ABSTRACT
Abstract Birt-Hogg-Dubé syndrome is a genodermatosis of auto somal dominant inheritance characterized by mutations in the folliculin (FLCN) gene. There is an inappropriate inhibition/activation of a protein, the foliculin, which may cause tumor lesions in skin, renal and lung lesions; they could have more risk of developing pneumothorax compared to the normal population. A 38-year-old male patient with bronchial asthma who consulted for hemop tysis three weeks after recovery from COVID-19 infection. A chest tomography was requested, showing an air cyst in the left lower lobe. Physical examination shows evi dence of thoracic skin lesions which a skin biopsy was performed on. The results were compatible with fibrofol liculoma. Differential diagnoses were proposed. A genetic disorder associated with skin lesions was suspected. A multi-genetic panel that includes BRCA1, BRCA2, TP53 and FLCN genes was requested, which reported the mu tation of the FLCN gene in heterozygosis classified as pathognomonic of Birt-Hogg-Dubé syndrome. Patient is currently under clinical follow-up while genetic counsel ing was requested for relatives.
Resumen El síndrome de Birt-Hogg-Dubé es una genoderma tosis de herencia autosómica dominante caracterizada por mutaciones en el gen foliculina (FLCN), donde existe inhibición/activación inapropiada de una proteína, la foliculina, que puede causar lesiones tumorales sisté micas, principalmente a nivel de la piel, renal y lesiones pulmonares, presentando mayor riesgo de desarrollar neumotórax en comparación con la población normal. Comunicamos el caso de un varón de 38 años con asma bronquial que consultó por hemoptisis 3 semanas des pués de la recuperación de la infección por COVID-19. Se solicitó una tomografía de tórax, que mostró un quiste aéreo en el lóbulo inferior izquierdo. Además, presentaba en el examen físico una lesión cutánea que fue biopsiada, presentando diagnóstico de foliculoma. Se plantearon diagnósticos diferenciales y ante la sospecha de probable desorden genético, un panel genético fue solicitado. Se confirmó síndrome de Birt-Hogg-Dubé ante el hallazgo de la deleción heterocigota que comprende el exón 1 del gen FLCN clasificada como patogénica. Actual mente el paciente se encuentra en seguimiento clínico mientras se solicitó estudio genético para familiares.
ABSTRACT
El síndrome de Birt-Hogg-Dubé es una rara enfermedad autosómica dominante causada por la mutación patogénica del gen de la foliculina, que se expresa principal mente en tres órganos que incluyen el pulmón, la piel y el riñón, y produce quistes pulmonares, tumores renales y cutáneos. Desde el punto de vista respiratorio es poco sintomática, pero los quistes presentan alto riesgo de neumotórax, por lo que es imprescindible realizar una adecuada semiología radiológica de los quistes para un diagnóstico oportuno. Los tumores más importantes son los renales porque incluyen varios tipos de carcinomas renales; debido a esto requieren seguimiento estricto y, en muchos, casos cirugía. Presentamos dos casos de pacientes con este síndrome; uno confirmado por la mutación genética y el otro, por la confirmación histológica de fibrofoliculoma, ambos criterios mayores para el diagnóstico de esta enfermedad. Es fundamental el diagnóstico temprano de esta entidad de acuerdo con lo expuesto anteriormente, por lo que hacemos esta revisión con una amplia discusión sobre la afectación pulmonar, la semiología radiológica de los quistes y los criterios diagnósticos.
The Birt-Hogg-Dubé syndrome is a rare autosomal dominant disease caused by the pathogenic mutation of the folliculin gene, which is mainly expressed in three organs that include the lung, the skin and the kidney, and produces lung cysts, and renal and skin tumors. From the respiratory point of view, it doesn't have many symptoms, but cysts have high risk of pneumothorax, so it is indispensable to carry out the correct radiological semiology of the cysts for a timely diagnosis. The most important tumors are the renal, because they include several types of renal carcinomas; that is why they require strict follow-up and, in many cases, surgery. We present two cases of patients with this syndrome: one confirmed by the genetic mutation, and the other one by the histological confirmation of fibrofolliculoma, both major criteria for the diagnosis of this disease. The early diagnosis of this entity is of fundamental importance, according to what has been previously presented, so we conduct this review with a broad discus sion about lung involvement, the radiological semiology of the cysts, and diagnostic criteria.
ABSTRACT
ABSTRACT Purpose: The purpose of this study was to report a series of cases of solitary fibrofolliculoma, a lesion seldom observed in the lids. Demographics, as well as clinical and histological aspects of the lesion were evaluated. Methods: This was a retrospective case series spanning a period of 18 years. All the included patients were diagnosed with solitary fibrofolliculoma confirmed by histological examination. Data regarding patient demographics, signs, and symptoms, course of the disease, location of the lesion, clinical and histological diagnosis, and outcome were collected. Results: Eleven cases of solitary fibrofolliculoma were diagnosed in the study period. The median age of patients was 51 ± 16.3 years (range: 27-78 years). Most patients were females (7/11; 64%). Five of the patients (45%) were asymptomatic; four (36%) reported bleeding, one (9%) had referred itching, and one (9%) rubbing of the lesion. The lesion occurred in a wide range of locations; one of them was located in the lids. The diagnosis for all lesions was histological based on characteristic findings of a hair follicle occasionally dilated and containing keratin material surrounded by a moderately well-circumscribed thick mantle of fibrous tissue. The infundibular follicular epithelium extended out into this fibrous mantle forming epithelial strands or cords. There were no relapses after exeresis. Conclusion: Solitary fibrofolliculoma is a rare lesion, seldom affecting the eyelids. We reported 11 cases, and the third case reported thus far in the literature affecting the lids. Diagnosis may be easily missed due to the nonspecific symptoms and clinical appearance. Therefore, it is necessary to perform excisional biopsy and histological examination for the recognition of this lesion.
RESUMO Objetivo: o objetivo deste estudo foi relatar uma série de casos de fibrofoliculoma solitário, uma lesão raramente observada nas pálpebras. Demografia, bem como aspectos clínicos e histológicos da lesão foram avaliados. Métodos: Trata-se de uma série de casos retrospectivos, com um período de 18 anos. Todos os pacientes incluídos foram diagnosticados com fibrofoliculoma solitário confirmado por exame histológico. Foram coletados dados referentes à demografia, sinais e sintomas dos pacientes, evolução da doença, localização da lesão, diagnóstico clínico e histológico e desfecho. Resultados: Onze casos de fibrofoliculoma solitário foram diagnosticados no período do estudo. A média de idade dos pacientes de 51 ± 16,3 anos (variação: 27-78 anos). A maioria dos pacientes era do sexo feminino (7/11, 64%). Cinco dos pacientes (45%) eram assintomáticos; quatro (36%) relataram sangramento, um (9%) referiu coceira e um (9%) fricção da lesão. A lesão ocorreu em luma ampla variedade de locais; um deles sendo nas pálpebras. O diagnóstico de todas as lesões foi histológico com base nos achados característicos de um folículo piloso ocasionalmente dilatado e contendo material de queratina, cercado por um manto espesso de tecido fibroso moderadamente bem circunscrito. O epitélio infundibular folicular se estendeu até esse manto fibroso, formando cordões ou cordões epiteliais. Não houve recaídas após exérese. Conclusão: Fibrofoliculoma solitário é uma lesão rara, mais ainda quando afeta as pálpebras. Relatamos 11 casos, e o terceiro relatado até o momento na literatura que afeta as pálpebras. O diagnóstico pode ser facilmente esquecido devido a sintomas inespecíficos e aparência clínica. Portanto, é necessário realizar biópsia excisional e exame histológico para o reconhecimento dessa lesão.
Subject(s)
Humans , Male , Female , Adult , Middle Aged , Aged , Skin Neoplasms , Hair Follicle , Hair Diseases , Skin , Skin Neoplasms/diagnosis , Skin Neoplasms/pathology , Retrospective Studies , Neoplasm Recurrence, LocalABSTRACT
A 45-year-old woman with a history of renal carcinoma was observed for facial, cervical and truncal flesh-colored papules. Relatives had similar skin findings and a brother had repeated episodes of pneumothorax. The computerized tomography scan revealed multiple cysts on both lungs. A skin biopsy revealed a perifollicular fibroma. The clinical diagnosis of Birt-Hogg-Dubé syndrome (BHDS) was corroborated by identification of a novel frameshift c.573delGAinsT (p.G191fsX31) mutation in heterozygosity on exon 6 of the folliculin gene. 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.
Uma mulher de 45 anos com história de carcinoma renal foi observada por pápulas cor da pele, faciais, cervicais e tronculares. Referia história familiar de achados cutâneos semelhantes e irmão com episódios repetidos de pneumotórax. Identificaram-se múltiplos quistos pulmonares por tomografia computorizada. Uma biópsia cutânea revelou fibroma perifolicular. O diagnóstico clínico de síndrome de Birt-Hogg-Dubé (BHDS) foi contudo corroborado pela identificação de uma nova mutação frameshift c.573delGAinsT (p.G191fsX31) em heterozigotia no exão 6 do gene da foliculina. A presença de múltiplos e típicos tumores benignos do folículo piloso, realça o papel do dermatologista no diagnóstico desta rara genodermatose, que está associada a um risco aumentado de tumores de células renais e cistos pulmonares, exigindo seguimento e aconselhamento pessoal e familiar.