Dissertation committee:
Αλέξανδρος Στρατηγός, Καθηγητής, Ιατρική, ΕΚΠΑ
Δημήτριος Ρηγόπουλος, Καθηγητής, Ιατρική, ΕΚΠΑ
Αργυρώ Χατζηιωάννου, Αν. Καθηγήτρια, Ιατρική, ΕΚΠΑ
Παναγιώτης Σταυρόπουλος, Καθηγητής, Ιατρική, ΕΚΠΑ
Σοφία Γεωργίου, Καθηγήτρια, Ιατρική, Πανεπιστήμιο Πατρών
Ηλέκτρα Νικολαΐδου, Αν. Καθηγήτρια, Ιατρική, ΕΚΠΑ
Ευαγγελία Παπαδαυΐδ, Αν. Καθηγήτρια, Ιατρική, ΕΚΠΑ
Summary:
Epidermolysis bullosa (EB) is a group of rare genodermatoses having as main
characteristics skin fragility and blister formation after minor skin mechanical injury and
varying degrees of mucosal involvement of the internal organs. EB presents great
clinical heterogeneity and various ways of inheritance.
First description of the disease and use of the term was made in 1886. As far as
EB terminology is concerned, modern science refers to the disease by the term "skinonion",
which extends to histological description and specific mutations.
The purpose of this study is to evaluate the diagnostic value of clinical findings in
relation to the results of laboratory/genetic testing for the correct diagnostic approach of
EB patients’. The identification of associations among types, subtypes and clinical
findings in conjunction with IMF findings and MA mutations, as well as recording EB
patients in the country, in order to evaluate the epidemiological data of the disease in
our country in comparison with other countries.
The patients were examined in Outpatient Departments of "A.Sygros" Hospital
and were referred for evaluation, investigation and follow-up at the Hospital’s Rare
Diseases Outpatient Clinic.
This study includes patients, following prospective research of 3 years (from
March 2012 to February 2015), which took place at "A.Sygros" Hospital.
During the period March 2012 - February 2015, 172.110 patients visited for the
first time the Hospital’s Outpatient Clinic; out of them 41 EB patients were referred at
Rare Disease Clinic.
Demographic and clinical characteristics of all patients were recorded in specially
formulated EB histories, designed for this purpose. Patients underwent:
1) Complete individual and family history specific to the disease.
2) Clinical examination with accompanying photographic material.
3) Clinical and laboratory investigations by doctors of other specialties, to evaluate other
systems, depending on the clinical type and subtype of the disease.
4) General laboratory testing.
5) Histological examination.
6) Special laboratory research in laboratories abroad, which included:
A) Histological examination by immunofluorescence by the three-step method: biotinstreptavidin-
fluorescein to determine the level of cleavage and type classification, as
well as the basis for molecular analysis, indicating the candidate genes.
B) Molecular analysis by PCR sequence and high-resolution liquid chromatography-
DHPLC, for the detection of mutations in each type.
The results were recorded as follows:
The EB prevalence among patients with dermatological diseases examined
during the aforementioned period was 0.024%.
Out of the 41 patients, 15 were adults and 26 were children. 58.5% of the
patients were male subjects and 41.5% were female.
A positive family history was recorded in 55.9% of the patients and parental
affinity was reported at 7.2%.
During the first clinical examination, skin clinical findings in the study’s patients
were as follows:
Skin fragility with destruction of its continuity by injury or pressure was detected
in all patients. All patients presented blisters, present in various locations depending on
disease type, except from 5 patients with KS. Albopapuloid lesions were observed in 10
patients, milia in 7, hyperhidrosis in 21, worsening in summer and due to heat in 33,
scarring in 26, palmoplantar hyperkeratosis in 9, skin hyperpigmentation in 18,
granulomatous tissue in 7, poikiloderma with telangiectasia, photosensitivity and skin
atrophy in 5, flattening of dermatoglyphic lines in 2, onychodystrophy in 14, nail loss in
13 and scaring alopecia in 2 patients.
The main features of extracutaneous involvement were as follows:
General physical development retardation, hand and feet finger fusion, and
flexural contractures of knees, elbows, wrists, hand and foot limbs were recorded in 1
patient, joints stiffness in 4, enamel pitting in 12, carries in 8, gingivitis in 5, artificial
denture in 5, oral cavity erosions in 6, microstomy in 2, squamous cell carcinoma in oral
cavity in 1, erosion and esophagus strictures in 7, pyloric stenosis in 1, constipation in 7,
urethral stenosis in 1, stiffness in 2, corneal erosions in 6, cardiomyopathy in 1 and
hoarseness in 5 patients.
According to the present study, on the basis of clinical and laboratory findings,
the frequencies of the types and major subtypes of the disease were determined:
- EB, Simplex in 29.3% of patients, and more specifically:
- EB, Simplex localized in 17.1% of them and
- EB Simplex, generalized in 12.2% of them with
- EB, Simplex generalized intermediate in 9.8% of them and
- EB, Simplex generalized intermediate or severe in 2.4%
- Dystrophic epidermolysis bullosa in 48.8% of patients, and more specifically:
- DEB, dominant in 29.3% of them and
- DEB, recessive generalized in 19.5% of them with
- DEB, recessive generalized intermediate in 12.2% of them,
- DEB, recessive generalized severe in 2.4% of them and
- DEB, recessive generalized intermediate or severe in 4.9%
- Junctional EB generalized intermediate in 7.3% of patients.
- Kindler's syndrome in 14.6% of patients.
EBS was clinically diagnosed in 12 patients (29.3%) and confirmed by
immunofluorescence in 8 patients. The most frequent subtype was EBS localized with 7
patients (17.1%), confirmed by IMF in 4, followed by EBS generalized with 5 patients
(12.2%), confirmed by IMF in 4 of them; 1 of them also performed MA, which detected
c.1399A>T mutation in K5 gene.
The most common type of EB was dystrophic, diagnosed in 20 patients
(48.8%) and confirmed by IMF in 11 of them. The most common subtype was DEB
dominant generalized with 12 patients (29.3%), confirmed by IMF in 5 of them, followed
by DEB recessive generalized with 8 patients (19.5%), confirmed by laboratory
diagnosis in 6 of them; 3 out of them additionally underwent genetic test, which
identified the responsible mutations in COL7A1 gene: c.2503G> T (exon 19) and
c.8026delG (exon 108) in the first patient, c.857_870del14 (exon 7) and c.6205C> T
(exon 74) in the second one and 7759G> A (exon 104) and c.7864C> T (exon 105) in
the third one.
JEB was diagnosed in 3 patients (7.3%); all of them presented generalized
intermediate subtype and 2 of them were tested by IMF.
KS was clinically diagnosed in 6 patients (14.6%) and IMF was performed in 5
of them and MA in 4 of them, identifying the responsible mutations FERMT1/KIND1
gene, c.676dupC (exon 5) και c.1209C>G (exon 10) in 2 of them (sisters) and c.676dupC
(exon 5) and c.877T> G (exon 7) in the other 2 (brothers).
During the present study, laboratory investigation was performed in 26 (63.4%)
out of the 41 EB patients. In 23 of them (56.1%), clinical and laboratory diagnosis were
in concordance. 9 patients refused the examination, while 6 patients postponed it due to
financial reasons. In 3 of these patients, the diagnosis was based on histological
examination.
Based on the results of the present study, both patient’s history and clinical
assessment constitute and remain valuable factors for evaluation and diagnosis of the
disease. However, in many cases, due to phenotypic overlap between EB types and
subtypes, especially in neonates, infancy and childhood, it is of fundamental importance
to perform laboratory-specific examinations for the exact definition of disease’s type and
appropriate genetic counseling in the family.
Epidemiological studies of the disease show significant heterogeneity in the
recording results. The two largest studies were conducted in U.S.A. and in Italy; in
comparison to them, the prevalence of the disease in Greece, according to the present
study is lower, due to many causative factors.
This study is the first report of EB in Greek patients.
