Cutaneous variant of angiokeratoma corporis diffusum associated with angiokeratoma circumscriptum
- Author(s): Sodeify, Manoochehr, MD;
- Aghaei, Shahin, MD;
- Monabbati, Ahmad, MD
- et al.
Published Web Locationhttps://doi.org/10.5070/D3548323hm
Cutaneous variant of angiokeratoma corporis diffusum associated with angiokeratoma circumscriptum.
From the Department of Dermatology1 and Pathology2, Shiraz University of Medical Sciences, Shiraz, Iran. : email@example.com
Manouchehr Sodaifi MD1, Shahin Aghaei MD1, and Ahmad Monabati MD2
Dermatology Online Journal 10 (1): 20
A 22-year-old male, born of non-consanguineous parents, was referred to our department with complaint of the insidious appearance of red-purple papules over the trunk with occasionally itching and pin-point bleeding, which had progressed over the past 4 years. These papules slowly increased in number and size. There was no history of anhidrosis, abdominal or bone pain, acral paresthesias, chest pain, or loss of visual acuity. No family member was affected by this disorder.
|Figure 3||Figure 4|
|Figure 3. Right lateral hip view of the same patient.|
|Figure 4. Left lateral hip view of the same patient.|
|Figure 5: Several weeks after treatment.|
On physical examination, the patient had normal physical and mental development. He was normotensive. Clusters of individual, punctate, dark red to blue-black papules were seen mainly over the anterior chest, back, and hips (Figs. 1 and 2). Thighs, penis, and scrotum were also involved (Figs. 3 and 4). The mucous membranes and nail folds were spared. Larger papules were hyperkeratotic. Over the lower back there was a circumscribed, dark brown, oval-shaped patch studded with hyperkeratotic, dark red-purple papules (Fig. 5). The latter localized lesions had been appeared at birth.
On investigation, his hemogram, urinalysis, CXR, abdominal ultrasound, slit-lamp examination of the cornea, ECG and echocardiography were within normal limits. Skin biopsies were obtained from papules of the diffuse lesions and circumscribed lesions. Histopathology results were the same in both diffuse and circumscribed lesions: mild hyperkeratosis, significant papillomatosis, and elongation of rete ridges. In the upper portion of dermis, just beneath the epidermis and between rete ridges, prominent dilated vascular spaces were noticed which were full of red blood cells. No significant pathology was seen in the mid and lower dermis and subcutaneous fat as well (Figs. 6 and 7).
On the basis of the above findings a final diagnosis of cutaneous angiokeratoma corporis diffusum associated with angiokeratoma circumscriptum was made.
We could not carry out enzyme deficiency detection studies in our case because of lack of such investigation facilities in our institution.
Systemic angiokeratoma corporis diffusum (Anderson-Fabry disease) is an unusual X-liked lysosomal disorder characterized by deficiency of α-galactosidase . The clinical manifestations of the disease predominantly result from the progressive deposition of Gal-Gal-Glc-Cer in the vascular endothelium . Onset of the disease usually occurs during childhood or adolescence with periodic crises of severe pain in the extremities (acroparesthesias) and the appearance of vascular cutaneous lesions (angiokeratomas), hypohidrosis or anhidrosis, and characteristic corneal and lenticular opacities .
Other features include varicose veins, stasis related edema, hypertension, cerebrovascular attacks, coronary artery disease , anorexia, weight loss, diarrhea , and febrile episodes with advancing age. The progressive accumulation of the ceramide leads to early demise associated with renal, cardiac, or cerebrovascular involvement .
The presumptive diagnosis of the hemizygous form of Fabry disease can be made by demonstration of corneal dystrophy, birefringent inclusions in the urinary sediment, or lipid-containing macrophages in skin or bone marrow biopsy .
Angiokeratoma circumscriptum is rare and most characteristically takes the form of an extensive vascular plaque, usually present from birth. The lesion is typically situated unilaterally on the foot or distal aspect of the leg, but can occur elsewhere. A typical lesion becomes increasingly studded with hyperkeratotic papules, and may bleed readily on trauma; it is without tendency to spontaneous improvement [3, 6].
Angiokertoma circumscriptum my be indistinguishable clinically from verrucous hemangioma. The main distinction between these conditions is the presence of angiomatous capillary endothelial proliferation in the latter .
When thrombosis occurs within the angiokeratoma circumscritum, malignant melanoma may be mimicked clinically . Association of angiokeratoma circumscriptum with angiokeratoma of the scrotum , angiodysplasia (Klipple-Trenaunay-Weber syndrome) Cobb syndrome, and other mixed vascular malformations have been reported .
Angiokeratoma circumscriptum is a nevoid hamartomatous lesion arising early in life during infancy or childhood, while the angiokeratoma corporis diffusum almost always occurs in association with enzyme disorders usually α-galactosidase-A enzyme deficiency (Anderson-Fabry disease ), an X-linked recessive disorder affecting male patients in adulthood .
The normal physical and mental development in our patient as well as normal physical and laboratory examinations are adequate reasons to exclude the systemic involvement seen in Fabry disease.
Few case reports of cutaneous variant of angiokeratoma corporis diffusum have been described in the literature [11, 12]. Absence of disease in the relatives of patients with purely cutaneous form and the apparent involvement of both males and females support the contention that this condition is a distinct clinical entity [11, 13, 14].
Small lesions may be treated by diathermy or curettage and cautery, but larger lesions will require treatment with argon laser , flash-lamp pumped dye laser , copper vapor laser , or surgical excision . We treated our patient by means of electrofulguration with a depilatory needle, and the outcome was acceptable (Fig. 5). To the best of our knowledge, there is no report of association between angiokeratoma corporis diffusum and circumscriptum in the literature to date.
References1. Calonje E, Jones EW. Vascular tumors. In: Elder D, Elenitsas R, Jaworsky C, Johnson BJ. Lever's histopathology of the skin. 8th. edn. Lippincott - Raven , Philadelphia 1997; 889- 932.
2. Desnick RJ, Eng CM. Fabry disease: _-galactosidase A deficiency (angiokeratoma corporis diffusum universale). In : Freedberg JM, Eisen AZ, Wolff K, Austen KF , Goldsmith LA , Katz SI , Fitzpatrick TB, eds. Dermatology in General Medicine Vol.2, 5th edn, McGraw-Hill, New York 1999; 1812-25 .
3. Black MM, Grawkrodger DJ, Seymour CA, Weismann K. Metabolic and nutritional disorders. In: Champion RH, Burton JL, Burns DA, Breathnach SM, eds. Textbook of Dermatology. Blackwell -Science, Oxford 1998; 2577 - 2677.
4. Nelis GF, Jacobs GJ. Anorexia, weight loss, and diarrhea as presenting symptoms of angiokeratoma corporis diffusum (Fabry - Anderson disease) Dig Dis Sci 1989 Nov ; 34(11):798-800.
5. Massi D, Martinelli F, Battini ML, Comin CE, Franchi A, Gioia O, et al. Angiokeratoma corporis diffusum (Anderson - Fabry's disease ): a case report. J Eur Acad Dermatol Venereol 2000 Mar ;14(2): 127-30.
6. Bang K. Two cases of angiokeratoma corporis circumscriptum. Acta Dermatol Venereol (Stockh ) 1947; 27:346-51
7. Lynch PJ, Kosanovich M. Angiokeratoma circumscriptum . Arch Dermatol 1967; 96: 665-8.
8. Goldman L, Gibson SH, Richfield DF . Thrombotic angiokeratoma circum- scriptum simulating melanoma. Arch Dermatol 1981; 117: 138-9.
9. Bruce DH. Angiokeratoma cirumscriptum and angiokeratoma scroti: report of a case. Arch Dermatol 1960; 81: 388-93.
10. Bisceglia M, Carosi I, Castelvetere M, Murgo R. Multiple Fordyce - type angiokeratoma of the scrotum. An iatrogenic case. Pathologica 1998 Feb; 90 (1): 46-50.
11. Gasparini G, Sarchi G, Cavicchini S, Bertagnolio B Angiokeratoma corporis diffusum in a patient with normal enzyme activities and Turner's syndrome. Clin Exp Dermatol 1992; 17:56-59.
12. Laxmisha C, Thappa DM, Karthikeyan K.Cutaneous variant of angiokeratoma corporis diffusum. Dermatology Online Journal 2003; 9(1):13.
13. Voglino A, Paradisi M, Dompe G, Onetti Muda A, Faraggiana T. Angiokeratoma corporis diffusum (Fabry's disease ) with unusual features in a female patient. Light and electron microscopic investigation. Am J Dermatopathol 1988 Aug ; 10(4) 343-8.
14. Gerbig AW, Wiesmann U, Gaeng D, Hunziker T. Angiokeratoma corporis diffusum without associated metabolic disorder (abstract). Hautarzt 1995 Nov; 46(11):785-8
15. Occella C, Bleidl D, Rampini P, et al. Argon laser treatment of cutaneous multiple angiokeratomas. Dermatol Surg 1995; 21: 170-2.
16. Grekin RC, Flynn TC, Cooper D, Geisse J. Efficacy of 2-mm spot size lens for the treatment of superficial vascular lesions with a flashlamp-pumped dye laser. Int J Dermatol 1997;36:865-9.
17. Lampins J, Emtestam L, Marcusson JA. Angiokeratomas in Fabry's disease and Fordyce's disease: Successful treatment with copper vapour laser. Acta Derm Venereol 1993;73:133-5.
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