Presented by Yoon Cohen, D.O.
Alta Dermatology
Mesa, Arizona
This patient's case courtesy of Bradley Kurgis, D.O. in San Luis Obispo, CA
Abstract: 54 yo woman with multiple white firm papules on the face since her 30s.
HPI: This is a 54 yo woman with multiple scattered 2-4 mm white firm papules on the face and upper neck. She has first noticed her facial lesions at her late 30s. Previously a biopsy was obtained on the right cheek which showed sebaceous hyperplasia.
The patient will be back in 2 weeks for another biopsy. If it shows fibrofolliculoma or trichodiscoma, we will obtain her renal ultrasound, abd/pelvic CTs and chest Xray.
O/E: There are multiple scattered 2-4 mm white firm shiny papules throughout the face, the ear lobes and the upper neck. There are multiple acrochordons in the axillary areas which can be common findings in any individuals in her age group. No gingival papules or palmoplantar keratoses noted that you commonly observe in Cowden syndrome.
Clinical Photos (with permission of the patient):
Pathology: The repeated biopsy will be obtained
Presumptive Diagnosis: Most likely Birt-Hogg-Dube Syndrome, but we also consider Cowden synydrome
Discussion:
Birt-Hogg-Dubé syndrome (BHDS) was originally described in 1977 as the grouping of 3 skin tumors-the fibrofolliculoma, trichodiscoma, and acrochordon-in family members with an autosomal dominant inheritance pattern. [1] The condition is caused by germline mutations in the FLCN gene, which encodes folliculin; the function of this protein is largely unknown.[3] The recent years it has become clear that these 3 lesions likely represent only 1 of these tumors, the fibrofolliculoma. More important, evidence now supports a definite susceptibility to malignant renal tumors and pulmonary disease in patients with BHDS. Clinical recognition of this entity is possible in spite of the fact that several syndromes exist that are characterized by the presence of multiple firm facial papules.[1] [5] Jarrett, et al reported dermatoscopic findings of BHDS which showed well-demarcated pallor with central follicular opening. [2] The notably similar dermatoscopic findings were found in this patient. The presence of multiple and typical benign hair follicle tumors highlights the role of the dermatologist in the diagnosis of this rare genodermatosis that is associated with an increased risk of renal cell cancer and pulmonary cysts, warranting personal and familial follow-up and counseling.[4]
The patient reported that she has seen many physicians including dermatologists for her facial lesions in the past. However, she was repeatedly told that they could not help due to the generalized nature of the lesions, and she was dismissed without any further work-ups. Her case demonstrates our orphan patient today.
Questions:
1. What are your thoughts? Any suggestions for diagnostic studies?
2. The patient's most concern at this time is her facial appearance. Any treatment suggestions would be greatly appreciated.
References:
1. Vincent A, Chan E, James W. Birt-Hogg-Dube syndrome: A review of the literature and the differential diagnosis of firm facial papules. J Am Acad Dermatol. 2003;49:698-705.
2. Jarrett R, Walker L, Side L, et al. Dermoscopic features of Birt-Hogg-Dube Syndrome. Arch Dermtol. 2009; 145 (10): 1208.
3. Menko FH, van Steensel MA, Giraud S, et al. Birt-Hogg-Dube syndrome: diagnosis and management. Lancet Oncol. 2009;10(12):1199-206.
4. Lencastre A, et al. Birt-Hogg-Dube syndrome. An Bras Dermatol. 2013;88:203-5.
5. Warwick Gm et al. Renal cancer associated with recurrent spontaneous pneumothorax in Birt-Hogg-Dube syndrome: a case report and review of the literature. J Med Case Reports. 2010;4:106.
Alta Dermatology
Mesa, Arizona
This patient's case courtesy of Bradley Kurgis, D.O. in San Luis Obispo, CA
Abstract: 54 yo woman with multiple white firm papules on the face since her 30s.
HPI: This is a 54 yo woman with multiple scattered 2-4 mm white firm papules on the face and upper neck. She has first noticed her facial lesions at her late 30s. Previously a biopsy was obtained on the right cheek which showed sebaceous hyperplasia.
She is not a smoker; however, she had four episodes of spontaneous pneumothorax in the past at her early 20s. At that time, she was informed that she had multiple "blebs" in her right lower lobe which resulted in the right lower lobectomy. Recently she had a colonoscopy with multiple benign polyps, otherwise, the only other heath issue is hypertension. Her father and paternal grandmother had the same skin findings on the face and the neck. Her paternal grandmother also had episodes of pneumothorax in her right lower lobe and died of renal failure. No actual renal or thyroid cancers history in the family. No GI related malignancy in the family.
Family medical history of the patient
Clinical Photos (with permission of the patient):
Dermatoscopic view shows well-demarcated areas of pallor with central follicular opening
Close-up view of dermatoscopic view
Jarrett R, Walker L, Side L, et al. Dermoscopic features of Birt-Hogg-Dube Syndrome. Arch Dermtol. 2009; 145 (10): 1208.
Patient's father with the same facial lesions, deceased 2 years prior
Presumptive Diagnosis: Most likely Birt-Hogg-Dube Syndrome, but we also consider Cowden synydrome
Discussion:
Birt-Hogg-Dubé syndrome (BHDS) was originally described in 1977 as the grouping of 3 skin tumors-the fibrofolliculoma, trichodiscoma, and acrochordon-in family members with an autosomal dominant inheritance pattern. [1] The condition is caused by germline mutations in the FLCN gene, which encodes folliculin; the function of this protein is largely unknown.[3] The recent years it has become clear that these 3 lesions likely represent only 1 of these tumors, the fibrofolliculoma. More important, evidence now supports a definite susceptibility to malignant renal tumors and pulmonary disease in patients with BHDS. Clinical recognition of this entity is possible in spite of the fact that several syndromes exist that are characterized by the presence of multiple firm facial papules.[1] [5] Jarrett, et al reported dermatoscopic findings of BHDS which showed well-demarcated pallor with central follicular opening. [2] The notably similar dermatoscopic findings were found in this patient. The presence of multiple and typical benign hair follicle tumors highlights the role of the dermatologist in the diagnosis of this rare genodermatosis that is associated with an increased risk of renal cell cancer and pulmonary cysts, warranting personal and familial follow-up and counseling.[4]
The patient reported that she has seen many physicians including dermatologists for her facial lesions in the past. However, she was repeatedly told that they could not help due to the generalized nature of the lesions, and she was dismissed without any further work-ups. Her case demonstrates our orphan patient today.
Questions:
1. What are your thoughts? Any suggestions for diagnostic studies?
2. The patient's most concern at this time is her facial appearance. Any treatment suggestions would be greatly appreciated.
References:
1. Vincent A, Chan E, James W. Birt-Hogg-Dube syndrome: A review of the literature and the differential diagnosis of firm facial papules. J Am Acad Dermatol. 2003;49:698-705.
2. Jarrett R, Walker L, Side L, et al. Dermoscopic features of Birt-Hogg-Dube Syndrome. Arch Dermtol. 2009; 145 (10): 1208.
3. Menko FH, van Steensel MA, Giraud S, et al. Birt-Hogg-Dube syndrome: diagnosis and management. Lancet Oncol. 2009;10(12):1199-206.
4. Lencastre A, et al. Birt-Hogg-Dube syndrome. An Bras Dermatol. 2013;88:203-5.
5. Warwick Gm et al. Renal cancer associated with recurrent spontaneous pneumothorax in Birt-Hogg-Dube syndrome: a case report and review of the literature. J Med Case Reports. 2010;4:106.
Thank you for posting this interesting rare case.
ReplyDeleteI agree with you that the clinical finding in this patient is not consistent with the diagnosis of sebaceous hyperplasia as reported in the biopsy.
The clinical features of multiple whitish firm shiny papules, dermoscopic findings together with a positive family history and pnuemothorax makes BHD syndrome a real possibility.
I would definitely choose a good representation of the follicle for a skin biopsy to look for fibrofolliculoma or trichodiscoma.
Once diagnosed if facilities is available gene studies to look for DNA mutation at the FLCN gene will confirm diagnosis.
Looking at the literature, very few treatment options are available. Surgical removal and electro desiccation has been mentioned but i am not sure if this is practical for this patient with extensive lesions. Perhaps we may have to do multiple sessions with electro desiccation followed by fractional CO2 laser surgery. We can start by doing a spot test and see if it responds.
This patient was further evaluated and finally confirmed her diagnosis with BHD syndrome.
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