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hyper-IgE syndromes&#44; has been described and extensively studied&#46; These entities are classified according to the pattern of transmission&#58; autosomal dominant &#40;AD&#41; or autosomal recessive &#40;AR&#41;&#46; Both types are characterized by elevated IgE and a clinical picture dominated by skin involvement&#44; with moderate or severe acute and subacute eczema that resembles atopic dermatitis&#44; and by recurrent skin and respiratory infection&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The other group comprises a series of low-prevalence congenital diseases that often present with episodes of refractory eczema associated with elevated IgE and that should be included in our diagnostic algorithm&#46; Omenn syndrome is a serious combined immunodeficiency of AR transmission that presents in the first year of life&#46; Wiskott-Aldrich syndrome is a primary X-linked immunodeficiency characterized essentially by bleeding diathesis secondary to thrombocytopenia or platelet dysfunction&#44; along with recurrent eczemas and bacterial infections from birth&#46; Prolidase deficiency is a multisystemic disease of AR transmission with a very variable clinical presentation and severity&#44; associated with limited or no prolidase enzyme in erythrocytes&#44; leukocytes&#44; or fibroblasts&#46; Loeys-Dietz syndrome is a connective tissue disease of AD transmission that is associated with a marfanoid appearance and abnormalities in the great arteries&#46; Immune dysregulation&#44; polyendocrinopathy&#44; enteropathy&#44; X-linked &#40;IPEX&#41; syndrome is a serious congenital autoimmune disease in which refractory diarrhea&#44; infections&#44; and multiple endocrine disorders are present in addition to skin involvement&#46; STAT5B deficiency is a condition of AR transmission included in the group of syndromes related to growth hormone insensitivity&#46; This entity is notable for the occurrence of primary immunodeficiency&#46; Pentasomy X is a congenital disease caused by chromosomal abnormalities in women leading to gonadal dysfunction&#44; delayed development&#44; short stature&#44; and musculoskeletal and craniofacial malformations&#46; Netherton syndrome is an AR genodermatosis characterized by ichthyosiform erythroderma&#44; trichorrhexis invaginata&#44; and atopic manifestations present almost from birth&#46; Finally&#44; we include 2 very recently described genodermatosis related to Netherton syndrome from the pathophysiological point of view&#58; peeling skin syndrome type B &#40;PSS-B&#41; and severe dermatitis&#44; multiple allergies&#44; and metabolic wasting &#40;SAM&#41; syndrome&#46; PSS-B is an AR genodermatosis with ichthyosiform erythroderma from birth which&#44; in addition&#44; presents with severe food allergies&#44; angioedema&#44; and urticaria&#46; Finally&#44; SAM is another rare AR genodermatosis in which skin involvement is combined with notable food allergies&#44; esophageal involvement&#44; and other characteristics that will be discussed later in this article&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Differential diagnosis of these syndromes can be very complex&#44; given that there may be considerable overlap and many clinical characteristics are shared&#46; The phenotypic expression of each of these conditions may also vary from one individual to another&#46; Thus&#44; in this article&#44; we provide key information to enable differential diagnosis from the clinical point of view&#44; with the intention of guiding which genetic studies to request&#46; Definitive diagnosis is made by identifying the causal mutation&#46; In <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#44; we have compiled the main genodermatosis that should be included in the differential diagnosis&#44; indicating the main characteristics to investigate in the diagnostic procedure to enable us reach a full diagnosis&#46; A complete detailed description of each of these diseases is not an objective of this article&#46; For this&#44; the reader is referred to literature for more information&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">It should be noted from the outset that the skin manifestations have a very early onset and many of these are common to several entities&#46; Dermatitis &#40;erythema&#44; intense pruritus&#44; dry skin&#44; and lichenification&#41; is moderate or severe in both types of hyper-IgE syndromes&#44;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">2&#8211;5</span></a> Wiskott-Aldrich syndrome&#44;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">6&#44;7</span></a> Netherton syndrome&#44;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">6&#44;8</span></a> SAM&#44;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">6</span></a> IPEX syndrome&#44;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">3&#44;9</span></a> and STAT5 deficiency&#44;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">9&#44;10</span></a> but is less frequent in PSS-B&#44;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">6</span></a> Loeys-Dietz syndrome&#44;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">11</span></a> and prolidase deficiency&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">12</span></a> Generally&#44; these conditions follow a severe course with poor response to the traditional topical and systemic treatments used in atopic dermatitis&#46; However&#44; seborrheic dermatitis-like lesions are much more common in Omenn syndrome&#46; In all entities&#44; erythroderma may present with variable frequency&#44; and even in Netherton syndrome and PSS-B&#44; ichthyosiform erythroderma will be a dominant feature of the clinical picture and will present at a very early stage&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">13</span></a> The differential diagnosis should include all these possible causes of erythroderma in children&#46; It should also be mentioned that cases of IPEX syndrome with psoriasiform dermatitis&#44; exfoliative dermatitis&#44; and pemphigoid nodularis have been reported&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">9</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">From the dermatopathological point of view&#44; we can find features of great help in the diagnosis of these diseases&#46; Perivascular dermatitis with abundant eosinophils and spongiosis is common in hyper-IgE syndromes&#46; Histological study of skin biopsy in Netherton syndrome is characterized by hypogranulosis&#44; parakeratosis&#44; and subcorneal detachment&#44; while premature secretion of lamellar bodies is also observed in electron microscopy&#59; immunohistochemical staining demonstrates the absence of LEKTI in the granular layer and inner root sheaf&#46; This is all a result of abnormal differentiation and accelerated scaling of the epidermis in this disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">6&#44;8</span></a> In contrast&#44; skin histology in PSS-B is noteworthy because of the presence of subcorneal acantholysis&#44; superficial inflammatory infiltrate&#44; and lack of expression of epidermal <span class="elsevierStyleItalic">CDSN</span> in the immunohistochemical study&#46; Electron microscopy demonstrates loss of corneodesmosomes&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">6</span></a> Finally&#44; in SAM&#44; subcorneal and intragranular acantholysis and psoriasiform dermatitis alternating with orthoparakeratosis&#47;parakeratosis and hypogranulosis or hypergranulosis are also found&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">6&#44;14</span></a> Electron microscope study shows the irregular distribution of desmosomes in the upper half of the epidermis&#44; with normal follicular histology&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">6&#44;14</span></a> Direct immunofluorescence shows the anomalous cytoplasmic distribution of desmoglein 1 in epidermal keratinocytes&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">14</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">A predisposition to skin infections is present in all entities&#44; although with certain particularities&#46; The most frequent are pyodermatitis and cutaneous abscesses&#44; as reflected in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; Mucocutaneous candidiasis appears in hyper-IgE syndromes&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">15</span></a> In AR hyper-IgE syndrome&#44; as well as in Wiskott-Aldrich syndrome&#44; viral infections such as molluscum contagiosum and HPV&#44; are also common&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">2&#8211;4</span></a> STAT5B deficiency has frequently been associated with severe cases of chicken pox or herpes zoster&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">10</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Apart from these common characteristics&#44; there are specific cutaneomucosal and morphological manifestations of certain entities which&#44; if present&#44; can greatly facilitate clinical diagnosis&#46; Typical facies is often present with AD hyper-IgE syndrome<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">5</span></a> &#40;but not in the AR variant&#41;&#44; Loeys-Dietz syndrome&#44;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">7</span></a> Omenn syndrome&#44; prolidase deficiency&#44; and STAT5B deficiency&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">9&#44;10</span></a> Purpuric lesions are characteristic of Wiskott-Aldrich syndrome and&#44; less frequently&#44; prolidase deficiency&#44; generally in form of petechiae and ecchymosis after minimal trauma&#46; In SAM palmoplantar keratoderma striata&#44; skin erosions&#44; substantial peeling&#44; and hypotrichosis are often present&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">6</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The skin fragility characteristic of prolidase deficiency is responsible for the development&#44; in addition&#44; of ulcers&#44; predominantly on the lower limbs and&#44; less frequently&#44; in the anogenital region&#46; These are generally recurrent&#44; with an onset in early infancy&#44; and with partial response to suitable topical treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">12</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Abnormalities in the hair follicles are varied&#46; In Netherton syndrome&#44; trichorrhexis invaginata &#40;<span class="elsevierStyleItalic">bamboo hair</span>&#41; is observed&#46; This is more apparent after the first year of life and is a key characteristic to differentiate this entity from PSS-B&#44; which is phenotypically very similar although children have normal hair&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">6&#44;8</span></a> STAT5B deficiency is associated with sparse fine hair&#44;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">9</span></a> and some cases of alopecia areata universalis have been reported in IPEX syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">10</span></a> Diffuse alopecia may develop in Omenn syndrome and very early greying may present in patients with prolidase deficiency&#44; with diffuse alopecia in adults&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">12</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Second&#44; respiratory manifestations are frequent in all these children&#46; In prolidase deficiency&#44; of note is the high frequency of upper respiratory infections&#44; which may help differential diagnosis with hyper-IgE syndromes&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">12</span></a> In fact&#44; in AD hyper-IgE syndrome&#44; the development of pneumatocele as a result of recurrent lung infections is relatively common&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">5</span></a> Recurrent pneumonia typically appears in all entities&#44; except in Netherton syndrome and PSS-B&#44; in which allergic asthma is more characteristic&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">16</span></a> In IPEX syndrome&#44; infections are uncommon<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">3</span></a> and are often a side effect of immunosuppressive treatment&#46; Finally&#44; rhinitis occurs principally in Loeys-Dietz syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">11</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Third&#44; we have musculoskeletal manifestations&#44; which are key for differential diagnosis&#46; Thus&#44; AD hyper-IgE syndrome is associated with osteopenia&#44; scoliosis&#44; and pathological fractures in more than half of those affected<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">3</span></a>&#59; however&#44; in the AR form&#44; postnatal growth retardation is the only musculoskeletal manifestation in some cases&#46; On the other hand&#44; PSS-B<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">6</span></a> and SAM<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">6</span></a> also show a delayed growth with short final stature&#44; whereas in Omenn syndrome&#44;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">17</span></a> prolidase deficiency&#44;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">12</span></a> and Netherton syndrome&#44;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">8</span></a> the delayed growth is limited&#44; uncommon&#44; and children will not necessarily have a short adult stature&#46; Prolidase deficiency can be associated at times with osteoporosis and joint hypermobility&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">12</span></a> Loeys-Dietz syndrome<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">11</span></a> usually presents with marfanoid features and joint hypermobility&#44; and in type <span class="elsevierStyleSmallCaps">i</span>&#44; bone abnormalities may also present&#44; including craniosynostosis&#44; pectus excavatum&#44; pectus carinatum&#44; cavus foot&#44; and joint contractures&#46; In Loeys-Dietz syndrome type <span class="elsevierStyleSmallCaps">ii</span>&#44; bone abnormalities are mild or absent&#46; The type <span class="elsevierStyleSmallCaps">iii</span> syndrome is essentially associated with multifocal osteoarthritis&#46; Pentasomy X is associated with cranial malformations&#44; often microcephaly&#44; as well as other bone abnormalities such as syndactylia&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">18</span></a> Finally&#44; dwarfism may occur with STAT5B deficiency from birth as a result of growth hormone &#40;GH&#41; receptor failure&#44; which is known as GH insensitivity syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">9</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">We will now review the main laboratory findings to discriminate between these diseases&#46; Determination of immunoglobulins is key&#46; Elevated IgE is observed in all entities&#44; although we should remember that IgE levels may be normal in some patients with Loeys-Dietz syndrome and pentasomy X&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">11&#44;19</span></a> In Wiskott-Aldrich syndrome and IPEX syndrome&#44; IgA is also elevated&#44; and in prolidase deficiency and STAT5B deficiency&#44; polyclonal hypergammoglobulinemia is common&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">11&#44;19</span></a> Multiple autoantibodies such as antiperoxidase and antivillin antibodies&#44; among others&#44; will be observed in IPEX syndrome and STAT5B deficiency&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">10</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">The hematology parameters may also show notable abnormalities&#46; Eosinophilia would point towards hyper-IgE syndromes&#44;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">2&#8211;5</span></a> Omenn syndrome&#44;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">17</span></a> PSS-B&#44;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">6</span></a> and IPEX syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">9</span></a> Eosinophilia is usually more marked in the recessive variant of hyper-IgE syndrome&#44; and progressive lymphopenia is also observed&#46; The absence of B cells is a key finding for the diagnosis of Omenn syndrome&#46; In Wiskott-Aldrich syndrome&#44;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">7</span></a> prolidase deficiency&#44;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">12</span></a> and IPEX syndrome&#44;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">9</span></a> thrombocytopenia&#44; and occasionally lymphopenia are observed&#46; With regards red blood cell parameters&#44; hemolytic anemia is present in IPEX syndrome&#44;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">9</span></a> Wiskott-Aldrich syndrome&#44;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">7</span></a> and&#44; to a lesser extent&#44; hyper-IgE syndromes&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">3&#44;5</span></a> Hypochromic microcytic anemia is most characteristic of prolidase deficiency&#44; and here we should also mention massive iminodipeptiduria along with elevated iminodipeptides &#40;with proline or hydroxyproline at the carboxy-terminal end&#41; as key laboratory findings pointing to diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">12</span></a> In turn&#44; and very characteristically&#44; in STAT5B deficiency&#44; we can find T cell lymphopenia along with low levels of <span class="elsevierStyleItalic">IGF1</span> and <span class="elsevierStyleItalic">IGFBP3</span> and normal or elevated GH&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">10</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Manifestations of atopy and allergy are characteristic of AR hyper-IgE syndrome&#44;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">20</span></a> Netherton syndrome&#44; PSS-B&#44; SAM&#44; and often Loeys-Dietz syndrome&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">15&#44;19</span></a> The most frequent such manifestations are rhinitis and episodes of urticaria&#46; In PSS-B&#44; and above all in hyper-IgE syndrome&#44; episodes of anaphylaxis and angioedema have been reported&#46; These may be recurrent&#46; In SAM&#44; food allergies are usually particularly severe&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">16</span></a> The radioallergosorbent test&#44; an analytical technique that quantitatively determines specific IgE levels for a range of allergens&#44; is usually abnormal in all these entities&#44; particularly in the case of alimentary antigens&#44; and more frequently in individuals with atopic dermatitis&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">16&#44;19</span></a> Pathological radioallergosorbent test results are less common in AD hyper-IgE syndrome than in the recessive form&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">19&#44;20</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Finally&#44; we highlight other manifestations that do not fit into the above categories and that might be useful in the differential diagnosis&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The clinical picture in IPEX syndrome and STAT5B deficiency is dominated by autoimmune phenomena&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">9&#44;10</span></a> In the case of IPEX syndrome&#44; type 1 diabetes mellitus&#44; thyroid disease&#44; and autoimmune enteropathy are almost always present&#46; In addition&#44; hemolytic anemia&#44; thrombocytopenia&#44; leukopenia&#44; hepatitis&#44; and tubular nephropathy may also be present&#46; In STAT5B deficiency&#44; enteropathy&#44; thyroid disease&#44; and lymphocytic interstitial pneumonitis are the most characteristic&#46; Autoimmune manifestations also occur in Wiskott-Aldrich syndrome &#40;in up to 40&#37; of patients&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">6&#44;7</span></a> and hyper-IgE syndromes&#44;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">3&#44;5&#44;20</span></a> above all in AR forms&#59; they are less common in AD forms&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">20</span></a> Hemolytic anemia&#44; leukocytoclastic vasculitis&#44; isolated cerebral vasculitis&#44; systemic small-vessel vasculitis&#44; arthritis&#44; and autoantibody-mediated glomerulonephritis can be present in hyper-IgE syndromes and Wiskott-Aldrich syndrome and&#44; in the case of Wiskott-Aldrich syndrome&#44; inflammatory bowel disease may also occur&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">6&#44;7</span></a> In hyper-IgE syndromes&#44; isolated cases associated with systemic lupus erythematosus and dermatomyositis have also been reported&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">20</span></a> In addition&#44; an increased risk of cancer at any age has been documented for these 3 entities&#46; Specifically&#44; in AD hyper-IgE syndrome<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">3&#44;20</span></a> and Wiskott-Aldrich syndrome&#44;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">6&#44;7</span></a> lymphoproliferative diseases predominate&#46; In AR hyper-IgE syndrome&#44;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">20</span></a> a higher risk ratio has been reported with respect to the AD variant&#44; and this higher risk is also present for neoplasms of epithelial and other origins&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">4</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">The appearance of neurological manifestation&#44; such as hemiplegia&#44; encephalopathy&#44; strokes&#44; and facial paralysis may point to AR hyper-IgE syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">4</span></a> However&#44; the delay in psychomotor development&#44; which may be very variable&#44; is mainly associated with pentasomy X<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">18</span></a> and prolidase deficiency&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">12</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">A manifestation common to IPEX syndrome&#44; STAT5B deficiency&#44; Netherton syndrome&#44; and Omenn syndrome is chronic diarrhea syndrome&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">3&#44;9&#44;10&#44;17</span></a> In the latter 2 entities&#44; hepatosplenomegaly and inflammatory adenopathies are also often reported&#46; The esophagus is affected more often in SAM<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">6</span></a> in the form of eosinophilic esophagitis and gastroesophageal reflux&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">From the cardiovascular point of view&#44; it is important to note that arterial aneurysms and episodes of aortic dissection are characteristic of Loeys-Dietz syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">11</span></a> In more than 80&#37; of cases of AD hyper-IgE syndrome&#44; peripheral&#44; cerebral&#44; and&#44; to a lesser extent&#44; coronary vascular malformations are present&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">4&#44;5</span></a> SAM is sometimes associated with minor cardiac defects&#44;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">6</span></a> whereas cardiovascular abnormalities can be very varied in the case of pentasomy X&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">17</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">With regards genital abnormalities&#44; gonadal dysfunction is only characteristic of pentasomy X<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">18</span></a> although the external genitals are normal&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a> shows a diagnostic algorithm based on laboratory results &#40;presence of eosinophilia and abnormalities in the radioallergosorbent test&#41; and preliminary classification of the patients to subsequently study the presence of other findings that may guide clinical diagnosis for each of the genetic disorders discussed&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">In conclusion&#44; this article aims to provide practical assistance in the differential diagnosis of a child with refractory eczema and elevated IgE&#46; The medical history&#44; physical exploration&#44; and laboratory results can guide us to the most appropriate genetic study for a definitive molecular diagnosis&#46; This will enable individualized treatment according to the most recent evidence available for each of these entities&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conflicts of Interest</span><p id="par0120" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The association of moderate to severe eczema and elevated plasma levels of immunoglobulin E is a characteristic not only of atopic dermatitis but also of various genodermatoses&#58; hyperimmunoglobulin E syndromes&#44; Omenn syndrome&#44; Netherton syndrome&#44; peeling skin syndrome type B&#44; severe dermatitis&#44; multiple allergies&#44; and metabolic wasting syndrome&#44; Wiskott-Aldrich syndrome&#44; prolidase deficiency&#44; Loeys-Dietz syndrome&#44; IPEX syndrome&#44; STAT5B deficiency&#44; and pentasomy X&#46; The clinical presentation of these genodermatoses &#8211;typically in children&#8211; is consistent with severe atopic dermatitis&#46; Immunoglobulin E is elevated from birth and response to conventional treatments is poor&#46; Diagnosis is further complicated by the fact that these genodermatoses often share other clinical manifestations and laboratory findings&#46; We present practical guidelines for differentiating among these various entities&#44; with the aim of helping physicians decide what type of genetic test should be carried out &#8211;and when&#8211; in order to establish a definitive diagnosis&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La asociaci&#243;n de eccema moderado-grave y niveles elevados de IgE en plasma es caracter&#237;stica no solo de la dermatitis at&#243;pica&#44; sino tambi&#233;n de diversas genodermatosis&#58; s&#237;ndromes hiper-IgE&#44; s&#237;ndrome de Omenn&#44; s&#237;ndrome de Netherton&#44; s&#237;ndrome de la piel exfoliada tipo B&#44; s&#237;ndrome de dermatitis grave-alergias m&#250;ltiples-desgaste metab&#243;lico&#44; s&#237;ndrome de Wiskott-Aldrich&#44; d&#233;ficit de prolidasa&#44; s&#237;ndrome de Loeys-Dietz&#44; s&#237;ndrome IPEX&#44; d&#233;ficit de STAT5B y pentasom&#237;a X&#46; Se trata de pacientes pedi&#225;tricos que presentan un cuadro cl&#237;nico compatible con dermatitis at&#243;pica grave&#44; con mala respuesta a los tratamientos cl&#225;sicos y que asocian elevaci&#243;n de IgE desde el nacimiento&#46; Adem&#225;s&#44; comparten con frecuencia otras manifestaciones cl&#237;nicas y anal&#237;ticas&#44; lo cual dificulta el diagn&#243;stico&#46; Presentamos una gu&#237;a pr&#225;ctica para orientar el diagn&#243;stico diferencial entre todas estas entidades y&#44; por lo tanto&#44; ayudar a decidir cu&#225;ndo y el tipo de test gen&#233;tico a realizar para establecer el diagn&#243;stico definitivo&#46;</p></span>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Arjona Aguilera C&#44; Albarr&#225;n Planelles C&#44; Tercedor S&#225;nchez J&#46; Trastornos gen&#233;ticos con eccema moderado-grave refractario y elevaci&#243;n de inmunoglobulina E&#58; diagn&#243;stico diferencial&#46; Actas Dermosifiliogr&#46; 2016&#59;107&#58;116&#8211;124&#46;</p>"
      ]
    ]
    "multimedia" => array:2 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 3765
            "Ancho" => 3381
            "Tamanyo" => 472503
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Suggested Diagnostic Algorithm for Clinical Diagnosis of Genodermatosis of Moderate-to-Severe Presentation and Elevated IgE&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">BC&#44; B cells&#59; DIF&#44; direct immunofluorescence&#59; DM&#44; diabetes mellitus&#59; DPT&#44; dermatopathology&#59; DSG1&#44; desmoglein 1&#59; GH&#44; growth hormone&#59; HPV&#44; human papillomavirus&#59; HSV&#44; herpes simplex virus&#59; IBD&#44; inflammatory bowel disease&#59; IGF-1&#44; insulin growth factor&#44; type 1&#59; IGFBP3&#44; insulin growth factor binding protein 3&#59; IHC&#44; immunohistochemistry&#59; IPEX&#44; immune-polyendocrinopathy-enteropathy&#44; X-linked dysregulation syndrome&#59; RAST&#44; radioallergoasorbent test&#59; SAH&#44; subarachnoid hemorrhage&#59; SLE&#44; systemic lupus erythematosus&#59; TC&#44; T cells&#59; VZV&#44; varicella-zoster virus&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Skin and Appendages&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Respiratory System&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Musculoskeletal system&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Autoimmunity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Others&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Laboratory&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Genetics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Autosomal dominant hyper-IgE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Moderate-to-severe eczema<br>Pyodermatitis Abscesses<br>Mucocutaneous candidiasis<br>Typical facies<br>Facial punctiform scars&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Recurrent pneumonia<br>Pneumatocele&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Osteopenia<br>Scoliosis &#40;50&#37;&#41;<br>Fractures &#40;60&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Infrequent</span><br>Vasculitis &#40;leukocytoclastic&#44; isolated cerebral&#44; systemic small vessel&#41;<br>Glomerulonephritis<br>Hemolytic anemia<br>SLE&#44; dermatomyositis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Lymphomas<br>Vascular malformations&#58; peripheral&#44; cerebral&#44; or coronary&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Elevated IgE<br>Eosinophilia<br>RAST&#58; normal or positive to food antigens<br>DPT&#58; perivascular dermatitis with eosinophilia&#44; spongiosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">STAT3</span> gene mutations &#40;70&#37;&#41;<br>Autosomal dominant<br>Unknown &#40;30&#37;&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Autosomal recessive hyper-IgE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Moderate-to-severe eczema<br>Urticaria<br>Pyodermatitis Abscesses<br>Mucocutaneous candidiasis<br>Viral infections &#40;HSV&#44; HPV&#44; molluscum&#44; etc&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Asthma &#40;30&#37;-50&#37;&#41;&#44; rhinitis<br>Pneumonia uncommon&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Postnatal growth retardation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Vasculitis &#40;leukocytoclastic&#44; isolated cerebral&#44; systemic small vessel&#41;<br>Glomerulonephritis<br>Hemolytic anemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cancer&#58; 17&#37; &#40;hematological&#44; epithelial&#44; others&#41;<br>Central nervous system&#58; SAH&#44; encephalopathy&#44; stroke&#44; facial paralysis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Elevated IgE<br>Extreme eosinophilia<br>Progressive lymphopenia<br>RAST&#58; positive to food allergens<br>DPT&#58; perivascular dermatitis with abundant eosinophils&#44; spongiosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">DOCK8</span> gene mutations<br>Others &#40;rare&#41;&#58; TYK2&#44; PGM3 gene mutations&#44; unknown<br>Autosomal recessive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Wiskott-Aldrich syndrome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Moderate-to-severe eczema<br>Seborrheic dermatitis<br>Piodermitis<br>Viral infection<br>Petechaie&#44; purpura&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Recurrent pneumonia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hemolytic anemia<br>Vasculitis<br>Nephritis<br>Arthritis<br>IBD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Bleeding<br>Lymphomas&#58; 13&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Elevated IgE and IgA<br>Thrombocytopenia<br>normal&#47;low BC and TC<br>RAST&#58; normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">WAS</span> gene mutations<br>X-linked&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Omenn syndrome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Seborrheic dermatitis<br>Erythroderma<br>Eczemas &#40;uncommon&#41;<br>Diffuse alopecia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Recurrent pneumonia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Postnatal growth retardation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hepatosplenomegaly<br>Adenopathies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Chronic multifactorial diarrhea syndrome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Elevated IgE<br>Eosinophilia<br>B cells absent<br>Anomalous TC clone<br>RAST&#58; normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">RAG1-2</span> gene mutations&#46; Less often&#58; <span class="elsevierStyleItalic">RMRP&#44; ADA&#44; IL2RG&#44; IL7RA&#44; DCLRE1</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">C&#44; CHD7&#44; LIG4&#44; AK2</span><br>Autosomal recessive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Netherton syndrome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Moderate-to-severe eczema<br>Urticaria<br>Pyodermatitis<br>Ichthyosiform erythroderma&#59; ichthyosis linearis circumflexa<br>Trichorrhexis invaginata&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Allergic asthma&#44; rhinitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Postnatal growth retardation<br>Short stature&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Chronic multifactorial diarrhea syndrome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Elevated IgE<br>TC differentiation abnormality<br>RAST&#58; positive to food allergens<br>DPT&#58; psoriasiform dermatitis&#44; hypogranulosis&#47;agranulosis&#44; parakeratosis&#44; premature lamellar body secretion&#44; subcorneal acantholysis<br>IHC&#58; LEKTI absence in granular layer and inner root sheaf&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">SPINK5</span> gene mutations<br>Autosomal recessive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Peeling skin syndrome&#44; type B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Ichthyosiform erythroderma<br>Urticaria&#44; angioedema<br>Pyodermatitis &#40;<span class="elsevierStyleItalic">Staphylococcus aureus</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Allergic asthma&#44; rhinitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Postnatal growth retardation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Elevated IgE<br>Eosinophilia<br>RAST&#58; positive to food allergens<br>DPT&#58; perivascular dermatitis&#44; subcorneal acantholysis IHC&#58; absence CDSN in epidermis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">CDSN</span> gene mutations<br>Autosomal recessive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Severe dermatitis&#44; multiple allergies&#44; metabolic wasting syndrome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Congenital erythroderma&#44; peeling<br>Palmoplantar keratoderma striata<br>Hypotrichosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pneumonia<br>Upper respiratory tract infections&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Postnatal growth retardation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Eosinophilic esophagitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Metabolic wasting<br>Gastroesophageal reflux<br>Minor cardiac defects&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Elevated IgE<br>RAST&#58; positive to food allergens<br>DPT&#58; subcorneal and intragranular acantholysis&#44; psoriasiform dermatitis&#44; orthokeratosis&#47;parakeratosis&#44; hypogranulosis&#47;hypergranulosis DIF&#58; anomalous DSG1 cytoplasmic distribution&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">DSG1&#44; DSP</span> gene mutations<br>Autosomal recessive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Prolidase deficiency&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Skin fragility&#44; ulcers &#40;legs&#44; perianal&#41;<br>Purpura&#44; telangiectasias<br>Photosensitivity<br>Acute eczema<br>Typical facies<br>Poliosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Recurrent upper airway infection<br>Pneumonia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Joint hypermobility<br>Short stature<br>Osteoporosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">SLE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Splenomegalia<br>Mental retardation<br>Less often&#58; deafness&#44; hepatomegalia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Elevated IgE&#47;hypergammaglobulinemia<br>Microcytic anemia<br>Thrombocytopenia<br>Imidodipeptiduria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">PEPD</span> gene mutations<br>Autosomal recessive &#40;very variable age and phenotype&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Loeys-Dietz syndrome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Marfanoid appearance&#44; cleft palate<br>Fine skin&#44; anomalous healing<br>Mild eczema&#47;occasionally severe&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pneumonia<br>Rhinitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hypermobility<br>I&#58; bone abnormalities &#40;cranium&#44; sternum&#44; phalanges&#44; etc&#46;&#41;<br>III&#58; Osteoarthritis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Arterial aneurysms<br>Aortic dissection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Normal&#47;elevated IgE<br>RAST&#58; normal&#47;positive to food and respiratory allergens&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">TGFBR1&#44; TGFBR2&#44; SMAD3</span> gene mutations<br>Autosomal dominant&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pentasomy X&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Typical facies<br>Mild eczema&#47;occasionally severe&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Recurrent pneumonia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cranial malformations &#40;microcephaly&#41;<br>Syndactylia&#44; other bone malformations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cardiovascular malformations<br>Gonadal dysfunction<br>Mental retardation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Normal&#47;elevated IgE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pentasomy X &#40;no maternal disjunction in meiosis&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">IPEX syndrome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Severe atopic dermatitis<br>Uncommon&#58; erythroderma&#44; exfoliative dermatitis&#44; psoriasiform dermatitis&#44; pemphigoid nodularis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pneumonia uncommon&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Enteropathy<br>Endocrine disorders&#58; DM-1&#44; thyroiditis&#44; others<br>Hemolytic anemia<br>Thrombocytopenia<br>Neutropenia<br>Hepatitis<br>Tubular nephropathy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sometimes severe systemic infections due to immunosuppression&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Elevated IgE<br>Elevated&#47;normal IgA<br>Eosinophilia<br>Cytopenias<br>Autoantibodies &#40;pancreatic&#44; thyroid&#44; intestinal mucosa antigens&#44; etc&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">FOXP3</span> gene mutations<br>X-linked&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">STAT5B deficiency&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Severe eczema<br>Pyodermatitis<br>Severe viral infection &#40;VZV&#41;<br>Craniofacial dysmorphia<br>Thin&#44; fine hair&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Infectious pneumonia<br>Interstitial lymphocytic pneumonia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Dwarfism&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Thyroid disease<br>Enteropathy<br>Interstitial lymphocytic pneumonia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">GH insensitivity syndrome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hypergammaglobulinemia<br>Lymphopenia &#40;TC&#41;<br>Normal&#47;elevated GH<br>Decreased IGF1&#44; IGFBP3<br>Autoantibodies &#40;thyroid&#44; intestinal mucosa antigens&#44; others&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">STAT5B</span> gene mutations<br>Autosomal recessive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Differential Clinical and Laboratory Diagnosis of Genodermatoses That Present With Moderate-to-Severe Eczema and Elevated IgE&#46;</p>"
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Practical Dermatology
Differential Diagnosis of Genetic Disorders Associated with Moderate to Severe Refractory Eczema and Elevated Immunoglobulin E
Trastornos genéticos con eccema moderado-grave refractario y elevación de inmunoglobulina E: diagnóstico diferencial
C. Arjona Aguileraa,
Autor para correspondencia
cintiaarjona@hotmail.com

Corresponding author.
, C. Albarrán Planellesa, J. Tercedor Sánchezb
a Unidad de Gestión Clínica de Dermatología y Venereología, Hospital Universitario Puerta del Mar, Servicio Andaluz de Salud, Cádiz, Spain
b Unidad de Gestión Clínica de Dermatología y Venereología, Hospital Universitario Virgen de las Nieves, Servicio Andaluz de Salud, Granada, Spain
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        "titulo" => "Trastornos gen&#233;ticos con eccema moderado-grave refractario y elevaci&#243;n de inmunoglobulina E&#58; diagn&#243;stico diferencial"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Suggested Diagnostic Algorithm for Clinical Diagnosis of Genodermatosis of Moderate-to-Severe Presentation and Elevated IgE&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The association between moderate-to-severe eczema and elevated plasma immunoglobulin &#40;Ig&#41; E levels is characteristic of atopic dermatitis and is also seen in other genetic diseases&#46; Many patients also have concurrent congenital immunodeficiency&#46; When faced with a patient with clinical signs and symptoms consistent with severe atopic dermatitis<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">1</span></a> who does not respond to traditional treatments &#40;hygiene and dietary interventions&#44; topical or systemic corticosteroids&#44; cyclosporin&#44; methotrexate&#44; or azathioprine&#41;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">1</span></a> and has elevated IgE from the first days of life&#44; we should suspect the presence of one of these syndromes&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">One group&#44; hyper-IgE syndromes&#44; has been described and extensively studied&#46; These entities are classified according to the pattern of transmission&#58; autosomal dominant &#40;AD&#41; or autosomal recessive &#40;AR&#41;&#46; Both types are characterized by elevated IgE and a clinical picture dominated by skin involvement&#44; with moderate or severe acute and subacute eczema that resembles atopic dermatitis&#44; and by recurrent skin and respiratory infection&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The other group comprises a series of low-prevalence congenital diseases that often present with episodes of refractory eczema associated with elevated IgE and that should be included in our diagnostic algorithm&#46; Omenn syndrome is a serious combined immunodeficiency of AR transmission that presents in the first year of life&#46; Wiskott-Aldrich syndrome is a primary X-linked immunodeficiency characterized essentially by bleeding diathesis secondary to thrombocytopenia or platelet dysfunction&#44; along with recurrent eczemas and bacterial infections from birth&#46; Prolidase deficiency is a multisystemic disease of AR transmission with a very variable clinical presentation and severity&#44; associated with limited or no prolidase enzyme in erythrocytes&#44; leukocytes&#44; or fibroblasts&#46; Loeys-Dietz syndrome is a connective tissue disease of AD transmission that is associated with a marfanoid appearance and abnormalities in the great arteries&#46; Immune dysregulation&#44; polyendocrinopathy&#44; enteropathy&#44; X-linked &#40;IPEX&#41; syndrome is a serious congenital autoimmune disease in which refractory diarrhea&#44; infections&#44; and multiple endocrine disorders are present in addition to skin involvement&#46; STAT5B deficiency is a condition of AR transmission included in the group of syndromes related to growth hormone insensitivity&#46; This entity is notable for the occurrence of primary immunodeficiency&#46; Pentasomy X is a congenital disease caused by chromosomal abnormalities in women leading to gonadal dysfunction&#44; delayed development&#44; short stature&#44; and musculoskeletal and craniofacial malformations&#46; Netherton syndrome is an AR genodermatosis characterized by ichthyosiform erythroderma&#44; trichorrhexis invaginata&#44; and atopic manifestations present almost from birth&#46; Finally&#44; we include 2 very recently described genodermatosis related to Netherton syndrome from the pathophysiological point of view&#58; peeling skin syndrome type B &#40;PSS-B&#41; and severe dermatitis&#44; multiple allergies&#44; and metabolic wasting &#40;SAM&#41; syndrome&#46; PSS-B is an AR genodermatosis with ichthyosiform erythroderma from birth which&#44; in addition&#44; presents with severe food allergies&#44; angioedema&#44; and urticaria&#46; Finally&#44; SAM is another rare AR genodermatosis in which skin involvement is combined with notable food allergies&#44; esophageal involvement&#44; and other characteristics that will be discussed later in this article&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Differential diagnosis of these syndromes can be very complex&#44; given that there may be considerable overlap and many clinical characteristics are shared&#46; The phenotypic expression of each of these conditions may also vary from one individual to another&#46; Thus&#44; in this article&#44; we provide key information to enable differential diagnosis from the clinical point of view&#44; with the intention of guiding which genetic studies to request&#46; Definitive diagnosis is made by identifying the causal mutation&#46; In <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#44; we have compiled the main genodermatosis that should be included in the differential diagnosis&#44; indicating the main characteristics to investigate in the diagnostic procedure to enable us reach a full diagnosis&#46; A complete detailed description of each of these diseases is not an objective of this article&#46; For this&#44; the reader is referred to literature for more information&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">It should be noted from the outset that the skin manifestations have a very early onset and many of these are common to several entities&#46; Dermatitis &#40;erythema&#44; intense pruritus&#44; dry skin&#44; and lichenification&#41; is moderate or severe in both types of hyper-IgE syndromes&#44;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">2&#8211;5</span></a> Wiskott-Aldrich syndrome&#44;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">6&#44;7</span></a> Netherton syndrome&#44;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">6&#44;8</span></a> SAM&#44;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">6</span></a> IPEX syndrome&#44;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">3&#44;9</span></a> and STAT5 deficiency&#44;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">9&#44;10</span></a> but is less frequent in PSS-B&#44;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">6</span></a> Loeys-Dietz syndrome&#44;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">11</span></a> and prolidase deficiency&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">12</span></a> Generally&#44; these conditions follow a severe course with poor response to the traditional topical and systemic treatments used in atopic dermatitis&#46; However&#44; seborrheic dermatitis-like lesions are much more common in Omenn syndrome&#46; In all entities&#44; erythroderma may present with variable frequency&#44; and even in Netherton syndrome and PSS-B&#44; ichthyosiform erythroderma will be a dominant feature of the clinical picture and will present at a very early stage&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">13</span></a> The differential diagnosis should include all these possible causes of erythroderma in children&#46; It should also be mentioned that cases of IPEX syndrome with psoriasiform dermatitis&#44; exfoliative dermatitis&#44; and pemphigoid nodularis have been reported&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">9</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">From the dermatopathological point of view&#44; we can find features of great help in the diagnosis of these diseases&#46; Perivascular dermatitis with abundant eosinophils and spongiosis is common in hyper-IgE syndromes&#46; Histological study of skin biopsy in Netherton syndrome is characterized by hypogranulosis&#44; parakeratosis&#44; and subcorneal detachment&#44; while premature secretion of lamellar bodies is also observed in electron microscopy&#59; immunohistochemical staining demonstrates the absence of LEKTI in the granular layer and inner root sheaf&#46; This is all a result of abnormal differentiation and accelerated scaling of the epidermis in this disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">6&#44;8</span></a> In contrast&#44; skin histology in PSS-B is noteworthy because of the presence of subcorneal acantholysis&#44; superficial inflammatory infiltrate&#44; and lack of expression of epidermal <span class="elsevierStyleItalic">CDSN</span> in the immunohistochemical study&#46; Electron microscopy demonstrates loss of corneodesmosomes&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">6</span></a> Finally&#44; in SAM&#44; subcorneal and intragranular acantholysis and psoriasiform dermatitis alternating with orthoparakeratosis&#47;parakeratosis and hypogranulosis or hypergranulosis are also found&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">6&#44;14</span></a> Electron microscope study shows the irregular distribution of desmosomes in the upper half of the epidermis&#44; with normal follicular histology&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">6&#44;14</span></a> Direct immunofluorescence shows the anomalous cytoplasmic distribution of desmoglein 1 in epidermal keratinocytes&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">14</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">A predisposition to skin infections is present in all entities&#44; although with certain particularities&#46; The most frequent are pyodermatitis and cutaneous abscesses&#44; as reflected in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; Mucocutaneous candidiasis appears in hyper-IgE syndromes&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">15</span></a> In AR hyper-IgE syndrome&#44; as well as in Wiskott-Aldrich syndrome&#44; viral infections such as molluscum contagiosum and HPV&#44; are also common&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">2&#8211;4</span></a> STAT5B deficiency has frequently been associated with severe cases of chicken pox or herpes zoster&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">10</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Apart from these common characteristics&#44; there are specific cutaneomucosal and morphological manifestations of certain entities which&#44; if present&#44; can greatly facilitate clinical diagnosis&#46; Typical facies is often present with AD hyper-IgE syndrome<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">5</span></a> &#40;but not in the AR variant&#41;&#44; Loeys-Dietz syndrome&#44;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">7</span></a> Omenn syndrome&#44; prolidase deficiency&#44; and STAT5B deficiency&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">9&#44;10</span></a> Purpuric lesions are characteristic of Wiskott-Aldrich syndrome and&#44; less frequently&#44; prolidase deficiency&#44; generally in form of petechiae and ecchymosis after minimal trauma&#46; In SAM palmoplantar keratoderma striata&#44; skin erosions&#44; substantial peeling&#44; and hypotrichosis are often present&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">6</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The skin fragility characteristic of prolidase deficiency is responsible for the development&#44; in addition&#44; of ulcers&#44; predominantly on the lower limbs and&#44; less frequently&#44; in the anogenital region&#46; These are generally recurrent&#44; with an onset in early infancy&#44; and with partial response to suitable topical treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">12</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Abnormalities in the hair follicles are varied&#46; In Netherton syndrome&#44; trichorrhexis invaginata &#40;<span class="elsevierStyleItalic">bamboo hair</span>&#41; is observed&#46; This is more apparent after the first year of life and is a key characteristic to differentiate this entity from PSS-B&#44; which is phenotypically very similar although children have normal hair&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">6&#44;8</span></a> STAT5B deficiency is associated with sparse fine hair&#44;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">9</span></a> and some cases of alopecia areata universalis have been reported in IPEX syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">10</span></a> Diffuse alopecia may develop in Omenn syndrome and very early greying may present in patients with prolidase deficiency&#44; with diffuse alopecia in adults&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">12</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Second&#44; respiratory manifestations are frequent in all these children&#46; In prolidase deficiency&#44; of note is the high frequency of upper respiratory infections&#44; which may help differential diagnosis with hyper-IgE syndromes&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">12</span></a> In fact&#44; in AD hyper-IgE syndrome&#44; the development of pneumatocele as a result of recurrent lung infections is relatively common&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">5</span></a> Recurrent pneumonia typically appears in all entities&#44; except in Netherton syndrome and PSS-B&#44; in which allergic asthma is more characteristic&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">16</span></a> In IPEX syndrome&#44; infections are uncommon<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">3</span></a> and are often a side effect of immunosuppressive treatment&#46; Finally&#44; rhinitis occurs principally in Loeys-Dietz syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">11</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Third&#44; we have musculoskeletal manifestations&#44; which are key for differential diagnosis&#46; Thus&#44; AD hyper-IgE syndrome is associated with osteopenia&#44; scoliosis&#44; and pathological fractures in more than half of those affected<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">3</span></a>&#59; however&#44; in the AR form&#44; postnatal growth retardation is the only musculoskeletal manifestation in some cases&#46; On the other hand&#44; PSS-B<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">6</span></a> and SAM<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">6</span></a> also show a delayed growth with short final stature&#44; whereas in Omenn syndrome&#44;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">17</span></a> prolidase deficiency&#44;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">12</span></a> and Netherton syndrome&#44;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">8</span></a> the delayed growth is limited&#44; uncommon&#44; and children will not necessarily have a short adult stature&#46; Prolidase deficiency can be associated at times with osteoporosis and joint hypermobility&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">12</span></a> Loeys-Dietz syndrome<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">11</span></a> usually presents with marfanoid features and joint hypermobility&#44; and in type <span class="elsevierStyleSmallCaps">i</span>&#44; bone abnormalities may also present&#44; including craniosynostosis&#44; pectus excavatum&#44; pectus carinatum&#44; cavus foot&#44; and joint contractures&#46; In Loeys-Dietz syndrome type <span class="elsevierStyleSmallCaps">ii</span>&#44; bone abnormalities are mild or absent&#46; The type <span class="elsevierStyleSmallCaps">iii</span> syndrome is essentially associated with multifocal osteoarthritis&#46; Pentasomy X is associated with cranial malformations&#44; often microcephaly&#44; as well as other bone abnormalities such as syndactylia&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">18</span></a> Finally&#44; dwarfism may occur with STAT5B deficiency from birth as a result of growth hormone &#40;GH&#41; receptor failure&#44; which is known as GH insensitivity syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">9</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">We will now review the main laboratory findings to discriminate between these diseases&#46; Determination of immunoglobulins is key&#46; Elevated IgE is observed in all entities&#44; although we should remember that IgE levels may be normal in some patients with Loeys-Dietz syndrome and pentasomy X&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">11&#44;19</span></a> In Wiskott-Aldrich syndrome and IPEX syndrome&#44; IgA is also elevated&#44; and in prolidase deficiency and STAT5B deficiency&#44; polyclonal hypergammoglobulinemia is common&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">11&#44;19</span></a> Multiple autoantibodies such as antiperoxidase and antivillin antibodies&#44; among others&#44; will be observed in IPEX syndrome and STAT5B deficiency&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">10</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">The hematology parameters may also show notable abnormalities&#46; Eosinophilia would point towards hyper-IgE syndromes&#44;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">2&#8211;5</span></a> Omenn syndrome&#44;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">17</span></a> PSS-B&#44;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">6</span></a> and IPEX syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">9</span></a> Eosinophilia is usually more marked in the recessive variant of hyper-IgE syndrome&#44; and progressive lymphopenia is also observed&#46; The absence of B cells is a key finding for the diagnosis of Omenn syndrome&#46; In Wiskott-Aldrich syndrome&#44;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">7</span></a> prolidase deficiency&#44;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">12</span></a> and IPEX syndrome&#44;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">9</span></a> thrombocytopenia&#44; and occasionally lymphopenia are observed&#46; With regards red blood cell parameters&#44; hemolytic anemia is present in IPEX syndrome&#44;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">9</span></a> Wiskott-Aldrich syndrome&#44;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">7</span></a> and&#44; to a lesser extent&#44; hyper-IgE syndromes&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">3&#44;5</span></a> Hypochromic microcytic anemia is most characteristic of prolidase deficiency&#44; and here we should also mention massive iminodipeptiduria along with elevated iminodipeptides &#40;with proline or hydroxyproline at the carboxy-terminal end&#41; as key laboratory findings pointing to diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">12</span></a> In turn&#44; and very characteristically&#44; in STAT5B deficiency&#44; we can find T cell lymphopenia along with low levels of <span class="elsevierStyleItalic">IGF1</span> and <span class="elsevierStyleItalic">IGFBP3</span> and normal or elevated GH&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">10</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Manifestations of atopy and allergy are characteristic of AR hyper-IgE syndrome&#44;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">20</span></a> Netherton syndrome&#44; PSS-B&#44; SAM&#44; and often Loeys-Dietz syndrome&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">15&#44;19</span></a> The most frequent such manifestations are rhinitis and episodes of urticaria&#46; In PSS-B&#44; and above all in hyper-IgE syndrome&#44; episodes of anaphylaxis and angioedema have been reported&#46; These may be recurrent&#46; In SAM&#44; food allergies are usually particularly severe&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">16</span></a> The radioallergosorbent test&#44; an analytical technique that quantitatively determines specific IgE levels for a range of allergens&#44; is usually abnormal in all these entities&#44; particularly in the case of alimentary antigens&#44; and more frequently in individuals with atopic dermatitis&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">16&#44;19</span></a> Pathological radioallergosorbent test results are less common in AD hyper-IgE syndrome than in the recessive form&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">19&#44;20</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Finally&#44; we highlight other manifestations that do not fit into the above categories and that might be useful in the differential diagnosis&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The clinical picture in IPEX syndrome and STAT5B deficiency is dominated by autoimmune phenomena&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">9&#44;10</span></a> In the case of IPEX syndrome&#44; type 1 diabetes mellitus&#44; thyroid disease&#44; and autoimmune enteropathy are almost always present&#46; In addition&#44; hemolytic anemia&#44; thrombocytopenia&#44; leukopenia&#44; hepatitis&#44; and tubular nephropathy may also be present&#46; In STAT5B deficiency&#44; enteropathy&#44; thyroid disease&#44; and lymphocytic interstitial pneumonitis are the most characteristic&#46; Autoimmune manifestations also occur in Wiskott-Aldrich syndrome &#40;in up to 40&#37; of patients&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">6&#44;7</span></a> and hyper-IgE syndromes&#44;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">3&#44;5&#44;20</span></a> above all in AR forms&#59; they are less common in AD forms&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">20</span></a> Hemolytic anemia&#44; leukocytoclastic vasculitis&#44; isolated cerebral vasculitis&#44; systemic small-vessel vasculitis&#44; arthritis&#44; and autoantibody-mediated glomerulonephritis can be present in hyper-IgE syndromes and Wiskott-Aldrich syndrome and&#44; in the case of Wiskott-Aldrich syndrome&#44; inflammatory bowel disease may also occur&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">6&#44;7</span></a> In hyper-IgE syndromes&#44; isolated cases associated with systemic lupus erythematosus and dermatomyositis have also been reported&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">20</span></a> In addition&#44; an increased risk of cancer at any age has been documented for these 3 entities&#46; Specifically&#44; in AD hyper-IgE syndrome<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">3&#44;20</span></a> and Wiskott-Aldrich syndrome&#44;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">6&#44;7</span></a> lymphoproliferative diseases predominate&#46; In AR hyper-IgE syndrome&#44;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">20</span></a> a higher risk ratio has been reported with respect to the AD variant&#44; and this higher risk is also present for neoplasms of epithelial and other origins&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">4</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">The appearance of neurological manifestation&#44; such as hemiplegia&#44; encephalopathy&#44; strokes&#44; and facial paralysis may point to AR hyper-IgE syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">4</span></a> However&#44; the delay in psychomotor development&#44; which may be very variable&#44; is mainly associated with pentasomy X<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">18</span></a> and prolidase deficiency&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">12</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">A manifestation common to IPEX syndrome&#44; STAT5B deficiency&#44; Netherton syndrome&#44; and Omenn syndrome is chronic diarrhea syndrome&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">3&#44;9&#44;10&#44;17</span></a> In the latter 2 entities&#44; hepatosplenomegaly and inflammatory adenopathies are also often reported&#46; The esophagus is affected more often in SAM<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">6</span></a> in the form of eosinophilic esophagitis and gastroesophageal reflux&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">From the cardiovascular point of view&#44; it is important to note that arterial aneurysms and episodes of aortic dissection are characteristic of Loeys-Dietz syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">11</span></a> In more than 80&#37; of cases of AD hyper-IgE syndrome&#44; peripheral&#44; cerebral&#44; and&#44; to a lesser extent&#44; coronary vascular malformations are present&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">4&#44;5</span></a> SAM is sometimes associated with minor cardiac defects&#44;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">6</span></a> whereas cardiovascular abnormalities can be very varied in the case of pentasomy X&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">17</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">With regards genital abnormalities&#44; gonadal dysfunction is only characteristic of pentasomy X<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">18</span></a> although the external genitals are normal&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a> shows a diagnostic algorithm based on laboratory results &#40;presence of eosinophilia and abnormalities in the radioallergosorbent test&#41; and preliminary classification of the patients to subsequently study the presence of other findings that may guide clinical diagnosis for each of the genetic disorders discussed&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">In conclusion&#44; this article aims to provide practical assistance in the differential diagnosis of a child with refractory eczema and elevated IgE&#46; The medical history&#44; physical exploration&#44; and laboratory results can guide us to the most appropriate genetic study for a definitive molecular diagnosis&#46; This will enable individualized treatment according to the most recent evidence available for each of these entities&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conflicts of Interest</span><p id="par0120" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        1 => array:2 [
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          "titulo" => "Keywords"
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          "identificador" => "xres818345"
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        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Conflicts of Interest"
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        5 => array:2 [
          "identificador" => "xack274600"
          "titulo" => "Acknowledgments"
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        6 => array:1 [
          "titulo" => "References"
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    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2015-06-29"
    "fechaAceptado" => "2015-09-19"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec815372"
          "palabras" => array:6 [
            0 => "Immunoglobulin E"
            1 => "Atopic dermatitis"
            2 => "Atopic eczema"
            3 => "Genetic diseases"
            4 => "Differential diagnosis"
            5 => "Immunodeficiency"
          ]
        ]
      ]
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec815373"
          "palabras" => array:6 [
            0 => "Inmunoglobulina E"
            1 => "Dermatitis at&#243;pica"
            2 => "Eccema at&#243;pico"
            3 => "Enfermedades gen&#233;ticas"
            4 => "Diagn&#243;stico diferencial"
            5 => "Inmunodeficiencia"
          ]
        ]
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    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The association of moderate to severe eczema and elevated plasma levels of immunoglobulin E is a characteristic not only of atopic dermatitis but also of various genodermatoses&#58; hyperimmunoglobulin E syndromes&#44; Omenn syndrome&#44; Netherton syndrome&#44; peeling skin syndrome type B&#44; severe dermatitis&#44; multiple allergies&#44; and metabolic wasting syndrome&#44; Wiskott-Aldrich syndrome&#44; prolidase deficiency&#44; Loeys-Dietz syndrome&#44; IPEX syndrome&#44; STAT5B deficiency&#44; and pentasomy X&#46; The clinical presentation of these genodermatoses &#8211;typically in children&#8211; is consistent with severe atopic dermatitis&#46; Immunoglobulin E is elevated from birth and response to conventional treatments is poor&#46; Diagnosis is further complicated by the fact that these genodermatoses often share other clinical manifestations and laboratory findings&#46; We present practical guidelines for differentiating among these various entities&#44; with the aim of helping physicians decide what type of genetic test should be carried out &#8211;and when&#8211; in order to establish a definitive diagnosis&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La asociaci&#243;n de eccema moderado-grave y niveles elevados de IgE en plasma es caracter&#237;stica no solo de la dermatitis at&#243;pica&#44; sino tambi&#233;n de diversas genodermatosis&#58; s&#237;ndromes hiper-IgE&#44; s&#237;ndrome de Omenn&#44; s&#237;ndrome de Netherton&#44; s&#237;ndrome de la piel exfoliada tipo B&#44; s&#237;ndrome de dermatitis grave-alergias m&#250;ltiples-desgaste metab&#243;lico&#44; s&#237;ndrome de Wiskott-Aldrich&#44; d&#233;ficit de prolidasa&#44; s&#237;ndrome de Loeys-Dietz&#44; s&#237;ndrome IPEX&#44; d&#233;ficit de STAT5B y pentasom&#237;a X&#46; Se trata de pacientes pedi&#225;tricos que presentan un cuadro cl&#237;nico compatible con dermatitis at&#243;pica grave&#44; con mala respuesta a los tratamientos cl&#225;sicos y que asocian elevaci&#243;n de IgE desde el nacimiento&#46; Adem&#225;s&#44; comparten con frecuencia otras manifestaciones cl&#237;nicas y anal&#237;ticas&#44; lo cual dificulta el diagn&#243;stico&#46; Presentamos una gu&#237;a pr&#225;ctica para orientar el diagn&#243;stico diferencial entre todas estas entidades y&#44; por lo tanto&#44; ayudar a decidir cu&#225;ndo y el tipo de test gen&#233;tico a realizar para establecer el diagn&#243;stico definitivo&#46;</p></span>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Arjona Aguilera C&#44; Albarr&#225;n Planelles C&#44; Tercedor S&#225;nchez J&#46; Trastornos gen&#233;ticos con eccema moderado-grave refractario y elevaci&#243;n de inmunoglobulina E&#58; diagn&#243;stico diferencial&#46; Actas Dermosifiliogr&#46; 2016&#59;107&#58;116&#8211;124&#46;</p>"
      ]
    ]
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      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Suggested Diagnostic Algorithm for Clinical Diagnosis of Genodermatosis of Moderate-to-Severe Presentation and Elevated IgE&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">BC&#44; B cells&#59; DIF&#44; direct immunofluorescence&#59; DM&#44; diabetes mellitus&#59; DPT&#44; dermatopathology&#59; DSG1&#44; desmoglein 1&#59; GH&#44; growth hormone&#59; HPV&#44; human papillomavirus&#59; HSV&#44; herpes simplex virus&#59; IBD&#44; inflammatory bowel disease&#59; IGF-1&#44; insulin growth factor&#44; type 1&#59; IGFBP3&#44; insulin growth factor binding protein 3&#59; IHC&#44; immunohistochemistry&#59; IPEX&#44; immune-polyendocrinopathy-enteropathy&#44; X-linked dysregulation syndrome&#59; RAST&#44; radioallergoasorbent test&#59; SAH&#44; subarachnoid hemorrhage&#59; SLE&#44; systemic lupus erythematosus&#59; TC&#44; T cells&#59; VZV&#44; varicella-zoster virus&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Skin and Appendages&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Respiratory System&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Musculoskeletal system&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Autoimmunity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Others&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Laboratory&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Genetics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Autosomal dominant hyper-IgE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Moderate-to-severe eczema<br>Pyodermatitis Abscesses<br>Mucocutaneous candidiasis<br>Typical facies<br>Facial punctiform scars&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Recurrent pneumonia<br>Pneumatocele&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Osteopenia<br>Scoliosis &#40;50&#37;&#41;<br>Fractures &#40;60&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Infrequent</span><br>Vasculitis &#40;leukocytoclastic&#44; isolated cerebral&#44; systemic small vessel&#41;<br>Glomerulonephritis<br>Hemolytic anemia<br>SLE&#44; dermatomyositis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Lymphomas<br>Vascular malformations&#58; peripheral&#44; cerebral&#44; or coronary&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Elevated IgE<br>Eosinophilia<br>RAST&#58; normal or positive to food antigens<br>DPT&#58; perivascular dermatitis with eosinophilia&#44; spongiosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">STAT3</span> gene mutations &#40;70&#37;&#41;<br>Autosomal dominant<br>Unknown &#40;30&#37;&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Autosomal recessive hyper-IgE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Moderate-to-severe eczema<br>Urticaria<br>Pyodermatitis Abscesses<br>Mucocutaneous candidiasis<br>Viral infections &#40;HSV&#44; HPV&#44; molluscum&#44; etc&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Asthma &#40;30&#37;-50&#37;&#41;&#44; rhinitis<br>Pneumonia uncommon&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Postnatal growth retardation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Vasculitis &#40;leukocytoclastic&#44; isolated cerebral&#44; systemic small vessel&#41;<br>Glomerulonephritis<br>Hemolytic anemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cancer&#58; 17&#37; &#40;hematological&#44; epithelial&#44; others&#41;<br>Central nervous system&#58; SAH&#44; encephalopathy&#44; stroke&#44; facial paralysis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Elevated IgE<br>Extreme eosinophilia<br>Progressive lymphopenia<br>RAST&#58; positive to food allergens<br>DPT&#58; perivascular dermatitis with abundant eosinophils&#44; spongiosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">DOCK8</span> gene mutations<br>Others &#40;rare&#41;&#58; TYK2&#44; PGM3 gene mutations&#44; unknown<br>Autosomal recessive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Wiskott-Aldrich syndrome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Moderate-to-severe eczema<br>Seborrheic dermatitis<br>Piodermitis<br>Viral infection<br>Petechaie&#44; purpura&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Recurrent pneumonia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hemolytic anemia<br>Vasculitis<br>Nephritis<br>Arthritis<br>IBD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Bleeding<br>Lymphomas&#58; 13&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Elevated IgE and IgA<br>Thrombocytopenia<br>normal&#47;low BC and TC<br>RAST&#58; normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">WAS</span> gene mutations<br>X-linked&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Omenn syndrome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Seborrheic dermatitis<br>Erythroderma<br>Eczemas &#40;uncommon&#41;<br>Diffuse alopecia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Recurrent pneumonia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Postnatal growth retardation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hepatosplenomegaly<br>Adenopathies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Chronic multifactorial diarrhea syndrome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Elevated IgE<br>Eosinophilia<br>B cells absent<br>Anomalous TC clone<br>RAST&#58; normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">RAG1-2</span> gene mutations&#46; Less often&#58; <span class="elsevierStyleItalic">RMRP&#44; ADA&#44; IL2RG&#44; IL7RA&#44; DCLRE1</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">C&#44; CHD7&#44; LIG4&#44; AK2</span><br>Autosomal recessive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Netherton syndrome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Moderate-to-severe eczema<br>Urticaria<br>Pyodermatitis<br>Ichthyosiform erythroderma&#59; ichthyosis linearis circumflexa<br>Trichorrhexis invaginata&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Allergic asthma&#44; rhinitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Postnatal growth retardation<br>Short stature&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Chronic multifactorial diarrhea syndrome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Elevated IgE<br>TC differentiation abnormality<br>RAST&#58; positive to food allergens<br>DPT&#58; psoriasiform dermatitis&#44; hypogranulosis&#47;agranulosis&#44; parakeratosis&#44; premature lamellar body secretion&#44; subcorneal acantholysis<br>IHC&#58; LEKTI absence in granular layer and inner root sheaf&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">SPINK5</span> gene mutations<br>Autosomal recessive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Peeling skin syndrome&#44; type B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Ichthyosiform erythroderma<br>Urticaria&#44; angioedema<br>Pyodermatitis &#40;<span class="elsevierStyleItalic">Staphylococcus aureus</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Allergic asthma&#44; rhinitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Postnatal growth retardation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Elevated IgE<br>Eosinophilia<br>RAST&#58; positive to food allergens<br>DPT&#58; perivascular dermatitis&#44; subcorneal acantholysis IHC&#58; absence CDSN in epidermis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">CDSN</span> gene mutations<br>Autosomal recessive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Severe dermatitis&#44; multiple allergies&#44; metabolic wasting syndrome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Congenital erythroderma&#44; peeling<br>Palmoplantar keratoderma striata<br>Hypotrichosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pneumonia<br>Upper respiratory tract infections&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Postnatal growth retardation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Eosinophilic esophagitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Metabolic wasting<br>Gastroesophageal reflux<br>Minor cardiac defects&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Elevated IgE<br>RAST&#58; positive to food allergens<br>DPT&#58; subcorneal and intragranular acantholysis&#44; psoriasiform dermatitis&#44; orthokeratosis&#47;parakeratosis&#44; hypogranulosis&#47;hypergranulosis DIF&#58; anomalous DSG1 cytoplasmic distribution&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">DSG1&#44; DSP</span> gene mutations<br>Autosomal recessive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Prolidase deficiency&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Skin fragility&#44; ulcers &#40;legs&#44; perianal&#41;<br>Purpura&#44; telangiectasias<br>Photosensitivity<br>Acute eczema<br>Typical facies<br>Poliosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Recurrent upper airway infection<br>Pneumonia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Joint hypermobility<br>Short stature<br>Osteoporosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">SLE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Splenomegalia<br>Mental retardation<br>Less often&#58; deafness&#44; hepatomegalia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Elevated IgE&#47;hypergammaglobulinemia<br>Microcytic anemia<br>Thrombocytopenia<br>Imidodipeptiduria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">PEPD</span> gene mutations<br>Autosomal recessive &#40;very variable age and phenotype&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Loeys-Dietz syndrome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Marfanoid appearance&#44; cleft palate<br>Fine skin&#44; anomalous healing<br>Mild eczema&#47;occasionally severe&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pneumonia<br>Rhinitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hypermobility<br>I&#58; bone abnormalities &#40;cranium&#44; sternum&#44; phalanges&#44; etc&#46;&#41;<br>III&#58; Osteoarthritis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Arterial aneurysms<br>Aortic dissection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Normal&#47;elevated IgE<br>RAST&#58; normal&#47;positive to food and respiratory allergens&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">TGFBR1&#44; TGFBR2&#44; SMAD3</span> gene mutations<br>Autosomal dominant&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pentasomy X&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Typical facies<br>Mild eczema&#47;occasionally severe&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Recurrent pneumonia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cranial malformations &#40;microcephaly&#41;<br>Syndactylia&#44; other bone malformations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cardiovascular malformations<br>Gonadal dysfunction<br>Mental retardation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Normal&#47;elevated IgE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pentasomy X &#40;no maternal disjunction in meiosis&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">IPEX syndrome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Severe atopic dermatitis<br>Uncommon&#58; erythroderma&#44; exfoliative dermatitis&#44; psoriasiform dermatitis&#44; pemphigoid nodularis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pneumonia uncommon&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Enteropathy<br>Endocrine disorders&#58; DM-1&#44; thyroiditis&#44; others<br>Hemolytic anemia<br>Thrombocytopenia<br>Neutropenia<br>Hepatitis<br>Tubular nephropathy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sometimes severe systemic infections due to immunosuppression&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Elevated IgE<br>Elevated&#47;normal IgA<br>Eosinophilia<br>Cytopenias<br>Autoantibodies &#40;pancreatic&#44; thyroid&#44; intestinal mucosa antigens&#44; etc&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">FOXP3</span> gene mutations<br>X-linked&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">STAT5B deficiency&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Severe eczema<br>Pyodermatitis<br>Severe viral infection &#40;VZV&#41;<br>Craniofacial dysmorphia<br>Thin&#44; fine hair&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Infectious pneumonia<br>Interstitial lymphocytic pneumonia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Dwarfism&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Thyroid disease<br>Enteropathy<br>Interstitial lymphocytic pneumonia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">GH insensitivity syndrome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hypergammaglobulinemia<br>Lymphopenia &#40;TC&#41;<br>Normal&#47;elevated GH<br>Decreased IGF1&#44; IGFBP3<br>Autoantibodies &#40;thyroid&#44; intestinal mucosa antigens&#44; others&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">STAT5B</span> gene mutations<br>Autosomal recessive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Differential Clinical and Laboratory Diagnosis of Genodermatoses That Present With Moderate-to-Severe Eczema and Elevated IgE&#46;</p>"
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