulosis (Degos disease) with central nervous system involvement was prompted by the characteristic skin lesions.

Worsening skin lesions but no diagnosis

A diagnosis was arrived at by doing something that the patient's other doctors hadn't: perform a biopsy.

Opioid associated intravenous and cutaneous microvascular drug abuse (skin-popping) masquerading as Degos disease (malignant atrophic papulosis) with multiorgan involvement

BACKGROUND

In 2012, a nephrologist reported the development of a multiorgan thrombotic syndromic complex resembling thrombotic thrombocytopenic purpura (TTP) in patients who were abusing long acting oxymorphone hydrochloride; all patients had hemolytic anemia and thrombocytopenia.

OBJECTIVE

Herein, we report another case involving a 31-year-old woman who self intravenously administered dissolved oral oxymorphone resulting in thrombotic sequelae resembling Degos disease.

METHODS

Formalin-fixed and paraffin embedded skin biopsies were prepared according to standard protocols for H&E and immunohistochemistry.

RESULTS

The clinical presentation and biopsy findings were held to be indicative of Degos disease/malignant atrophic papulosis (MAP) but with unusual clinical features including renal failure and severe respiratory insufficiency. Given the efficacy of eculizumab in the treatment of the acute thrombotic phase of Degos disease/MAP, the patient received this drug, resulting in rapid resolution of signs and symptoms associated with her multiorgan failure. Although she developed recurrent cutaneous ulcers despite complete complement inhibition with eculizumab., her other extracutaneous manifestations did not recur. The patient's pre and post eculizumab skin biopsies showed a striking pauci-inflammatory thrombogenic vasculopathy associated with marked endothelial cell injury along with deposits of C3d and C4d within the cutaneous vasculature; the C5b-9 deposits were limited to the pre-eculizumab biopsy. We discovered that her syndromic complex was a self-inflicted one related to the localized administration of dissolved oxymorphone.

CONCLUSION

Our patient's biopsy along with the rapid response to eculizumab indicates that this distinct thrombotic microangiopathy is another complement mediated thrombotic microangiopathy syndrome. Opioid thrombotic microangiopathy has a varied clinical presentation and can mimic other catastrophic microangiopathy syndromes, all of which have in common a responsiveness to complement inhibition.

Degos disease: report of a case and review of the literature

We report the case of a 20-year-old woman with one-year history of asymptomatic pink papules on the abdomen, with central atrophy. Fever and symptoms suggesting involvement of other organs were absent. Histological examination revealed wedge-shaped area of cutaneous ischemia extending into the deep dermis with superficial and deep perivascular lymphocytic infiltrate. On this basis, we diagnosed malignant atrophic papulosis. Laboratory tests and instrumental investigation did not reveal any systemic involvement. The rarity of this disease makes early diagnosis challenging, even if clinical and histological patterns of the skin lesions are peculiar.

Degos' syndrome complicated by bowel perforation: focus on radiological findings

We describe a 50-year-old man who first presented with multiple skin lesions which were characteristic of Degos' syndrome. The patient developed multiple episodes of abdominal pain. Some episodes resolved with conservative management, for others he underwent urgent operations for bowel perforations. The patient subsequently underwent extensive small bowel resection, but further systemic deterioration ensued and he died. The imaging findings of Degos' syndrome and the implications of pneumatosis intestinalis and pneumoperitoneum are discussed.

Commentary on 'Degos disease: a C5b-9/interferon-α-mediated endotheliopathy syndrome' by Magro et al: a reconsideration of Degos disease as hematologic or endothelial genetic disease

Magro et al in April of 2011 published a new article in the American Journal of Clinical Pathology on the etiology and treatment of Degos Disease (DD), and importantly, its fatal variant malignant atrophic papulosis (MAP). Specifically, Magro noted that MAP is a disease involving the complement cascade that can be treated effectively with eculizumab. DD has two variants, a benign variant confined to the skin and a malignant (heretofore fatal) variant that involves the skin and systemic organs. Five aspects of DD are discussed: (1) the clinical findings of DD, (2) thrombosis and DD, (3) the histology of DD, (4) the presence of viral like inclusions in the endothelial cells of patients with DD, and (5) the lack of any apparent immune defect that relates to DD. It seems the previous criteria for Degos Disease must be amended. Paroxysmal nocturnal hemoglobinuria (PNH) is discussed and its relationship with DD explored. Eculizumab has been approved to treat paroxysmal nocturnal hemoglobinuria. A review of the data suggests that MAP is a hematological or endothelial disease like PNH. PNH, eculizumab, and data about DD is discussed to give a basis for understanding DD and speculate why eculizumab may be promising for the treatment of MAP.

Infantile neurological Degos disease

Degos disease, or malignant atrophic papulosis, is a rare vasculopathy of uncertain aetiology manifesting as a primary dermatological disorder in most cases, but with widespread systemic involvement developing in an undefined proportion of patients. Reported neurological features of Degos disease include ischaemic and haemorrhagic stroke, subdural effusion, seizures, neuropathy, transverse myelitis, and optic atrophy. The description of contrast enhancement of the leptomeninges possibly indicates a defect of blood vessel integrity likely explaining the pleiotropic neurological manifestations. Degos disease is usually considered a disorder of adulthood, although a small number of infantile cases have been described. Here, we report a female who demonstrated a neonatal onset of Degos disease, eventually showing the highly characteristic skin lesions together with ptosis and a generalized weakness as part of her systemic disorder. Subsequent exacerbations led to an inexorable neurodevelopmental and physical decline. CT scan revealed intracranial calcification, a feature described in two previous cases. Our report highlights the need to consider Degos disease in the differential diagnosis of childhood neurological disease with skin involvement.

Prominent Degos-like skin lesions in a patient with chronic cutaneous lupus erythematosus

Malignant atrophic papulosis, commonly known as Degos disease, is a rare vasculopathy encompassing both benign, cutaneous and lethal systemic variants. We report a case of chronic cutaneous lupus erythematosus in a 41-year-old male presenting with prominent Degos-like skin lesions. Multiple atrophic, porcelain-white, scar-like papules and plaques with dusky, erythematous borders, suggestive of malignant atrophic papulosis, were noted on the patient's back. Additional cutaneous findings included photo-distributed facial erythema and discoid lupus-like plaques on the face, shoulders, and arms. Clinicopathological correlation supported a diagnosis of chronic cutaneous lupus erythematosus; hydroxychloroquine was initiated with good clinical response. No new or active lesions were observed at the sixteen-month follow-up. This case highlights a rare skin finding associated with chronic cutaneous lupus erythematosus and underscores the importance of ruling out primary autoimmune disease, particularly lupus, before a diagnosis of malignant atrophic papulosis can be made.

[Case of disseminated intestinal and cutaneous thromboangiitis (Kohlmeier-Degos' syndrome)]

Disseminated intestinal and cutaneous thromboangiitis (Kohlmeier-Degos' syndrome) is a rare syndrome of unknown etiology, which is characterized by cutaneous and visceral involvement. Two (cutaneous and visceral) stages are identified. A fatal outcome is inevitable although there may be a long (8-20-year) course of the disease during a benign process. The causes of death are peritonitis, central nervous system impairments, pleurisy, pericarditis. The paper describes a case of disseminated intestinal and cutaneous thromboangiitis (Kohlmeier-Degos' syndrome) in a 32-year-old female patient who has died from intoxication due to severely impaired permeability of the epithelial barrier mainly of the large bowel (diphtheritic inflammation of the mucosa, severe inflammatory edema of the submucous layer, and fibrinous impregnation of the serous membrane).

[Köhlmeier-Degos disease (Malignant Atrophic Papulosis): a cause of recurrent multiple intestinal perforations]

Malignant Atrophic Papulosis (MAP) or Degos disease is a very rare vasculopathy affecting multiple systems. When associated with gastrointestinal tract or central nervous system involvment, patients with Degos disease have a poor prognosis and a high mortality. We report a case of Degos disease with systemic involvement, which ultimately caused peritonitis, sepsis, and death, despite all treatment. A 29-year-old man was admitted in June 2007 on the surgical ward of our hospital with acute generalized abdominal pain and multiple skin lesions. The patient had an appendectomy at another hospital 6 weeks before the current presentation. The exploratory laparotomy showed 2 perforations of the ileum. After the initial procedure, the patient developed spontaneous recurrent perforations of the small bowel and suffered another 3 reoperations. Neuroradiologic reports described central and peripheral nervous system involvement with progressive clinical deterioration and a meningovascular pattern at cerebral MRI. Despite aggressive treatment the patient died 3 months after the first surgical intervention.

[Degos' disease: A case report and review of literature]

A 18-year-old male patient's case was diagnosed as Degos'disease with pathognomonic skin lesions, accompanied by small bowel perforation, and reported here. Skin histopothological test show that the typical wedge-shaped necrobiosis and lymphocyte inflammatory infiltration. Vessels showed narrowing and thrombosis, with lymphocyte infiltration. Degos' disease is a systemic necrotizing vasculitis. Skin biopsy can confirm its diagnosis. Severe systemic complication should be prevented. Degos' disease should be considered in the differential diagnosis of skin lesions associated with systemic involvement.

Degos' disease (malignant atrophic papulosis) as a fatal cause of acute abdomen: report of a case

Degos' disease, otherwise known as "malignant atrophic papulosis," is a rare condition characterized by typical cutaneous lesions. Its involvement of the gastrointestinal (GI) tract is usually associated with a poor prognosis. We report a case of Degos' disease with GI involvement, which ultimately caused peritonitis, sepsis, and death, despite all treatment measures. A 59-year old woman was admitted to our hospital with acute generalized abdominal pain. The patient had presented initially with multiple skin lesions 2 years earlier, and even with surgery for small-bowel perforation 10 months before this admission, Degos' disease had not been diagnosed. Explorative laparotomy revealed multifocal, ischemic changes in the small bowel with perforation in the mid-jejunum. After the operation, she suffered recurrent small-bowel fistulas and died within 3 months. In a patient with acute abdominal pain and typical atrophic papules, clinicians should retain a high index of suspicion for Degos' disease with GI involvement, even though it is rare.

Lethal systemic Degos disease with prominent cardio-pulmonary involvement

Degos disease DD is a rare obstructive vasculopathy characterized by distinctive skin lesions. Involvement of the soles, palms and genitalia is rare. In most cases, disease has an unfavorable course and involves gastrointestinal tract, central nervous system and occasionally other organs. Pleural and pericardial involvements are usually minor manifestations with prolonged course. Death occurs in approximately 50% of the patients usually due to intestinal perforation or central nervous system bleeding. We describe a 48-year-old man of lethal systemic DD. Widespread skin lesions with involvement of palmoplantar surfaces, genitalia and scalp were ignored for 3 years, whereas the disease revealed own malignant nature. The disorder progressed to nervous, gastrointestinal and cardiopulmonary system that led to death after 5 months from onset of systemic involvement as severe restrictive cardio-pulmonary insufficiency. Autopsy showed diffuse fibrotic changes in serosal membranes and internal organs.

Small bowel infarcts in Degos disease

Degos disease is a rare idiopathic vasculopathy with multisystem involvement. We present a previously healthy 40-year-old woman who developed spontaneous small bowel infarctions and perforations 17 months after presentation with characteristic skin lesions. The abdominal CT findings of Degos disease, which have not been previously depicted in the radiology literature, are discussed.

Fallberichte

Morbus Köhlmeier-Degos is a rare systemic disease characterized by pathognomonic cutaneous lesions with typical histology. We report the case of a 22-year-old woman with a benign course of this disease and discuss therapeutical options. The patient presented with whitish papules on neck, trunk and extremities that slowly developed within seven months. Examination of the skin revealed about 20 papules of 2-5 mm size. The lesions were partly skin-colored, partly with an erythematous rim and showed a central porcelain-like atrophy. Histology showed an interface-dermatitis and a wedge-shaped mucin deposition with sclerosis of the upper reticular dermis. Organ manifestation was absent. The patient was started on a daily therapy of 300 mg acetyl salicylic acid. Over the course of 24 months single new lesions appeared at a reduced frequency. Apart from the malignant form of Morbus Köhlmeier-Degos there exists a benign course which may be successfully controlled with anti-platelet therapy. We speculate that the lack of vessel occlusion in the histology could be a hallmark of a benign form of this rare disease.