Connections between serum Trimethylamine N-Oxide (TMAO), a gut-derived metabolite, and vascular biomarkers evaluating arterial stiffness and subclinical atherosclerosis in children with obesity

Introduction

Childhood obesity leads to early subclinical atherosclerosis and arterial stiffness. Studying biomarkers like trimethylamine N-oxide (TMAO), linked to cardio-metabolic disorders in adults, is crucial to prevent long-term cardiovascular issues.

Methods

The study involved 70 children aged 4 to 18 (50 obese, 20 normal-weight). Clinical examination included BMI, waist measurements, puberty stage, the presence of acanthosis nigricans, and irregular menstrual cycles. Subclinical atherosclerosis was assessed by measuring the carotid intima-media thickness (CIMT), and the arterial stiffness was evaluated through surrogate markers like the pulse wave velocity (PWV), augmentation index (AIx), and peripheral and central blood pressures. The blood biomarkers included determining the values of TMAO, HOMA-IR, and other usual biomarkers investigating metabolism.

Results

The study detected significantly elevated levels of TMAO in obese children compared to controls. TMAO presented positive correlations to BMI, waist circumference and waist-to-height ratio and was also observed as an independent predictor of all three parameters. Significant correlations were observed between TMAO and vascular markers such as CIMT, PWV, and peripheral BP levels. TMAO independently predicts CIMT, PWV, peripheral BP, and central SBP levels, even after adding BMI, waist circumference, waist-to-height ratio, puberty development and age in the regression model. Obese children with high HOMA-IR presented a greater weight excess and significantly higher vascular markers, but TMAO levels did not differ significantly from the obese with HOMA-IR

Conclusion

Our study provides compelling evidence supporting the link between serum TMAO, obesity, and vascular damage in children. These findings highlight the importance of further research to unravel the underlying mechanisms of this connection.

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Key Words

• TMAO
• arterial stiffness
• atherosclerosis
• cardiovascular risk
• carotid intima-media thickness
• childhood obesity
• high blood pressure
• pulse wave velocity

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MESH Headings

• Adult
• Female
• Humans
• Child
• Pediatric Obesity/complications
• Carotid Intima-Media Thickness
• Vascular Stiffness/physiology
• Pulse Wave Analysis
• Acanthosis Nigricans
• Atherosclerosis/diagnosis
• Atherosclerosis/etiology
• Biomarkers

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Berardinelli-Seip Congenital Lipodystrophy - A Case Report and Review of Literature

Berardinelli-Seip Congenital Lipodystrophy (BSCL), also known as congenital generalised lipodystrophy, is a genetic disorder where there is an absolute deficiency of adipose tissue. It affects the development of adipocytes and ultimately leads to an inability to store fat in adipocytes. It is extremely rare. Most of the cases reported are from Africa and North America. Only a handful of cases have been reported in the world. The aim of this case report is to highlight the significance of this rare metabolic disorder, which should be considered whilst managing young patients with severe insulin resistance. We present a case of a young Asian child with an increasing need for insulin for his diabetes. He was previously managed on the lines of type 1 diabetes mellitus and his insulin requirements kept on increasing. Diagnosis on the basis of genetic studies was not possible due to the non-availability of the test in Pakistan. BSCL is an infrequent condition leading to several cardiometabolic complications. Timely diagnosis can lead to better management and prevention of complications. Keywords: Insulin resistance, Lipodystrophy, Acanthosis nigricans, Hypertriglyceridemia, Genetic disease.

[Correlation between total testosterone levels and insulin resistance in patients with acanthosis nigricans and non-acanthosis nigrican]

OBJECTIVE

To investigate the correlation of the total testosterone (TT) level with insulin secretion and resistance in patients with acanthosis nigricans (AN) and non-acanthosis nigricans (NAN).

METHODS

This study was conducted in a total of 639 overweight patients (body mass index ≥24 kg/m²), including 137 female AN patients, 277 female NAN patients, 129 male AN patients, and 146 male NAN patients. Each group was further divided into 4 subgroups according to the quartile of TT level for comparison of insulin secretion and insulin resistance parameters.

RESULTS

Both female and male patients with AN showed obvious hyperinsulinemia with increased area under the curve for insulin (AUC-INS) (P < 0.05), increased homeostatic model assessment of insulin resistance (HOMA-IR) index (P < 0.05) and decreased whole-body insulin sensitivity index (WBISI) (P < 0.01) as compared with those in NAN groups, but these parameters did not show significant variations with the change of TT levels. In female patients with NAN, insulin secretion level increased progressively as the TT level increased; the AUC-INS increased (P < 0.01) and WBISI decreased significantly (P < 0.05) when the TT levels increased to Q4. In male patients with NAN, insulin secretion level increased progressively as the TT levels decreased, and the AUC-INS increased (P < 0.05) and the WBISI decreased significantly (P < 0.05) when the TT levels decreased to Q1.

CONCLUSIONS

The TT level has a significant effect on insulin resistance and insulin secretion, but its effect varies between genders and is more significant in NAN patients than in AN patients.

Metabolic Syndrome Among Primary Health Care Nursing Professionals: A Cross-Sectional Population-Based Study

This research aims at evaluating prevalence and factors associated with metabolic syndrome (MS) in primary health care (PHC) nursing professionals. A multicenter, population-based and cross-sectional study was conducted in a team-tested sample of 1125 PHC nurses in the state of Bahia, Brazil. Sociodemographic, labor, lifestyle and human biology variables were investigated by mean of anamnesis. MS was evaluated according to the criteria of the first Brazilian Guideline for Metabolic Syndrome, which fully adopts the criteria of the National Cholesterol Education Program's Adult Treatment Panel III. MS-associated factors were tested by using robust Poisson Regression. The prevalence of MS found was 24.4%; low High Density Lipoprotein (HDL) cholesterol was the most prevalent component of the syndrome. In the multivariate analysis, physical inactivity (PR = 1.25, 95% CI = 1.02-1.53), alcohol use (PR = 1.84, 95% CI = 1.22-2.77), acanthosis nigricans (PR = 3.23, 95% CI = 2.65-3.92), burnout syndrome (PR = 1.45, 95% CI = 1.17-1.81), (PR = 1.37, 95% CI = 1.12-1.69), working as a nursing technician (PR = 1.43, 95% CI = 1.14-1.80), were associated to MS. It was found that the prevalence of MS was high, which evidences the need for interventions in the PHC environment, improvement of working conditions, monitoring of worker safety and health, diet programs and physical activity.

[Paraneoplastic syndromes]

A paraneoplastic syndrome is a phenomenon or complex of symptoms that can occur with malignancy, without this being the result of tumour cells in the affected area. In this article, we describe the following paraneoplastic syndromes: thrombophlebitis migrans, clubbing, pemphigus, acanthosis nigricans, blue fingers, dermatomyositis, and myasthenia gravis.

Clinical and Biochemical Characteristics of Polycystic Ovarian Syndrome among Women in Bangladesh

Clinical and Biochemical characteristics age, central obesity, Glucose intolerance, lipid abnormality, thyroid function, prolactin level, clinical signs & symptoms and ultrasonographic ovarian feature of 70 women were studied and prevalence of hyper-prolactinemia, hypothyroidism and Metabolic syndrome were calculated in the Endocrine OPD of BIRDEM during November 2010 to May 2011.Age of the PCOS population was 23.02±7.04 year, central obesity in 81.4%, abnormal glucose tolerance in 47.1%, dyslipidemia in 45.7%, hypertension in 24.3%, hirsutism in 88.6%, acanthosis nigricans in 50%, polycystic ovaries by ultrasound (87%) cases. One third of the PCOS cases i.e.; 33% were without hyperprolactinemia or hypothyroidism or Metabolic Syndrome. And the rest 47 cases had one, two or all the 3 with them. The distribution was PCOS with hyperprolactinemia 18.6%, PCOS with hypothyroidism 11.4%, PCOS with Metabolic Syndrome 15.3%, PCOS with hyperprolactinemia with MS 8.6%, PCOS with hypothyrodism with MS 5.6%, PCOS with hypothyrodism with hyperprolactinemia 4.3% and rest 4.3% had all the 4 in combination. Blood glucose levels during OGTT and TSH levels of the group without Hypothyrid, hyperprolactinoma or Metabolic Syndrome were significantly lower (p≤0.008). Significant proportion of Bangladeshi women with PCOS has hypothyroidsm with or without high prolactin and also have higher incidence of metabolic syndrome. So, all PCOS patients should also be screened for hypothyroidsm and hyperprolactinemia.

[Leptin, adiponectin and sex hormone in benign acanthosis nigricans of males]

OBJECTIVE

To explore the serum levels of leptin, adiponectin and sex hormone and their relationship in benign acanthosis nigricans of males.

METHODS

A total of 15 males patients with benign acanthosis nigricans were recruited from January 2010 to December 2013. The serum concentrations of leptin, adiponectin and sex hormone were measured with radioimmunoassay and enzyme-linked immunoabsorbant assay (ELISA) respectively.

RESULTS

As compared with normal control, the values of body mass, body mass index and %Fat were much higher in benign acanthosis nigricans of males ((88 ± 6) vs (62 ± 5) kg, (31.7 ± 2.1) vs (22.2 ± 2.7) kg/m(2), 33.3% ± 2.6% vs 29.0% ± 5.8%, all P < 0.05) , leptin was much higher ((8.0 ± 1.1) vs (4.5 ± 1.5) µg/L, P < 0.01) , adiponectin was much lower ((27.7 ± 4.8) vs (38.6 ± 5.8) µg/L, P < 0.01) , estradiol and testosterone were much higher ((112 ± 28) vs (38 ± 7) pmol/L, (7.3 ± 1.9) vs (3.9 ± 2.0) nmol/L, both P < 0.01), luteinizing hormone was much lower ((128 ± 11) vs (155 ± 24) U/L, P < 0.01) . And prolactin and follicle stimulating hormone were not significantly different between two groups (both P > 0.05).

CONCLUSIONS

Benign acanthosis nigricans is associated with abnormal levels of lepin, adiponectin and sex hormone. And there may be some relationship between the abnormal levels of lepin and sex hormone in benign acanthosis nigricans.

Presence of type 2 diabetes risk factors in children

This study aimed to identify the prevalence of type 2 diabetes risk factors among elementary school-age children and determine eligibility for type 2 diabetes screening. A cross-sectional review of 971 school-based health clinic medical records of children in grades 1 through 5 was conducted. Relationships of risk factors associated with type 2 diabetes mellitus were examined to determine the prevalence of these risk factors in elementary school-age children. Screening guidelines for type 2 diabetes were applied to determine the prevalence of students meeting criteria for further screening. Almost 40% of the students had a body mass index (BMI) above the 85th percentile for age and gender. Forty-nine percent of the students belonged to a high-risk ethnic group. Acanthosis nigricans, an indicator of insulin resistance, was identified in nearly 27% of the student records. Forty-eight percent of the records identified the student as having a family history of diabetes. Significant correlations were found between the presence of acanthosis nigricans, high BMI, and a family history of diabetes. According to screening guidelines for type 2 diabetes in children, 39.3% of the elementary school children 10 years of age and older were eligible for type 2 diabetes screening. Almost 40% of children younger than 10 years of age had risk factors associated with screening criteria. These findings support the need for early detection of high-risk children and intervention strategies to decrease modifiable risk factors in elementary school-age children. The school nurse is in a pivotal role of identifying such at-risk students during annual, routine health screening practices.

Malignant acanthosis nigricans in rectal adenocarcinoma

A case of generalized malignant acanthosis nigricans is reported. The patient was asymptomatic of any gastrointestinal complaints and investigations revealed the presence of adenocarcinoma of the rectum. The association between paraneoplastic acanthosis nigricans and internal malignancy is well established and the most common association is with adenocarcinoma of gastrointestinal origin.

Metabolic consequences of childhood obesity - a preliminary report

INTRODUCTION

Childhood obesity is increasing in Sri Lanka. Obesity related morbidity is mainly associated with the metabolic syndrome (MetS) and non-alcoholic steatohepatitis (NASH). Recent studies have shown these serious health consequences in obese children.

OBJECTIVES

The objectives of our study were to document the presence of MetS and NASH in obese Sri Lankan children, to correlate the fat mass (FM) with the waist circumference (WC) and the body mass index (BMI), and to compare the association of the WC, BMI and the WHR (waist-hip ratio) with the metabolic derangements.

METHOD

Children attending the Obesity Clinic at Lady Ridgeway Hospital, Colombo, from November 2004 to September 2005 were studied. The relevant sociodemographic data, anthropometric measurements and examination findings were documented. After a 12-hour overnight fast, blood was taken for estimation of lipid profile, serum insulin, liver enzymes and blood glucose. The oral glucose tolerance test (OGTT) was done in children over 5 years of age. Fatty infiltration of the liver was assessed by identifying specific features on ultrasonography and the degree of infiltration was given a score. We modified the International Diabetes Federation (IDF) 2004 guidelines to define MetS. NASH was defined as fatty infiltration of the liver associated with a raised serum ALT.

RESULTS

Seventy children (40 boys) were studied. The mean (SD) age was 9.7 (2.5) and 9.3 (3.0) years for boys and girls respectively. Mean BMI was 25.9 in both groups. All patients had a WC > 98th percentile. MetS was found in 13 of the 63 (21%) children on whom all criteria were assessed. Sixty children had ultrasonography and NASH was seen in 11 (18%). The correlation of the percentage FM was greater with the BMI (r = 0.80; p < 0.001) than with the WC (r = 0.56; p < 0.001), but the WC was more significantly associated with the metabolic derangements than either BMI or WHR.

CONCLUSIONS

Serious metabolic abnormalities are found in obese Sri Lankan children and the WC is a reliable indicator of these derangements.

Influence of skin color on the diagnostic utility of clinical acanthosis nigricans to predict insulin resistance in obese patients

BACKGROUND

Skin color may influence the presence of acanthosis nigricans (AN) as predictor of insulin resistance (IR). The objective of this study was to determine how skin color influences the diagnostic utility of AN as a marker of IR.

METHODS

We designed a cross-sectional study. Subjects were classified according to their skin color (phototypes I-VI of Fitzpatrick), presence, and severity of AN (Burke quantitative scale). Blood samples were taken for measurement of glucose and insulin to calculate the Matsuda insulin sensitivity index (ISI).

RESULTS

Sixty two obese subjects with BMI of 39.6 +/- 8 were included. Males were more prone to AN (9/12, 75% vs. 24/50, 48%, p <0.085) than females. The neck was the most frequent affected body region (53/62, 85.5%), followed by the elbows (15/62, 24.2%), knuckles (6/62, 9.7%), and knees (4/62, 6.5%). No concordance was found among them. AN was more frequent in those with skin phototype IV (18/23, 78.3%, p = 0.001) than those with phototype III (12/23, 52.2%) and phototype II (3/16, 18.8%). The utility of AN on the neck to predict ISI <3.5 (surrogate of insulin resistance) was sensitivity, 66.7 (95% CI 40.9-79.5); specificity, 82.5 (95% CI 56-95); positive predictive value, 91%; negative predictive value, 48% (p <0.001 for all values).

CONCLUSIONS

People with skin phototype IV have a high frequency of AN on the neck, compared with those with phototypes II and III. Those with AN and skin phototype II showed high specificity and positive predictive values for insulin resistance. Thus, AN is a good marker for IR only in lower phototypes.

[Two cases of Costello syndrome]

We report two unrelated cases of Costello syndrome, presenting with poor postnatal growth, mild mental retardation, poor feeding, curly hair, coarse characteristic face, loose skin, hypotonia, and cardiac involvement. Nasal papilloma and acanthosis nigricans were the most characteristic features of this syndrome. Both cases had atrial fibrilation from infancy to early childhood. One patient had hypertonia in the lower extremities and pes equinovarus, while the other had hypotonia and pes planovalgus.

Ophthalmologic and systemic features of the Alström syndrome: report of 9 cases

The Alström syndrome is a rare autosomal recessive disorder characterized by pigmentary retinopathy, diabetes mellitus, sensorineural deafness and obesity. A normal intelligence is often present. We report 9 patients.

Nonalcoholic steatohepatitis in children

BACKGROUND

Nonalcoholic steatohepatitis occurs commonly in adults with obesity or diabetes mellitus. There are only a few reports of this condition in children.

METHODS

Prospective consecutive clinical series.

RESULTS

Between December 1985 and April 1995, 36 children (21 boys, 15 girls) were diagnosed with nonalcoholic steatohepatitis at the Hospital for Sick Children, Toronto. The median age at diagnosis was 12 years (range, 4-16 years). Most patients were referred because of elevated serum aminotransferases or abnormal hepatic sonogram. Thirty patients (83%) were obese. Two patients had diabetes mellitus at diagnosis, and it developed later in two. Fifteen patients had palpable hepatomegaly, and one of these had splenomegaly. None had physical signs of chronic liver disease. Thirteen of 36 patients had acanthosis nigricans. Serum aminotransferases were elevated in all but one patient. Tests for Wilson disease and chronic hepatitis B and C were negative. Serum lipid profiles were abnormal in 18 patients: 7 had hypercholesterolemia, and 11 had hypertriglyceridemia. Twenty-four of 31 examined had abnormal liver sonograms suggestive of fatty infiltration. Twenty-four patients underwent percutaneous liver biopsy: all showed large-droplet fat. Inflammation was present in 88% and fibrosis-cirrhosis in 75%. One 10-year-old patient had established cirrhosis at diagnosis.

CONCLUSIONS

Nonalcoholic steatohepatitis occurs in children, is clinically diverse, and may not be benign.

Partial face-sparing lipodystrophy (Köbberling-Dunnigan syndrome): report of a sporadic case

A sporadic case is presented of a 20-year-old female with partial face-sparing lipodystrophy, also known as the Köbberling-Dunnigan syndrome with the Type 1 clinical phenotype. This disorder affects the limbs and spares the face. The trunk is spared in the Type 1 phenotype but is affected in the Type 2 phenotype. The patient had the associated features of this syndrome including the hyperinsulinaemia, acanthosis nigricans and mildly raised triglycerides, but not diabetes mellitus.

Dunnigan-Kobberling syndrome: an autosomal dominant form of partial lipodystrophy

Dunnigan-Kobberling syndrome is a form of partial lipodystrophy characterized by sparing of the face. Despite descriptions of six families since 1974, details of total body adipose tissue distribution and studies of carbohydrate and fat metabolism are lacking. The mode of inheritance also remains unclear, with most authors favouring an X-linked dominant transmission lethal in the hemizygous male. We examined 23 members of a family, of whom at least eight had partial lipodystrophy. Auxological evaluation and cross-sectional imaging showed absence of subcutaneous fat, presence of adipose tissue inside the body cavities, and skeletal muscle hypertrophy. Biochemical evaluation identified insulin resistance but revealed inadequate suppression of non-esterified fatty acids. In this family, male-to-male transmission supports an autosomal dominant mode of inheritance for Dunnigan-Kobberling syndrome.

[A case of familial insulin resistance due to type A insulin receptor disorder]

We report a case of familial insulin resistance due to Type A insulin receptor disorder. The patient, a product of consanguineous marriage, was a 34-year-old man who had had diabetes mellitus since the age of 14 years. He was treated by insulin therapy but became blind due to diabetic retinopathy at the age of 25 years. He was 154 cm tall and weighed 41kg. He had hirsutism and acanthosis nigricans. Laboratory data revealed hyperinsulinemia (140-350 microU/ml), and glucose clamp study showed insulin resistance, i.e. decreased glucose metabolic clearance rate, 20% of normal. Insulin binding was decreased to 10.7-16.6% of normal in erythrocytes, cultured fibroblasts and transformed lymphocytes. Glucagon stimulated C-peptide levels decreased gradually during a 3 year follow-up period. Homologous missense mutation from Proline193 to Leucine193 was found in this patient. Heterologous mutation was found in his mother who showed mild diabetes but did not show hirsutism or acanthosis nigricans. These findings suggested that the patient's father had this mutation in his insulin receptor gene and that the homologous mutation gene provoked more severe diabetes mellitus than heterologous mutation in this case. The efficacy of sulfonylurea agents was seen in this patient. Furthermore, sulfonyl urea agents may be indicated for treating these patients, probably by increasing insulin sensitivity.

Hyperandrogenism: new insights into etiology, diagnosis, and therapy

Mutations in the genes for the insulin receptor, 21-hydroxylase, 11 beta-hydroxylase, and 3 beta-hydroxysteroid dehydrogenase isomerase enzymes are associated with hyperandrogenism. These genetic causes of hyperandrogenism account for less than 10% of all cases. A major goal of future research will be to identify other genetic causes of hyperandrogenism. Evidence continues to accumulate that luteinizing hormone, insulin-like growth factor I, and insulin are major factors regulating ovarian androgen production. Optimal therapy for hyperandrogenism probably includes simultaneous suppression of androgen production and blockade of androgen action.

Insulin resistant diabetes mellitus without the presence of insulin antibodies. A case report

A case of a 26-year old woman suffering from an insulin resistant diabetes mellitus for 14 years is described. Acanthosis nigricans was diagnosed in the patient's second year and the syndrome of Stein-Leventhal at the age of 15. Diabetes could not be properly controlled either with the daily dosis of insulin as high as 1140 U or with peroral tolbutamide. Fasting serum IRI concentrations were elevated, the secretoric response to the stimulation by glucose or tolbutamide was substantial and protracted. The hypoglycemic response to the i.v. application of commercial insulin was insignificant. Serum growth hormone levels were normal. No presence of insulin antibodies in the serum was detected.

Congenital generalized lipodystrophy

Six patients with congenital generalized lipodystrophy are described. They had generalized paucity of fat tissue, acanthosis nigricans, prominent superficial veins and muscle hypertrophy. They were mentally retarded. Three had corneal opacities. They had normal external genitalia and none was tall for age. Their bone age was advanced and some had minor skeletal anomalies and nephromegaly. The muscle histology on light microscopy was normal. The majority had elevated serum aldolase and to a lesser degree serum lactic dehydrogenase and creatinine phosphokinase. Four of five examined had a myopathic electromyogram. They had normal or deranged liver function tests. The fatty liver infiltration in one seems to be progressive. Four had a normal and two an abnormal metyrapone test. They had an age-dependent abnormality of growth hormone, insulin and carbohydrate homeostasis.

Patch testing in the rabbit using a modified human patch test method. Application of histological and visual assessement

A 5 h, semi-occlusive human patch test repeated daily for 5 days, was modified for use in the rabbit Using this method, the relative irritancy of three cosmetic samples of known human irritancy was determined in the rabbit. In addition, attention was paid to assessment methods and a detailed histological scoring system is described as well as two methods of visual assessment. In order to compare the effectiveness of these methods, the reaction to a series of concentrations of sodium lauryl sulphate was examined. All three assessment methods gave similar results and the merits of combining histological and visual assessment are discussed.

Cell-mediated immunity and antibodies to Herpesvirus hominis type 1 in oral leukoplakia and carcinoma

Cell-mediated and humoral immune responses to Herpesvirus hominis type 1 (HVH1) and Candida albicans were studied in patients with leukoplakia, showing a histological spectrum of changes from epithelial keratosis to acanthosis and atypia, and in patients with carcinoma. The results were ranked according to increasing values of stimulation indices of lymphocyte transformation to HVH1, and the corresponding macrophage migration inhibition indices, and complement fixing antibody titres of each patient were correlated. This revealed that most patients with epithelial atypia were clustered to that end of the spectrum which had the highest stimulation and migration indices to HVH1; this relationship was not evident with C. albicans. In patients with keratosis and acanthosis there was a significant lack of correlation between lymphocyte transformation and migration inhibition to both HVH1 and C. albicans. In carcinoma the indices of lymphocyte transformation and migration inhibition to HVH1 and C. albicans were depressed. Furthermore, a significant negative correlation was found between lymphocyte transformation and migration inhibition to HVH1, unlike the positive correlation in control subjects. Complement fixing antibodies to HVH1, HVH2, cytomegalovirus and adenovirus, and fluorescent antibodies to C. albicans failed to show a significant change in titre in any one group of subjects tested. The results suggest a cell-mediated immune defect in leukoplakia, with a dissociation between lymphocyte transformation and macrophage migration inhibition to HVH1 and C. albicans in cases of keratosis or acanthosis. A specific increase in cell-mediated immunity to HVH1 in leukoplakia with epithelial atypia and the sequential changes argue in favour of a possible participation of HVH1 in carcinomatous transformation of some leukoplakias.

CUTANEOUS LESIONS ASSOCIATED WITH INTERNAL MALIGNANCY

Internal malignant tumours may stimulate the formation of tumour antigens which, by means of an antigen-antibody mechanism, can cause pruritus, ichthyosis, erythroderma, acanthosis nigricans, dermatomyositis, erythema-urticarial and vesiculo-bullous skin eruptions.Tumours may also interfere with normal immunity responses and allow various localized skin eruptions such as herpes zoster and epidermophytoses to escape their normal boundaries and become generalized.Skin malignancies may also be a sign of decreased immunoallergic response and by their presence alert the physician to search for an internal malignancy, either one associated with the skin lesion, such as a lymphoma, or an unrelated tumour.