Advances in treatment for lipoid proteinosis (Urbach-Wiethe disease): a case report and systematic review

BACKGROUND

Lipoid proteinosis (LP), also known as Urbach-Wiethe disease, is a rare autosomal recessive genodermatosis, caused by mutations in the ECM1 gene. This results in the deposition of periodic acid-Schiff (PAS)-positive, hyaline-like material on the skin, mucosae and internal organs.

OBJECTIVES

To present a case report of LP and a systematic review to synthesize the scientific literature on the management of this uncommon and frequently missed diagnosis.

METHODS

We present a case report of a 48-year-old man with LP who exhibited significant improvement after oral acitretin therapy. To address the lack of large case-control studies on LP treatment, we performed a systematic review of the literature following the PRISMA 2020 criteria. The search was conducted in PubMed, Web of Science, Cochrane and Scopus databases from inception until June 2023. To assess the methodological quality of case reports and case series, we used the Joanna Briggs Collaboration critical appraisal tool.

RESULTS

We included 25 studies that met eligibility criteria. Data from 44 patients with a histopathologically confirmed diagnosis were analysed. Treatment ranged from systemic therapies (acitretin, etretinate, dimethyl sulfoxide, corticosteroids, penicillamine) to surgical or laser procedures. Regarding methodological quality, the main discrepancies arose in the reporting of participant characteristics and treatment interventions.

CONCLUSIONS

Low-dose oral acitretin could have potential in managing LP, exhibiting fewer side-effects compared with other therapeutic agents. Further research is needed to establish more comprehensive and evidence-based treatment guidelines.

[An atypical case of lipoid proteinosis]

The lipoid proteinosis is a rare autosomic recessive genodermatosis characterized histologically by deposits of hyaline-like eosinophilic material of characteristic distribution. We herein report the case of a 56-year-old man admitted for progressive aggravated dementia associated with a late-onset dysphonia. Histologic examination of cutaneous and laryngeal biopsies showed deposits of an amorphous and eosinophilic material arranged around vessels, and adnexal structures, stained by PAS and congo red negative. The detection of a mutation in the ECM1 gene confirmed the diagnosis of lipoid proteinosis of atypical clinical presentation.

Urbach-Wiethe disease in a young woman: A case report

Urbach-Wiethe disease (lipoid proteinosis) is an autosomal recessive disorder that is characterized by a general thickening of the skin and mucous membranes. We report the case of a 22-year-old woman with lipoid proteinosis who presented with hoarseness, poor dentition, and skin lesions, and we discuss the management of this rare disease.

Lipoid Proteinosis: An Unusual Presentation with Verruca Vulgaris

Lipoid proteinosis (LP) is a very rare, autosomally recessive, inherited disease. It is also known as Urbach Wiethe disease or Hyalinosis cutis et mucosa. LP usually runs a benign, stable, and slowly progressing course. We present one LP case with additional unusual dermatologic involvement; verruca vulgaris was superimposed on papular lesions of LP. To our knowledge, this case is the first and only one described in the literature. In this presentation, we discuss the possibility of predisposition to Human Papilloma Virus (HPV) infections in LP.

[Lipoid proteinosis of Urbach-Wiethe: a case report]

Lipoid proteinosis or Urbach-Wiethe disease is a rare autosomal recessive mucocutaneous disorder caused by mutation in the EMC1 gene. Hoarseness is observed in early childhood associated with infiltration and thickening of skin. Multiple systemic manifestations develop involving mucosal deposition of hyalin material. We describe a 12-year-old boy with typical manifestations: a hoarse voice, thick skin with yellowish papules, including the typical disposition on the margin of the eyelids, infiltration of the tongue and lips, and varicella-like scars. Histopathological examination revealed deposition of hyaline substance with PAS-positive diastase-resistance at the dermoepidermal junction and around vessels. Ultrastructural study showed considerable thickening of the basal lamina of vessels besides the intense deposition of amorphous material in the dermis. Genetic analysis was not available.

[Hyalinosis cutis et mucosae : 5 cases from Tabarka (Tunisia)]

BACKGROUND

Hyalinosis cutis et mucosae (HCM), is a rare autosomal recessive genodermatosis. Cutaneous features are characteristic and allow to suspect diagnosis.

AIM

To report a series of HCM.

METHODS

A retrospective study of all cases of HCM, diagnosed in a dermatology department over a period of 25 years (1983-2007).

RESULTS

Over the considered period, 5 new cases of HCM were diagnosed. Patients were aged between 14 and 41 years. They were 3 females and 2 males. All patients were native of Tabarka (northwestern Tunisia). The age of the onset of the disease varied from neonatal period to 5 years. Hoarseness was the first clinical manifestation in all cases. Skin lesions developed between the ages of 3 and 8 years. Vesiculobullous lesions were observed in 2 patients. Moniliform blepharosis was seen in all patients. Warty and hyperkeratotic papules were observed in 3 patients. Diffuse thickening of the skin was seen in 3 patients. Lesions were primarily distributed on the face. All patients presented diffuse scars. Linear palmoplantar keratoderma was seen in one patient. Asymptomatic endocranial calcifications were noted in 4 patients. A pituitary adenoma was noted in one patient. Histopathological examination of a skin lesion revealed a typical pattern of HCM. Two patients were treated with systemic retinoids without improvement.

CONCLUSION

We reported five new cases of HCM. All patients were native from Tabarka. We report also one case of linear palmar keratoderma associated with HCM. This association was not reported in the literature. Finally, the association HCM-pituitary adenoma, seen in one patient, may be fortuitous.

[Manifestation and treatment of lipoid proteinosis in larynx]

OBJECTIVE

To investigate the manifestation, characteristics and treatment of lipoid proteinosis (LP) in larynx.

METHODS

Sixteen cases of LP with hoarseness as the first sign were reported. The onset was in the newborn period in 10 cases. The upper eyelids were infiltrated in all cases, 13 of them reported an age of onset older than 6 - 8 years. The laryngeal behaviors and its treatment, multisystem manifestations, and characteristics of histopathology were evaluated.

RESULTS

One patient had moderate hoarseness, and the others had severe hoarseness. Videolaryngoscopy revealed thickening of the interarytenoid region and irregularities along the rims and the surface of the vocal folds due to yellowish papules. Oral tissues showed yellow-white infiltrates in 13 cases (81.3%). Whitish moniliform papules on the upper eyelids were found in all cases. Pock-like or acneiform scars were particularly evident on the face and the limbs in 14 cases (87.5%). Histologically, it was characterized by deposition of hyaline material in the submucosa and dermis of the eyelid or larynx with periodic acid-Schiff-positive and Congo red stain-negative. Eight patients underwent microlaryngosurgery for the excision of deposits in the vocal folds. The vocal function was significantly improved after surgery.

CONCLUSIONS

One of the most common features of lipoid proteinosis is hoarseness since infancy with laryngeal involvement. LP patients also display skin or mucosa infiltration of multiple systems. Microlaryngosurgical excision of the deposits in the vocal fold could improve the voice.

Urbach-Wiethe disease: experience at a tertiary care hospital in Abbottabad, Pakistan

BACKGROUND

Urbache-Wiethe disease (Lipoid Proteinosis) is a rare autosomal recessive disorder characterized by the deposition of an eosinophilic hyaline-like material in the skin, larynx, mucous membranes, brain, and other internal organs.

METHODS

A survey of one year duration was carried out prospectively at the Department of Dermatology, Ayub Teaching Hospital Abbottabad to document cases of lipoid proteinosis. Cases were selected from the outpatients department on the basis of clinical presentation and were subjected to detailed examination and investigations after admission.

RESULTS

Five cases were diagnosed as suffering from Lipoid Proteinosis over the study period. All had typical features of hoarseness, skin lesions and tongue involvement. All were born of consanguineous parents. Three (60.0%) cases also gave a history of involvement of other family members, particularly cousins.

CONCLUSION

This rare disease occurs in Hazara Division of North West Frontier Province of Pakistan with an as yet undetermined frequency and clinical suspicion is warranted to diagnose cases with the typical presentation.

Lipoid proteinosis (Urbach-Wiethe disease): a case report from India

Lipoid proteinosis (Urbach-Wiethe disease) is a rare autosomal-recessive anomaly that primarily affects the skin and the mucosa of the upper aerodigestive tract in children. It is caused by hyaline deposits in tissues. Hoarseness secondary to laryngeal involvement is frequently the first presenting feature. It is important to consider this disease in the differential diagnosis of hoarseness because it might lead to life-threatening airway compromise. We report a case of lipoid proteinosis in a 12-year-old girl who presented with hoarseness and skin lesions.

Vesiculobullous lesions in lipoid proteinosis: a case report

Vesiculobullous disorders in a child can be a diagnostic challenge. Common causes of blisters in early childhood include genodermatoses like epidermolysis bullosa and infections like herpes simplex. Lipoid proteinosis may rarely present with vesiculobullous lesions in childhood. We report a child, who presented in early childhood with blistering dermatosis. On long term follow-up, typical features of lipoid proteinosis developed. A high index of suspicion is required when one deals with blistering dermatosis in a child.

Síndrome de Urbach-Wiethe: relato de caso

We present a case of Urbach-Wiethe syndrome with typical findings, including ocular lesions. A 15-year-old girl was referred to our department complaining of itchy eyelid lesions (moniliform blepharosis) associated with other systemic manifestations. Diagnosis was confirmed by performing skin biopsy. Artificial tears were prescribed, with partial relief of the symptom. The objective of the present study is to describe a typical case of Urbach-Wiethe syndrome attended at the Ophthalmologic Sector of the Medical School of Marília.

Bilateral lens subluxation in a case of lipoid proteinosis

We report a patient who presented with pain, redness, and diminution of vision in the right eye and low vision in the left eye. Ophthalmologic examination showed characteristic eyelid lesions, anterior dislocation of the crystalline lens in the right eye, and nasal subluxation in the left eye. The patient's voice was hoarse, and he had skin lesions. After histopathologic examination of the skin biopsy, lipoid proteinosis (LP) was diagnosed. Bilateral pars plana lensectomy was performed. The ophthalmic manifestations of LP are discussed.

Epilepsy and migraine in a patient with Urbach-Wiethe disease

We report the clinical, neuroradiological, and molecular genetic findings in a patient with lipoid proteinosis or Urbach-Wiethe disease. Interestingly, in this patient epilepsy and migraine were the symptoms leading to the diagnosis of the disease, contrary to most patients in whom skin abnormalities are the first recognized symptoms.

[Lipoid proteinosis in the mouth and laryngeal structures: a case report]

Lipoidproteinosis is an uncommon autosomal recessive disorder characterized by accumulation of hyaline material in the skin, oral and laryngeal mucosa. A 23-year-old woman presented with complaints of hoarseness and dryness of the mouth. Yellowish papular deposits were noted in the oral and laryngeal mucosa on physical examination, and in vocal cords and laryngeal structures during laryngoscopy. The lesions were removed and histopathologic diagnosis was made as lipoidproteinosis. A slight improvement was obtained in hoarseness. A control examination after two years showed an increase in the extent of hoarseness and new deposits in the vocal cords. The lesions were removed by microlaryngeal surgery.

Manifestations ophtalmologiques de la hyalinose cutanéo-muqueuse

INTRODUCTION

Lipoid proteinosis (LP), also known as hyalinosis (or lipoidosis) cutis et mucosae or Urbach-Wiethe disease, is a rare autosomal recessive disorder. It is associated with deposits of protein-lipid complexes in various tissues including the skin and mucous membranes. Ophthalmologic manifestations are frequent and can affect visual prognosis.

CASE

This 28-year-old patient presented vesiculobullous lesions of the face that developed into varioloid scars associated with hoarseness. Ophthalmologic examination revealed unilateral lesions including hyaline deposits on the palpebral margins, iris, and trabecular zone, complicated by uveitis, cataract, and glaucoma, which caused the functional loss of the left eye. Histological examination of a cutaneous biopsy confirmed the diagnosis.

DISCUSSION

Involvement of the eyelids is characteristic, and moniliform blepharosis is pathognomonic and frequent. This case featured a rare intraocular form (uveitis). Deposits may be found on the conjunctiva, cornea, trabecula and Bruch membrane. Conjunctival or cutaneous biopsy confirms the diagnosis. Available treatment is quite limited.

"Free-floating" desmosomes in lipoid proteinosis: an inherent defect in keratinocyte adhesion?

The classic features of lipoid proteinosis - beadlike papules and hoarseness - result from the accumulation of hyaline material in the mucocutaneous dermis. However, the characteristic manifestation in children - erosive, crusted lesions that lead to scarring - is rarely discussed and poorly understood. Lipoid proteinosis results from mutations in extracellular matrix protein 1, but the function of this protein is largely unknown. We performed ultrastructural studies on lesional epidermis, cultured monolayer keratinocytes, and raft keratinocyte cultures from blistering lesions of a child with lipoid proteinosis. All sections showed the dissociation of relatively intact desmosomes from keratinocytes, with desmosomes that were "free-floating" in the intercellular spaces or attached by thin strands to the cell membrane. These changes were present in serial sections of both tissue and cultured keratinocytes, suggesting this observation to be an inherent feature of keratinocytes devoid of extracellular matrix protein 1, rather than an artifact. Although additional patients should be studied, the diminished appearance of the inner dense plaque - the region of attachment of keratin intermediate filaments to desmosomal proteins - provides preliminary evidence that extracellular matrix protein 1 may participate in attaching keratin intermediate filaments to desmosomal region protein(s).

[Unusual presentation of pulmonary alveolar proteinosis]

Pulmonary alveolar proteinosis is a rare disease characterized by the accumulation of granular lipoproteinaceous material within the alveoli; the interstitium is preserved. We report the case of a 27-year-old patient hospitalized for exploration of asymptomatic bilateral interstitial syndrome. Neither the radiographic signs nor the aspect of bronchoalveolar lavage was typical. The diagnosis was confirmed by pathology examination of surgical lung biopsy specimen which revealed lesions of interstitial fibrosis and cholesterol granulomas in association with pulmonary alveolar proteinosis. Since there was no functional deterioration, therapeutic abstention was decided.

Clinical and molecular abnormalities in lipoid proteinosis

Lipoid proteinosis (hyalinosis cutis et mucosae) is a rare, autosomal recessive disease. The main clinicopathological features comprise skin and mucous membrane infiltration and scarring with deposition of hyaline material. In this report, we describe a 6-year-old boy in whom a diagnosis of lipoid proteinosis was first suspected when he presented with blisters and erosions at 4 years, a history of life-long dysphonia and a previous epileptic convulsion. The diagnosis was confirmed by histology and identification of a homozygous frameshift mutation, 501insC, in exon 6 of the gene encoding extracellular matrix protein 1, ECM1. Lipoid proteinosis may show protean clinical features and be difficult to diagnose on clinical grounds alone. This case report illustrates that lipoid proteinosis may show protean clinical features and yet remain undiagnosed for many years. Although the gold standard for definite diagnosis remains histology, molecular characterisation of the gene mutation will add to our understanding of genotype-phenotype correlation and perhaps to the development of a rationale for future therapeutics.

Lipoid proteinosis of larynx: review of four cases

Lipoid proteinosis is a rare autosomal recessive disorder characterized by intercellular deposition of an amorphous hyaline material. It mainly involves skin and mucosal membranes of upper aerodigestive tract as well as central nervous system, lung, lymph nodes and striated muscles. Etiology and pathogenesis are unknown. Infantile hoarseness is a common presenting feature of the disease due to infiltration of larynx. In two-thirds of the cases, voice changes are present at birth or in early infancy as the first manifestation. We present four patients with lipoid proteinosis involving skin, oropharynx and larynx.

Hyalinosis cutis et mucosae: a 30 year follow up of a female patient

Hyalinosis cutis et mucosae is an inherited disease, characterized by deposition of a hyaline-like substance in the dermis and internal organs. In the present study, we report a 30 year follow up in a female patient with hyalinosis cutis et mucosae treated using dermabrasion and oral retinoids. In our opinion, the lesion on uncovered body areas should be corrected as soon as possible to enable a normal psychophysical development. The lesions on skin and oral mucosa may be successfully removed without remission with dermabrasion in early childhood. In addition, oral retinoids in adulthood may produce some improvement.

Lipoid proteinosis in siblings

Two sisters, aged 16 and 11, presented with skin lesions and hoarseness since early childhood. Skin lesions consisted of infiltrated warty nodules, and papules over elbows, axillae, and hands. The oral mucosa, tongue, lips, larynx, and vocal cords also showed infiltration. The characteristic beaded papules on eyelid margin and hoarseness pointed to the rare diagnosis of lipoid proteinosis.

Lipoid proteinosis in two siblings: a report from south India

A 6-year-old girl and her 9-year-old brother, born of nonconsanguineous parents, had hoarseness and multiple, asymptomatic, raised skin lesions present since childhood. On examination, both siblings had hoarseness and numerous skin-colored, waxy papules distributed over the forehead, face, neck, axilla, groin, and extremities. Acneiform (pocklike) scars were present on the face, trunk, and extremities. Eyelid beading (moniliform blepharosis) was present over bilateral upper and lower eyelids. The tongue, lips, and frenulum were thickened and infiltrated, and the patients were unable to protrude the tongue out of the mouth. The scalp had patchy alopecia. Histological examination of representative skin specimens (from both siblings) showed deposition of pink, amorphous material in the papillary dermis, around blood vessels, and around appendages. These deposits stained positive with Periodic Acid-Schiff stain, were diastase resistant, and were negative for Congo red, confirming our clinical diagnosis of lipoid proteinosis. Over 250 cases of this rare disorder have been described in the literature, but occurrence of lipoid proteinosis in siblings is rare.

D-penicillamine treatment for lipoid proteinosis

Lipoid proteinosis, a rare disorder inherited in an autosomal recessive fashion, is characterized by the deposition of hyaline-like material in the skin, mucous membranes, and other tissues. Perturbation of collagen metabolism has been suggested to play an important role in the pathogenesis. No effective therapy is available for the disease. The chelating agent D-penicillamine has long been used to treat several diseases. In addition to its immunosuppressive and anti-inflammatory effects, it also impairs fibroblast proliferation and inhibits the formation of the cross-links in collagen and elastin fibers. A 13-year-old girl was clinically and histologically diagnosed with lipoid proteinosis. We treated her with 600 mg/day of D-penicillamine for 2 years. The patient had improved clinically and histopathologically by the end of this treatment. We suggest D-penicillamine as a promising agent, even in low doses, for the treatment of lipoid proteinosis.

[Pulmonary alveolar proteinosis]

Pulmonary alveolar proteinosis (PAP) is a rare, diffuse infiltrative lung disease of unknown etiology characterized by accumulation of abnormal lung surfactant in the alveoli and distal airways. Although it was first described in 1958, few large scale studies have been published. The diagnosis is conventionally based on lung biopsy and the value of less invasive procedures such as bronchoalveolar lavage (BAL) remains controversial. A multi-center retrospective study was conducted in an attempt to update epidemiological, clinical and long term outcome and to assess the usefulness of chest CT scan and BAL in the management of a large homogeneous series of 41 patients. Inclusion criteria required a clinical picture compatible with PAP and either histological confirmation, or a BAL with a milky macroscopic appearance coupled with positive staining to PAS. Mean age was 48.8 years with a 4: 1 male predominance. The prevalence of smokers (80%) and occupational exposure to various inhaled dusts (39%) was high. The clinical, roentgenographic and functional features were in keeping with previous series. Worsening dyspnea was the most common symptom. Other common manifestations were dry cough, recurrent lung infections, weight loss, finger clubbing, crackles and cyanosis. LDH serum levels were increased in 51% of cases. Lung function tests usually showed a mild restrictive ventilatory defect with hypoxemia and reduced DLCO. Chest X ray revealed bilateral ground glass opacities with consolidation or air bronchogram involving peri-hilar or lower lobes. Chest CT scan, performed in 38 patients, revealed a similar pattern in most of them with diffuse intra-alveolar ground glass opacities (33/38) and interlobular thickening (35/38), resulting in a crazy paving appearance in the typical geographic pattern (32/38). This latter aspect was highly suggestive of the diagnosis. Segmental BAL led to a definitive diagnosis in 62% and lung biopsy was only required in 38% of cases. These data suggest that careful BAL analysis can be sufficient to provide a diagnosis without the need for a lung biopsy. During follow-up, spontaneous remission or improvement was reported in 26%. Segmental (n=3) or whole lung lavage (n=22) was required in 62.5% with a favorable course (complete remission 37%, improvement 34%, stable course 21%) in 92% of the cases. In this series the overall prognosis for PAP remained good, although unpredictable.

Periodontal lesions in lipoid proteinosis

Lipoid proteinosis is a rare autosomal recessive heritable disease. Clinical features are hoarseness starting in infancy and the formation of yellowish papules and plaques on the skin and mucous membranes of the nose, oral cavity, pharynx and larynx. Light and electron microscopy demonstrates a subepithelial accumulation of PAS-positive (hyaline) material around blood vessels and in the dermis. This case is unusual in that the gingiva is also involved in the lipoid proteinosis.

Lipoid proteinosis: report of four siblings and brief review of the literature

Lipoid proteinosis (Urbach-Wiethe disease) is a rare autosomal recessive disorder associated with deposition of periodic acid-Schiff (PAS)-positive hyaline material in various tissues including skin, mucous membranes, and internal organs. A family is reported in which four siblings (two boys and two girls) born to nonconsanguineous parents had lipoid proteinosis. All had the characteristic hoarseness of voice and three had skin lesions. The diagnosis was confirmed by the presence of typical features on light and electron microscopy.

[Idiopathic diffuse lung diseases with alveolar infiltration]

Diffuse idiopathic pneumonia with alveolar filling gather disorders whose clinical and radiological aspects are varied. It is important to precisely identify them because of the prognostic and therapeutic implications suitable for each one of them. Among these, it is necessary to distinguish the eosinophilic pneumonias, wether acute or chronic, which are characterized by circulating and (or) alveolar hypereosinophilies; the diffuse alveolar haemorrhages whose potential severity requires an early recognition in order to institute a treatment without delay; the pulmonary alveolar phospholipoproteinosis can be easily evoked because of their particular radiological features, associated with a lactescent aspect of bronchoalveolar lavage. Lastly, bronchiolo-alveolar carcinoma and more exceptionally the pulmonary alveolar microlithiasis must be considered.

Late onset hyalinosis cutis et mucosae

Two cases of non-familial, late onset (50 and 62-years-old) hyalinosis cutis et mucosae were studied and compared with classical early onset cases. Late onset cases showed essentially the same histological and ultrastructural features described for early onset cases. The late onset variety should be distinguished from other diseases; they resemble systemic amyloidosis and sometimes the adult form of colloid milium.

Lipoid proteinosis of the oral mucosa: case report and review of the literature

We describe a 37-year-old woman who presented with progressive mouth dryness. Physical examination revealed long-standing plaques on the face and upper limbs, papular lesions of the oral cavity and tongue firmness. A lower lip biopsy was performed. Light microscopy demonstrated accumulation of PAS-positive material around blood vessels, capillaries and salivary gland canaliculi as well as focally massive hyaline deposits in the submucosa. Immunohistochemistry revealed widespread presence of type IV collagen in the hyaline material and around thickened blood vessels. Laminin immunoreactivity was particularly strong at thickened basement membranes. The above findings were compatible with lipoid proteinosis, which is likely to involve primary perturbation of collagen metabolism and production of glycoproteins.

Cutaneous deposition diseases. Part I

The cutaneous deposition disorders are a group of unrelated conditions characterized by the presence of either endogenous or exogenous substances within the dermis or the subcutis. Part I of this two-part series will focus on metabolic processes involved in the endogenous deposition in the various forms of amyloidosis, porphyria, colloid milium, and lipoid proteinosis. We will also review the clinical, histologic, biochemical, and ultrastructural findings relevant to each disorder. Basic mechanisms of pathogenesis, diagnostic modalities, and treatment options are also discussed.

Lipoid proteinosis: a case report

An 8-year-old Italian boy, born to consanguineous parents, with clinical, histopathologic, and ultrastructural findings of lipoid proteinosis is reported. The main signs of the syndrome-papulonodular, hyperkeratotic and verrucous lesions distributed over the skin of the head and extremities, hoarseness, and dysphagia-were present in the child. The mother had papulonodular lesions on her hands and also complained of slowness in healing.