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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Medical History</span><p id="par0005" class="elsevierStylePara elsevierViewall">A 9-year-old girl with no family history of interest was undergoing follow-up in pediatrics for functional chronic constipation since childhood&#46; She was referred to dermatology for multiple lesions on the tip of the tongue that had developed at 7 years of age&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Physical Examination</span><p id="par0010" class="elsevierStylePara elsevierViewall">The initial physical examination revealed marfanoid habitus &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#41;&#44; with thickening and mild eversion of the lip and the free margin of the eyelid&#46; Several firm&#44; opaque&#44; papular lesions were observed on the tip of the tongue &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#41;&#46; A single skin-colored papular lesion was observed in the right nasal choana &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a><span class="elsevierStyleHsp" style=""></span>C&#41; and several others on the lips &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Additional Tests</span><p id="par0015" class="elsevierStylePara elsevierViewall">A punch biopsy of one of the lingual papules revealed well-circumscribed nodular lesions in the dermis&#44; consisting of hyperplastic nerve fibers that were positive for neurofilament and S100 staining &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Based on these histological finding magnetic resonance imaging of the adrenal glands was performed&#44; and levels of urine catecholamines and blood calcitonin were determined&#46; All test results were normal&#46; However&#44; thyroid ultrasound revealed 3 vascularized&#44; hypodense&#44; bilateral nodules&#44; strongly suggesting malignancy&#46; A genetic study revealed a mutation in the <span class="elsevierStyleItalic">RET</span> proto-oncogene &#40;p&#46;Met918Thr&#41;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">What Is Your Diagnosis&#63;</span></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Diagnosis</span><p id="par0030" class="elsevierStylePara elsevierViewall">Mucosal neuromas in a case of multiple endocrine neoplasia&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Course</span><p id="par0035" class="elsevierStylePara elsevierViewall">Based on the histological confirmation of mucosal neuromas and the patient&#769;s clinical history of chronic constipation&#44; several additional tests were conducted to confirm the presence of multiple endocrine neoplasia &#40;MEN&#41;&#46; A thyroidectomy&#44; performed given the strong suspicion of malignant infiltration of the thyroid&#44; confirmed the presence of medullary thyroid cancer&#46; The final diagnosis was MEN type 2B with cutaneous&#44; thyroid&#44; and gastrointestinal involvement&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Comments</span><p id="par0040" class="elsevierStylePara elsevierViewall">MEN type 2B syndrome is an inherited autosomal dominant disorder caused by a mutation in the <span class="elsevierStyleItalic">RET</span> proto-oncogene&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">1</span></a> MEN type 2 is classified into 3 types&#58; 2A&#44; 2B&#44; and familial medullary thyroid cancer&#46; MEN type 2B has a low incidence &#40;1 case per 200&#160;000&#41;&#44; and represents 5&#37; of all MEN type 2 cases&#46; This disorder is characterized by endocrine neoplasias such as pheochromocytoma &#40;50&#37; of cases&#41; and medullary thyroid cancer &#40;95&#37; of cases&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">2</span></a> The latter is usually the first neoplasia to develop&#44; and has a poor prognosis owing to its aggressive and multicentric nature and its high rate of metastasis &#40;mainly in the lung and liver&#41;&#46; A prophylactic thyroidectomy is thus recommended in such cases&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">2</span></a> MEN type 2B is also characterized by intestinal ganglioneuromatosis resulting in chronic constipation&#44; and a peculiar phenotype with marfanoid habitus and thickening of the lips and eyelids&#44; as seen in our patient&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">3</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Mucosal neuromas are the guiding sign for the early diagnosis of this disease&#44; and are usually located in the midface region&#44; predominantly in the lingual and labial mucosa&#44; and less frequently in the conjunctiva and palate&#46; In severe cases&#44; mucosal neuromas may be present at birth&#59; the number and&#47;or size of these neuromas may increase over time or remain unchanged&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">4</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Mucosal neuromas&#44; given their almost pathognomonic character&#44; can thus constitute the key to early identification of MEN&#46; The dermatologist plays a crucial role in such cases&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conflicts of Interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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Journal Information
Vol. 106. Issue 3.
Pages 227-228 (April 2015)
Visits
4561
Vol. 106. Issue 3.
Pages 227-228 (April 2015)
Case for Diagnosis
Open Access
Mucosal Papules in a 9-Year-Old Girl
Pápulas mucosas en una niña de 9 años
Visits
4561
L. Padilla-España
Corresponding author
laupadesp@gmail.com

Corresponding author.
, J. del Boz-González, M. de Troya Martín
Servicio de Dermatología, Hospital Costa del Sol, Marbella, Málaga, Spain
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Medical History

A 9-year-old girl with no family history of interest was undergoing follow-up in pediatrics for functional chronic constipation since childhood. She was referred to dermatology for multiple lesions on the tip of the tongue that had developed at 7 years of age.

Physical Examination

The initial physical examination revealed marfanoid habitus (Fig. 1A), with thickening and mild eversion of the lip and the free margin of the eyelid. Several firm, opaque, papular lesions were observed on the tip of the tongue (Fig. 1B). A single skin-colored papular lesion was observed in the right nasal choana (Fig. 1C) and several others on the lips (Fig. 1).

Figure 1
(0.01MB).
Additional Tests

A punch biopsy of one of the lingual papules revealed well-circumscribed nodular lesions in the dermis, consisting of hyperplastic nerve fibers that were positive for neurofilament and S100 staining (Fig. 2).

Figure 2.

A, Hematoxylin-eosin, original magnification ×100. B, Hematoxylin-eosin, original magnification ×200. C, Neurofilament immunohistochemistry. D, S100 immunohistochemistry.

(0.62MB).

Based on these histological finding magnetic resonance imaging of the adrenal glands was performed, and levels of urine catecholamines and blood calcitonin were determined. All test results were normal. However, thyroid ultrasound revealed 3 vascularized, hypodense, bilateral nodules, strongly suggesting malignancy. A genetic study revealed a mutation in the RET proto-oncogene (p.Met918Thr).

What Is Your Diagnosis?

Diagnosis

Mucosal neuromas in a case of multiple endocrine neoplasia.

Course

Based on the histological confirmation of mucosal neuromas and the patient́s clinical history of chronic constipation, several additional tests were conducted to confirm the presence of multiple endocrine neoplasia (MEN). A thyroidectomy, performed given the strong suspicion of malignant infiltration of the thyroid, confirmed the presence of medullary thyroid cancer. The final diagnosis was MEN type 2B with cutaneous, thyroid, and gastrointestinal involvement.

Comments

MEN type 2B syndrome is an inherited autosomal dominant disorder caused by a mutation in the RET proto-oncogene.1 MEN type 2 is classified into 3 types: 2A, 2B, and familial medullary thyroid cancer. MEN type 2B has a low incidence (1 case per 200 000), and represents 5% of all MEN type 2 cases. This disorder is characterized by endocrine neoplasias such as pheochromocytoma (50% of cases) and medullary thyroid cancer (95% of cases).2 The latter is usually the first neoplasia to develop, and has a poor prognosis owing to its aggressive and multicentric nature and its high rate of metastasis (mainly in the lung and liver). A prophylactic thyroidectomy is thus recommended in such cases.2 MEN type 2B is also characterized by intestinal ganglioneuromatosis resulting in chronic constipation, and a peculiar phenotype with marfanoid habitus and thickening of the lips and eyelids, as seen in our patient.3

Mucosal neuromas are the guiding sign for the early diagnosis of this disease, and are usually located in the midface region, predominantly in the lingual and labial mucosa, and less frequently in the conjunctiva and palate. In severe cases, mucosal neuromas may be present at birth; the number and/or size of these neuromas may increase over time or remain unchanged.4

Mucosal neuromas, given their almost pathognomonic character, can thus constitute the key to early identification of MEN. The dermatologist plays a crucial role in such cases.

Conflicts of Interest

The authors declare that they have no conflicts of interest.

References
[1]
J. Moline, C. Eng.
Multiple endocrine neoplasia type 2: An overview.
Genet Med, 13 (2011), pp. 755-764
[2]
M.J. Lee, K.H. Chung, J.S. Park, H. Chung, H.C. Jang, J.W. Kim.
Multiple endocrine neoplasia type 2B: Early diagnosis by multiple mucosal neuroma and its DNA analysis.
Ann Dermatol, 22 (2010), pp. 452-455
[3]
F. Raue, K. Frank-Raue.
Update multiple endocrine neoplasia type 2.
Fam Cancer, 9 (2010), pp. 449-457
[4]
M. Majidi, V. Haghpanah, M. Hedayati, P. Khashayar, M.R. Mohajeri-Tehrani, B. Larijani.
A family presenting with multiple endocrine neoplasia type 2B: A case report.
J Med Case Rep, 5 (2011), pp. 587

Please cite this article as: Padilla-España L, del Boz-González J, de Troya Martín M. Pápulas mucosas en una niña de 9 años. Actas Dermosifiliogr. 2015;106:227–228.

Copyright © 2014. Elsevier España, S.L.U. and AEDV
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