Oral involvement of recessive dystrophic epidermolysis bullosa inversa

The inversa subtype of autosomal recessive dystrophic epidermolysis bullosa (EBDR-I) is a rare variant characterized by lesions involving primarily the flexural areas of the body. The purpose of this investigation was to characterize the oral manifestations of this unusual dermatologic condition. Ten individuals having EBDR-I were evaluated and compared with an age and sex-matched population of unaffected individuals that served as controls. The diagnosis of EBDR-I was confirmed by skin biopsy that demonstrated tissue separation below the lamina densa and the clinical presentation of blister formation that typically localized to flexural areas. There was clinical variability in the severity and distribution of skin involvement; however, none of the affected individuals demonstrated pronounced digital webbing, severe generalized blistering or growth retardation characteristic of the Hallopeau-Siemens form of EBDR. Oral involvement was seen in all cases with ankyloglossia, loss of tongue papillae and obliteration of the oral vestibule between the lips and gingiva being typical. The oral opening was significantly reduced in older EBDR-I individuals compared with matched controls, confirming that acquired microstomia is a characteristic of EBDR-I. The teeth were not clinically abnormal or malformed and showed no evidence of generalized enamel hypoplasia. Despite this, the prevalence of dental caries in EBDR-I individuals was significantly higher than the control group. The inversa form of EBDR presents with oral findings that are similar but generally milder than those seen in the Hallopeau-Siemens variant of EBDR.     

Cultured keratinocyte allografts and wound healing in severe recessive dystrophic epidermolysis bullosa

BACKGROUND: Patients with recessive dystrophic epidermolysis bullosa (RDEB) frequently have painful erosions that are slow to heal. There is no definitive treatment; therefore any therapy that improves wound healing would be beneficial to these patients. OBJECTIVE: Our purpose was to assess the effects of cultured allogeneic keratinocytes on wound healing in RDEB. METHODS: Ten patients with RDEB and dermatome-induced superficial dermal wounds were studied. Cultured keratinocyte grafts were applied to part of the wound, with another part left ungrafted. Both sites were assessed clinically and microscopically, particularly with regard to basement membrane zone reconstitution. RESULTS: Apart from minor differences in keratinocyte differentiation and a moderate analgesic effect induced by the graft, there were no other distinguishing findings in wound healing in the grafted and nongrafted sites. CONCLUSION: There was little clinical benefit from cultured keratinocyte allografts in wound healing in RDEB. However, this study showed that RDEB keratinocytes have an inherent capacity to express some type VII collagen epitopes transiently during wound healing, although this was not associated with the detection of anchoring fibrils.     

A case of dystrophic epidermolysis bullosa: surgical treatment for hand contracture using abdominal skin flap

OBJECTIVE: To describe a new method for measuring lateral neck flexion range of motion (ROM), document the reliability of the method and present estimates of normal. SUBJECTS: One hundred thirty-five subjects ranging in age from 14-95 yr. Two physical therapists with 13 and 2 yr of experience, respectively, served as testers. INTERVENTION: Measurement of active lateral neck flexion ROM using a universal goniometer modified by the placement of a portion of a small paper clip through the axis. The goniometer arms were aligned with the subject's nose, and the free-swinging paper clip (pendulum) was used as a marker. The more experienced therapist measured lateral flexion of 100 subjects to establish intratester reliability and estimates of normal. Both therapists measured 35 subjects to determine intertester reliability. MAIN OUTCOME MEASURE: Degrees of lateral neck flexion. RESULTS: Intraclass correlation coefficients for intratester reliability exceeded 0.90. Coefficients for intertester reliability were 0.86 and 0.65. ROM decreased with increasing age. CONCLUSION: The modified goniometer is inexpensive, easy to use and can yield high intratester reliability and satisfactory intertester reliability. The estimates of normal provide preliminary values with which a patient's lateral neck flexion ROM can be compared.     

Novel COL7A1 mutations in dystrophic forms of epidermolysis bullosa

OBJECTIVE: To characterize the use of the esophageal tracheal combitube (ETC) in trauma patients who fail orotracheal rapid sequence intubation (RSI). DESIGN: Prospective protocol design and retrospective chart review. MATERIALS AND METHODS: Flight nurses were trained in the use of the ETC by mannequin simulation, videotape review, and didactic sessions. ETC insertion was attempted after failure of two or more attempts at orotracheal RSI. Over a 12-month period, 12 patients had ETC insertion, and 10 cases qualified for review. Injuries, number of failed orotracheal RSI attempts, definitive airway, initial arterial blood gas results, and outcome were recorded. RESULTS: ETC insertion was successful in all 10 patients in whom it was attempted. Definitive airway control was achieved by conversion to orotracheal intubation in seven patients, emergency department cricothyroidotomy in one patient, and operative room tracheostomy in two patients. No patient died because of failure to control the airway. Seven patients requiring ETC had mandible fractures. CONCLUSION: ETC insertion is an effective method of airway control in trauma patients who fail orotracheal RSI. It may be particularly useful in the patient with maxillofacial trauma and offers a practical alternative to surgical cricothyroidotomy in difficult airway situations.     

Differential regulation of collagenase and stromelysin mRNA in late passage cultures of human fibroblasts

Nontransformed human fibroblast cell cultures have been extensively studied as an in vitro model for cellular senescence. Recently there has been considerable interest in using the human fibroblast in the identification of genes relevant to the process of replicative senescence. We demonstrated that in comparison with early passage cultures the expression of collagenase and stromelysin mRNAs and proteins was increased > 8 x in late passage cultures of human fibroblasts and, in addition, expression of Il-1 alpha, a cytokine that regulates collagenase and stromelysin expression, was also significantly increased in late passage cell cultures. These findings suggested the hypothesis that constitutive Il-1 alpha expression in late passage cells may coordinately regulate the age-associated increase in the expression of collagenase and stromelysin. To test this hypothesis we examined the effects of long-term Il-1 alpha treatment, serum starvation, and cycloheximide inhibition on collagenase and stromelysin mRNA levels in early and late passage human fibroblast cell cultures. Here we report that in late passage cell cultures, collagenase and stromelysin mRNAs respond differentially to Il-1 alpha, serum starvation, and cycloheximide addition. Continuous exposure to Il-1 alpha reduced the half-life of stromelysin mRNA but had little effect on the half-life of collagenase mRNA. In contrast to stromelysin, the collagenase mRNA level is dependent on serum factors. Collagenase is induced during recovery from cycloheximide inhibition, but stromelysin expression is not affected. These results establish that collagenase and stromelysin mRNAs are differentially regulated in both early and late passage human fibroblasts and suggest that the mechanisms responsible for the age-associated increase in the two mRNAs are different. In addition, these studies support the conclusion that continuous long-term exposure to Il-1 alpha, a condition that is characteristic of late passage cells, is not the factor responsible for the high levels of collagenase expression, but may be critical for stromelysin expression.     

Identification of a glycine substitution and a splice site mutation in the type VII collagen gene in a proband with mitis recessive dystrophic epidermolysis bullosa

Dystrophic epidermolysis bullosa (DEB) is a genodermatosis characterized by fragility of the skin and mucous membranes. Underlying mutations in the DEB phenotype have been detected in the gene encoding type VII collagen (COL7A1), both in the dominant and recessive forms of DEB. In this study, we searched for mutations in a proband with a mild form of DEB by PCR amplification of segments of COL7A1, followed by heteroduplex analysis. Examination of PCR fragments corresponding to exons 3-4 and exons 51-53 revealed heteroduplexes. Direct sequencing of the PCR fragment containing exon 3 revealed a previously reported A-to-G transition in the 5' donor splice site of exon 3 in the proband and in the clinically unaffected father, while direct sequencing of the PCR fragment containing exon 53 revealed a novel glycine substitution G1652R in the proband and in the clinically unaffected mother. Patients with relatively mild DEB and no family history are frequently diagnosed as a de novo case of dominant DEB, although a mild case of RDEB cannot be excluded on the basis of clinical and ultrastructural examination. We proved this case to be a recessively inherited disease. This information had a profound impact on the genetic counselling, because if the disease of the patient were to have had a new dominant mutation, he would have been counselled that the risk of his offspring being affected was one in two, but he could be accurately counselled that the risk of this offspring being affected was as low as the general population.     

Monoclonal antibodies against human collagenase and stromelysin

Mouse monoclonal antibodies against recombinant human fibroblast procollagenase and prostromelysin have been generated and characterized. The epitope-containing domains for the antibodies have been assigned based on their immunoreactivities against recombinant proenzymes, mature enzymes, truncated collagenases, proteolytic fragments of stromelysin, and chimeric molecules constructed from different domains of the two enzymes. These antibodies can be divided into four groups: (1) antibodies that recognize the truncated 19-kDa NH2-terminal collagenase, (2) antibodies that recognize the C-terminal domain of collagenase and stromelysin, (3) antibodies that recognize a 31-kDa NH2-terminal collagenase fragment, and (4) antibodies that recognize the 19-kDa NH2-fragment of stromelysin. The prostromelysin-specific antibody 11N13 is of particular interest; it neutralizes stromelysin activity in a stromelysin peptide substrate assay, with an IC50 value of 75 nM. MAb 11N13 may be useful for in vivo and in vitro studies to validate the roles of stromelysin in tumor cell invasion, metastasis, and connective tissue disorders.     

Oesophageal involvement in epidermolysis bullosa

Epidermolysis bullosa dystrophica causing oesophageal stricture in two males of a family of 4 siblings--2 females and 2 males, and whose parents are not related, is reported. The stricture was treated with repeated dilatations and oral prednisolone on and off with complete success. A brief comment is also made with regards to the pathology and management of this condition.     

Compound heterozygosity for a nonsense mutation and a splice site mutation in the type VII collagen gene (COL7A1) in recessive dystrophic epidermolysis bullosa

The genes encoding the nucleoprotein, PB1, PB2, and PA proteins of the influenza virus strain B/Panamá/45/90 have been cloned under control of the T7 RNA polymerase promoter of plasmid pGEM-3. Transfection of the recombinant plasmids obtained into mammalian cells, which had been infected with a vaccinia virus encoding the T7 RNA polymerase, resulted in expression of the expected influenza B virus polypeptides. Moreover, it is shown that coexpression of the four recombinant core proteins in COS-1 cells reconstituted a functional polymerase capable of expressing a synthetic influenza B virus-like CAT RNA. By using the influenza B virus recombinant plasmids and a set of pGEM-derived plasmids encoding the homologous core proteins of the influenza A virus A/Victoria/3/75 (I. Mena et al. (1994). J. Gen. Virol. 75, 2109-2114), the capabilities of homo- and heterotypic mixtures of the four core proteins to express synthetic type A and B CAT RNAs were analyzed. Both the influenza A and B virus polymerases were active in expressing, albeit with reduced efficiencies, the heterotypic model CAT RNAs. However, none of all possible heterotypic mixtures of the core proteins reconstituted a functional polymerase. In order to fully characterize the recombinant plasmids obtained, the nucleotide sequences of the cloned genes were determined and compared to sequences of other type B virus isolates. The results obtained from these latter analyses are discussed in terms of the conservation and evolution of the influenza B virus core genes.     

Corneal involvement in epidermolysis bullosa simplex

A 17-year-old boy and his mother represent the first reported cases of ocular (corneal) involvement of the simplex form of epidermolysis bullosa. Both had a ring-like configuration of fine bullous lesions in the midperiphery bilaterally at the level of deep corneal epithelium superficial to Bowman's membrane (basal cell layer), with the son manifesting symptoms when some of his bullae ruptured through to the corneal epithelial surface. Nonscarring blistering was present in three generations of this family, suggestive of dominantly inherited epidermolysis bullosa simplex, and was confirmed by electron microscopy of a skin specimen from the son. Thus, ocular involvement has now been observed in all of the major types of epidermolysis bullosa.     

Deletions within COL7A1 exons distant from consensus splice sites alter splicing and produce shortened polypeptides in dominant dystrophic epidermolysis bullosa

We describe two familial cases of dominant dystrophic epidermolysis bullosa (DDEB) that are heterozygous for deletions in COL7A1 that alter splicing, despite intact consensus splice-site sequences. One patient shows a 28-bp genomic deletion (6081del28) in exon 73 associated with the activation of a cryptic donor splice site within this exon; the combination of both defects restores the phase and replaces the last 11 Gly-X-Y repeats of exon 73 by a noncollagenous sequence, Glu-Ser-Leu. The second patient demonstrates a 27-bp deletion in exon 87 (6847del27), causing in-frame skipping of this exon; consensus splice sites, putative branch sites, and introns flanking exons 73 and 87 showed a normal sequence. Keratinocytes from the probands synthesized normal and shortened type VII collagen polypeptides and showed intracellular accumulation of type VII procollagen molecules. This first report of genomic deletions in COL7A1 in DDEB suggests a role for exonic sequences in the control of splicing of COL7A1 pre-mRNA and provides evidence that shortened type VII collagen polypeptides can alter, in a dominant manner, anchoring-fibril formation and can cause DDEB of differing severity.     

Anesthesia in a patient with epidermolysis bullosa

A 6-year-old-boy with epidermolysis bullosa underwent plastic surgeries for the scar contraction of hands. Anesthesia was induced with inhalation of sevoflurane in combination with nitrous oxide and oxygen. The tracheal was not intubated. Anesthesia was maintained with sevoflurane, nitrous oxide and oxygen with continuous intravenous infusion of ketamine. The courses of anesthesia and the operations were uneventful. The most important point in the anesthetic management of the patient with this disease is to avoid mechanical stimulation to skin and mucous membrane.     

Esophageal stenosis in epidermolysis bullosa hereditaria]

Benign esophageal strictures in the upper esophagus may be caused by systemic diseases. A rare reason for esophageal strictures are the mechanobullous disorders marked by blister formation following relatively minor trauma, e.g. epidermolysis bullosa. In this report we present a 63-year-old patient who had suffered from epidermolysis bullosa simplex since birth. The epicutaneous symptoms were no longer present but an esophageal stricture had developed. The stricture was treated by X-ray-controlled balloon dilation twice, with a functionally good result. We suggest managing a recurrence recidiv of stricture with balloon dilation to minimize trauma and prevent further lesions.