Exogenous Ochronosis (EO): Skin lightening cream causing rare caviar-like lesion with banana-like pigments; review of literature and histological comparison with endogenous counterpart

Ochronosis is a cutaneous disorder caused by the accumulation of phenols, either endogenously as homogentisic acid in patients with alkaptonuria (autosomal recessive disorder with deficiency of the enzyme homogentisic acid oxidase), or exogenously in patients using phenol products such as topical creams containing hydroquinone or the intramuscular application of antimalarial drugs. Exogenous ochronosis (EO) typically affects the face and was reported in patients with dark skin such as Black South Africans or Hispanics who use skin-lightening products containing hydroquinone for extended periods. Recently more cases have been reported worldwide even in patients with lighter skin tones, to include Eastern Indians, Asians, and Europeans. However, just 39 cases of EO have been reported in the US literature from 1983 to 2020. Here we present two cases; a 69 and a 45-year-old female who were seen for melasma, given hydroquinone 4% cream daily and tretinoin 0.05%. Both patients noticed brown spots on their cheeks, which progressively enlarged and darkened in color. The diagnosis of ochronosis was confirmed by characteristic histopathological features on the punch biopsy. Unfortunately, neither patient responded to multiple treatments (to include, tazarotene 0.1% gel and pimecrolimus ointment, topical corticosteroids, and avoidance of hydroquinone containing products). We also present a case of classic (endogenous) ochronosis in a patient with alkaptonuria to picture the histological similarities of these two entities. EO is an important clinical consideration because early diagnosis and treatment may offer the best outcome for this notoriously refractory clinical diagnosis.

Effects of Homogentisic Acid and Natural Products Derived from Pinellia ternata on Secretion, Production and Gene Expression of MUC5AC Mucin from Cultured Airway Epithelial Cells

In this study, we investigated whether adenosine, adenine, uridine and homogentisic acid derived from Pinellia ternata affect the secretion, production and gene expression of MUC5AC mucin from airway epithelial cells. Confluent NCI-H292 cells were pretreated with adenosine, adenine, uridine or homogentisic acid for 30 min and then stimulated with PMA (phorbol 12-myristate 13-acetate) for 24 h. The MUC5AC mucin gene expression, mucin protein production and secretion were measured by RT-PCR and ELISA, respectively. The results were as follows: (1) Adenine and homogentisic acid decreased PMA-induced MUC5AC mucin gene expression, although adenosine and uridine did not affect the mucin gene expression; (2) Adenosine, adenine, uridine and homogentisic acid inhibited PMA-induced MUC5AC mucin production; (3) Homogentisic acid inhibited the secretion of MUC5AC mucin from NCI-H292 cells. These results suggest that, among the four compounds examined, homogentisic acid showed the regulatory effect on the steps of gene expression, production and secretion of mucin, by directly acting on airway epithelial cells.

Cervical Spondylotic Myelopathy due to the Ochronotic Arthropathy of the Cervical Spine

Ochronosis is a musculoskeletal manifestation of alkaptonuria, a rare hereditary metabolic disorder occurs due to the absence of homogentisic acid oxidase and leading to various systemic abnormalities related to deposition of homogentisic acid pigmentation (ochronotic pigmentation). The present case reports the clinical features, radiographic findings, treatments and results of a cervical spondylotic myelopathy woman patient due to the ochronotic arthropathy of the cervical spine. The patient aged 62 years was presented with gait disturbance and hand clumsiness. Physical examination, X-rays, computed tomography and lab results of the urine sample confirmed the presence of ochronosis with the involvement of the cervical spine. The patient underwent a modified cervical laminoplasty due to multi-segment spinal cord compression. The postoperative follow-up showed a good functional outcome with patient satisfaction. The present study concludes the conditions and important diagnostic and surgical aspects of a patient. It is necessary to identify the condition clinically and if cord compression is observed, appropriate surgical interventions needs to be instituted.

Primer reporte de alcaptonuria en el Perú / First report of alkaptonuria in Peru

La alcaptonuria es un error innato del metabolismo causado por la deficiencia de la homogentisiato 1,2 dioxidasa (HGD), produciéndose un exceso de ácido homogentísico (HGA). Se presenta el caso de una mujer de 57 años quien, desde que nació, su orina se tornaba de color negro; desde hacía 9 años presentaba una pigmentación verdosa en los lechos ungueales que no mejoró con tratamientos antifúngicos y en los últimos 9 meses presentó artrosis de articulaciones grandes que fue empeorando, forzándola a usar una silla de ruedas por el intenso dolor generado por la artrosis de caderas y columna lumbar. Por la descripción de los síntomas se le solicitó la medición de HGA en orina lo que confirmó el diagnóstico de alcaptonuria. Se sugirieron analgésicos, dieta sin productos que contuvieran tirosina y fue referida para cirugía de reemplazo de cadera. Se trata del primer reporte de caso de alcaptonuria en el Perú.

Alkaptonuria is an inborn error of metabolism caused by deficiency of homogentisate 1,2-dioxygenase (HGD) which produces an excess of homogentisic acid (HGA). A case is presented of a 57 year old woman whose urine has turned black since birth. For 9 years she presented a greenish pigmentation in her nail beds that did not improve with antifungal treatments, and in the last 9 months she showed worsening large joint osteoarthritis. This situation forced her to use a wheelchair due to the intense pain caused by osteoarthritis in her hips and lumbar spine. From the description of symptoms, her urinary HGA was measured which confirmed the diagnosis of alkaptonuria. Analgesics and a diet without tyrosine-containing products were suggested. The patient was also referred for hip replacement surgery. This is the first reported case of alkaptonuria in Peru.

Instituto de Radium de Minas Gerais: vanguarda da radioterapia no Brasil, 1923-1935 / Minas Gerais Radium Institute: at the forefront of radiotherapy in Brazil, 1923-1935

Este artigo propõe estudar os primeiros 12 anos de existência do Instituto de Radium de Minas Gerais, fundado em 1922. Sua atuação na luta contra o câncer no Brasil, ainda pouco conhecida, começa a ser esboçada pelo estudo de documentação institucional inédita. Através de um banco de dados elaborado com informações constantes em seu livro de registro de pacientes, foram feitos levantamentos estatísticos dos tipos de câncer e das formas de tratamento existentes entre 1923 e 1935. Esse livro faz parte de um conjunto de outros cinco recentemente descobertos no Centro de Memória da Medicina/UFMG. A documentação permite resgatar os primórdios das intervenções de radioterapia no país e acompanhar seu desenvolvimento e a influência exercida por esse hospital modelo.

This article proposes to study the first 12 years of the Minas Gerais Radium Institute, founded in 1922. Its work in the fight against cancer in Brazil, albeit still little known, is coming to light as its institutional documents are studied. A database has been prepared using information from its patient register, based on which statistical analyses have been done to identify the types of cancer and treatments available there between 1923 and 1935. This register is one of five recently unearthed at the Medicine Memory Center of the Universidade Federal de Minas Gerais. Through them, the earliest experiments in radiotherapy in Brazil can be reconstituted, and its development and the influence of this model hospital can be mapped out.

Alkaptonuria: A very rare metabolic disorder.

Alkaptonuria (AKU) is a very rare autosomal recessive disorder of tyrosine metabolism in the liver due to deficiency of homogentisate 1,2 dioxygenase (HGD) activity, resulting in the accumulation of homogentisic acid (HGA). Circulating HGA pass into various tissues through-out the body, mainly in cartilage and connective tissues, where its oxidation products polymerize and deposit as a melanin-like pigment. Gram quantities of HGA are excreted in the urine. AKU is a progressive disease and the three main features, according the chronology of appearance, are: darkening of the urine at birth, then ochronosis (blue-dark pigmentation of the connective tissue) clinically visible at around 30 yrs in the ear and eye, and finally a severe ochronotic arthropathy at around 50 yrs with spine and large joints involvements. Cardiovascular and renal complications have been described in numerous case report studies. A treatment now is available in the form of a drug nitisinone, which decreases the production of HGA. The enzymatic defect in AKU is caused by the homozygous or compound heterozygous mutations within the HGD gene. This disease has a very low prevalence (1:100,000-250,000) in most of the ethnic groups, except Slovakia and Dominican Republic, where the incidence has shown increase up to 1:19,000. This review highlights classical and recent findings on this very rare disease.

Early diagnosis of co-existent ß-thalassemia and alkaptonuria.

Since the aggregate incidence of inborn errors of metabolism is relatively high, a high degree of suspicion is essential to correctly diagnose an inborn error of amino acid metabolism. We report a case of alkaptonuria an autosomal recessive disorder that occurs due to deficiency of homogentisic acid oxidasein a β-thalassemia infant presenting with reddish discoloration of nappies and clothes, breath holding spells, and microcytic hypochromic anemia. Born to consanguineous cousins, to our knowledge, the combination of β-thalassemia and alkaptonuria, which we have described in this baby, has not been reported earlier.

Alkaptonuria in 17-month-old female child: a case report

Alkaptonuria is a rare inborn metabolic disorder with Mendelian recessive inheritance characterized by triad of homogentisic aciduria, arthritis and ochronosis. The incidence is one per 0.25 - 1 million persons. A 17-month- old female child of non-consanguineous parents presented with darkening of clothes / diapers moistened with urine when left unwashed for hours. There was no other medical problem in the family. Physical examination including joints revealed a healthy child with normal growth parameters. There was no pigmentation of the sclera, conjunctiva and cornea and ear cartilage. Her urine appeared normal colored on voiding. However, it turned black on standing at room temperature. Regular laboratory investigations were within normal range and skeletal survey showed no degenerative changes. Urine for alkalization and reducing substances was positive. Urine organic acidogram-chromatogram study showed [1137.87%] 2845-fold increase in homogentisic acid and confirmed the diagnosis of alkaptonuria. She was started on Vitamin C [0.5 gm twice a day]. She is now asymptomatic over a 13-month follow-up period

Ocronosis: descripción de dos casos familiares, reseña histórica y revisión de la literatura / Ochronosis: report of two familial cases, historical overview and review of the literature

La ocronosis es la manifestación de la alcaptonuria en el tejido conjuntivo, se origina por la alteración en el metabolismo del ácido homogentísico, producto de la mutación autosómica recesiva del gen HGO, en el brazo largo del cromosoma 3 (3q21-23). Es una patología infrecuente, que se caracteriza por la presencia de calcificaciones de los discos intervertebrales y depósito de ácido homogentísico en el tejido conjuntivo y los tendones. Se presentan dos casos compatibles con las características clínicas y radiológicas de ocronosis.

Ochronosis is the manifestation of alkaptonuria in the connective tissue. It is originated by the alteration in the metabolism of homogentisic acid, a product of autosomal recessive mutation of HGO, gene in the long arm of chromosome 3 (3q21-23). It is a rare disease, characterized by the presence of calcifications in the intervertebral discs and deposit of homogentisic acid in connective tissue and tendons. We present two compatibles cases with the clinical and radiological features of ochronosis.

Gonartrosis por ocronosis alkaptonurica: reporte de un caso y revisión de la literatura / Gonarthrosys by ochronosis alkaptonuria: a case report and literature review

La ocronosis alkaptonurica es una rara enfermedad autosómica recesiva del metabolismo de la tirosina y fenilalanina caracterizada por una triada de orinas oscura (alkaptonuria), coloración negruzca de tejidos conectivos (ocronosis) y degeneración articular en adultos jóvenes (artritis ocronotica), por deficiencia del la 1,2 dioxigenasa homogentísica, produciendo la acumulación del Ácido Homogentísico (HGA). De tratamiento poco efectivo tanto con Vitamina C como con Nitisinone, aunque este último inhibe síntesis HGA. Se hace el reporte de una paciente femenina de 53 años, con gonartrosis bilateral severa a predominio izquierdo, sin antecedentes patológicos conocidos, que durante la artroplastia se evidenciaron lesiones negruzcas en todo el cartílago articular, por lo que se tomaron muestras para anatomía patológica que reportaron lesiones sugestivas de artrítis ocronótica. Posteriomente se evidencia orinas oscuras a la exposición al aire libre, artropatía degenerativa no limitante en esqueleto axil y parentesco de consanguinidad tanto de sus abuelos como de sus padres. Se hace este reporte por ser el primer caso registrado en la literatura nacional, además de su excepcional frecuencia.

Alkaptonuria and intramedullary calcification.

Alkaptonuria is a rare disorder of metabolism caused by deficiency of homogentisic acid oxidase enzyme and characterized by triad of homogentisic aciduria (dark urine), relentlessly progressive arthritis and ochronosis. We have documented a case with typical features of alkaptonuria along with intramedullary calcification which has not been reported in the literature before.

Alcaptonúria (ocronose): relato de dois casos / Alkaptonuria (ochronosis): report of two cases

A alcaptonúria (ocronose) é um erro inato do metabolismo da fenilalanina e tirosina, transmitido de forma autossômica recessiva. Resulta da deficiência completa da enzima ácido homogentísico oxidase (HGO), causada por mutação no gene 3q (3q21 - q23), levando ao acúmulo do ácido em diversos órgãos e tecidos, com aumento de sua excreção urinária. Os achados clínicos característicos incluem artropatia ocronótica, pigmentação anormal da cartilagem de outros tecidos conjuntivos e urina enegrecida. A incidência é rara, estimada em 1-4: 1.000.000 indivíduos, tendo maior prevalência em populações com alto grau de consangüinidade. A seguir, relataremos o caso de dois irmãos (um homem e uma mulher) com ocronose, discutindo sua patogênese, manifestações clínicas, diagnóstico e tratamento(1, 2).

Alkaptonuria (ochronosis) is an autossomal recessive disorder which results from an innate error of phenylalanine and tyrosine's metabolism. This defect causes accumulation of homogentisic acid on the tissue and usually is excreted in the urine. This disorder results from a complete deficiency of the homogentisate 1,2 - dioxygenase (HGO) caused by chromosome 3q(3q21-q23) mutation. The clinical features include: ochronotic artropathy, black-gray pigmentation of the cartilage and the urine turns black. This is a rare disorder and incidence is about 1-4 in 1.000.000 of people and the prevalence is higher in consanguineous groups. The author will describe two affected brothers and discuss the pathophysiology, clinical features, diagnosis and treatment of ochronosis.

A case of alkaptonuria: the first case in Korea / 소아과

Alkaptonuria is a rare metabolic disease in which homogentisic acid cannot be metabolized due to a lack of the enzyme homogentisic acid oxidase. The disease often manifests itself in childhood by darkening of the urine upon standing. The disease leads to such serious consequences as ochronosis of cartilage and connective tissues with arthritis. It is expected that treatment with ascorbic acid and a dietary restriction of protein may decrease the late and serious consequences by diminishing the serum concentration of the metabolite benzoquinone acetic acid. A thirteen month-old girl was recently diagnosed with alkaptonuria by urine organic acid analysis. She excreted pinkish urine on a diaper and as time went by the urine color changed to a light brown. In laboratory findings, urine examination and culture results were normal. But urine organic acid analysis detected abnormal findings a prominent and massive elevation of homogentisic acid. The other physical findings were normal. This is the first case diagnosed in Korea.

Hip arthroplasty for ochronosis

Alkaptonuria is a metabolic disorder in which homogentisic acid oxidase is absent. Therefore, homogentisic acid accumulates in cartilage and connective tissues. We can diagnose ochronotic arthropathy, a manifestation of long standing alkaptonuria, through careful radiological, physical, and laboratory examination. In this report, we describe 4 cases of ochronotic arthropathy to which we applied cementless total hip prosthesis due to severe hip involvement

Alcaptonúria: relato de dois casos e revisão bibliográfica / Alcaptonuria: A propos of two cases and bibliographic review

A alcaptonúria é uma doença rara, na qual ocorre a formaçäo de um pigmento que se acumula na cartilagem, pele e tecidos conectivos (ocronose), resultando em artrite, lesöes cardiovasculares, hiperpigmentaçäo da pele e outras patologias. Os autores descrevem dois casos de alcaptonúria, detectados em dois irmäos, sendo um do sexo masculino, com idade de 12 anos, e outro do sexo feminino, com dois meses de idade, que foram diagnosticados através da anamnese e dosagem de AH urinário por cromatografia.