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compatible with nevus flammeus&#46; There was also a reticular pattern erythema on the right side of the body with clear demarcation in the anterior midline&#44; compatible with cutis marmorata telangiectatica congenita&#44; and extensive blue-gray macules on the lower limbs&#44; gluteal area and back&#44; compatible with mongolian spots&#46; He also had grayish sclerae bilaterally and a slight asymmetry in the circumference of the lower limbs&#46; The vascular lesions became more intense while crying or after exposure to cold &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">An echocardiogram and transfontanellar&#44; and abdominal ultrasonography were performed&#44; which showed no alterations&#46; The neurological&#44; ophthalmic&#44; and orthopedic evaluations showed no abnormalities&#46; Dermatological ultrasonography identified subcutaneous tissue hypoplasia in the right leg compared to the contralateral limb&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The whole exome sequencing in peripheral blood identified a probably pathogenic heterozygous variant in the COL17A1 gene&#44; &#40;c&#46;3277&#43;1G&#62;A&#41;&#44; in addition to a pathogenic heterozygous variant in the HBB gene&#44; &#40;c&#46;20A&#62;T&#58; p&#46;&#44; Glu7Val&#41; attributing betalassemia minor&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">At the time of this publication&#44; the patient is one year old&#44; showing normal neuropsychomotor development and partial improvement of the vascular lesions&#46; The diagnosis of phacomatosis pigmentovascularis was made&#59; however&#44; the findings do not completely align with the current criteria&#44; which made the classification challenging&#46; The name phacomatosis cesio-flammeo-marmorata has already been proposed in the literature&#44; with seven cases identified to date&#44;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> which show heterogeneity of characteristics and one case with the described triad associated with nevus of Ota and anemic nevus&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Phacomatosis</span><p id="par0030" class="elsevierStylePara elsevierViewall">PPV is a group of rare congenital syndromes characterized by the combination of capillary malformations and pigmented lesions&#44; associated or not with systemic manifestations&#46; Initially&#44; it was classified into four types according to the phenotype &#40;I - Nevus flammeus and nevus pigmentosus or verrucous&#59; II - flammeus &#43;&#47;- anemic and mongolian spots&#59; III - flammeus &#43;&#47;- anemic and spilus&#59; IV - flammeus &#43;&#47;- anemic and spilus with mongolian spot&#41; and subtypes &#40;a &#8211;cutaneous involvement only&#59; b &#8211; systemic involvement&#41;&#46; Happle<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> reclassified it into phacomatosis cesioflamea&#44; cesiomarmorata&#44; spilorosea&#44; and unclassified&#44; with or without systemic manifestations&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The syndrome pathogenesis is not well understood&#46; The GNAG and GNA11 genes have been associated with some cases&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The COL17A1 gene&#44; identified in the patient of the present case&#44; encodes collagen XVII&#44; essential in epidermal stabilization&#44; and&#44; to the best of the authors knowledge&#44; this is the first time that possibly pathogenic variants have been identified in this gene in a patient with these characteristics&#46; This gene is related to epidermolysis bullosa&#59; however&#44; it does not have 100&#37; penetrance&#44; which may explain the lack of the expected phenotype&#46; The patient does not have skin fragility so far&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The diagnosis of PPV is clinical&#59; however&#44; the classification is challenging when it does not meet all the criteria or if there is an overlap between them&#44; which is why it has been proposed that the combination of the three conditions found in this patient merit a distinct classification as phacomatosis cesio-flammeo-marmorata&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The investigation of ocular and neurological involvement is generally recommended&#44;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> as well as other tests&#44; depending on clinical suspicion&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Financial support</span><p id="par0045" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Authors&#8217; contributions</span><p id="par0050" class="elsevierStylePara elsevierViewall">Luciane Zagonel&#58; Approval of the final version of the manuscript&#59; drafting and editing of the manuscript&#59; critical review of the literature&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">M&#244;nica Vannucci Nunes Lipay&#58; Approval of the final version of the manuscript&#59; drafting and editing of the manuscript&#59; critical review of the literature&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Glaucos Ricardo Paraluppi&#58; Approval of the final version of the manuscript&#59; critical review of the manuscript&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied case&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">C&#233;lia Ant&#244;nia Xavier de Moraes Alves&#58; Approval of the final version of the manuscript&#59; critical review of the manuscript&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied case&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conflicts of interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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Letter - Clinical
Phacomatosis cesio-flammeo-marmorata: report of a rare association
Luciane Zagonel
Autor para correspondência
celiaalves@g.fmj.br

Corresponding author.
, Mônica Vannucci Nunes Lipay, Glaucos Ricardo Paraluppi, Célia Antônia Xavier de Moraes Alves
Department of Dermatology, Faculty of Medicine of Jundiaí, Jundiaí, SP, Brazil
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Phacomatosis pigmentovascularis &#40;PPV&#41; is a rare congenital anomaly characterized by the presence of vascular and pigmentary lesions&#46; The present case describes a rare association of congenital telangiectatic cutis marmorata&#44; nevus flammeus and aberrant mongolian spots&#46; These findings do not allow it to be classified under any item of the classification of PPV&#44; except for the proposed name phacomatosis cesio-flammeo-marmorata&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">A late preterm baby was born from a dichorionic and diamniotic twin pregnancy to non-consanguineous parents&#59; the mother had SARS-CoV-2 during an otherwise uneventful pregnancy and childbirth&#46; The twin brother presented no alterations&#46; Since birth&#44; the reported brother however showed an erythematous lesion affecting almost the entire facial region&#44; compatible with nevus flammeus&#46; There was also a reticular pattern erythema on the right side of the body with clear demarcation in the anterior midline&#44; compatible with cutis marmorata telangiectatica congenita&#44; and extensive blue-gray macules on the lower limbs&#44; gluteal area and back&#44; compatible with mongolian spots&#46; He also had grayish sclerae bilaterally and a slight asymmetry in the circumference of the lower limbs&#46; The vascular lesions became more intense while crying or after exposure to cold &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">An echocardiogram and transfontanellar&#44; and abdominal ultrasonography were performed&#44; which showed no alterations&#46; The neurological&#44; ophthalmic&#44; and orthopedic evaluations showed no abnormalities&#46; Dermatological ultrasonography identified subcutaneous tissue hypoplasia in the right leg compared to the contralateral limb&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The whole exome sequencing in peripheral blood identified a probably pathogenic heterozygous variant in the COL17A1 gene&#44; &#40;c&#46;3277&#43;1G&#62;A&#41;&#44; in addition to a pathogenic heterozygous variant in the HBB gene&#44; &#40;c&#46;20A&#62;T&#58; p&#46;&#44; Glu7Val&#41; attributing betalassemia minor&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">At the time of this publication&#44; the patient is one year old&#44; showing normal neuropsychomotor development and partial improvement of the vascular lesions&#46; The diagnosis of phacomatosis pigmentovascularis was made&#59; however&#44; the findings do not completely align with the current criteria&#44; which made the classification challenging&#46; The name phacomatosis cesio-flammeo-marmorata has already been proposed in the literature&#44; with seven cases identified to date&#44;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> which show heterogeneity of characteristics and one case with the described triad associated with nevus of Ota and anemic nevus&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Phacomatosis</span><p id="par0030" class="elsevierStylePara elsevierViewall">PPV is a group of rare congenital syndromes characterized by the combination of capillary malformations and pigmented lesions&#44; associated or not with systemic manifestations&#46; Initially&#44; it was classified into four types according to the phenotype &#40;I - Nevus flammeus and nevus pigmentosus or verrucous&#59; II - flammeus &#43;&#47;- anemic and mongolian spots&#59; III - flammeus &#43;&#47;- anemic and spilus&#59; IV - flammeus &#43;&#47;- anemic and spilus with mongolian spot&#41; and subtypes &#40;a &#8211;cutaneous involvement only&#59; b &#8211; systemic involvement&#41;&#46; Happle<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> reclassified it into phacomatosis cesioflamea&#44; cesiomarmorata&#44; spilorosea&#44; and unclassified&#44; with or without systemic manifestations&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The syndrome pathogenesis is not well understood&#46; The GNAG and GNA11 genes have been associated with some cases&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The COL17A1 gene&#44; identified in the patient of the present case&#44; encodes collagen XVII&#44; essential in epidermal stabilization&#44; and&#44; to the best of the authors knowledge&#44; this is the first time that possibly pathogenic variants have been identified in this gene in a patient with these characteristics&#46; This gene is related to epidermolysis bullosa&#59; however&#44; it does not have 100&#37; penetrance&#44; which may explain the lack of the expected phenotype&#46; The patient does not have skin fragility so far&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The diagnosis of PPV is clinical&#59; however&#44; the classification is challenging when it does not meet all the criteria or if there is an overlap between them&#44; which is why it has been proposed that the combination of the three conditions found in this patient merit a distinct classification as phacomatosis cesio-flammeo-marmorata&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The investigation of ocular and neurological involvement is generally recommended&#44;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> as well as other tests&#44; depending on clinical suspicion&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Financial support</span><p id="par0045" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Authors&#8217; contributions</span><p id="par0050" class="elsevierStylePara elsevierViewall">Luciane Zagonel&#58; Approval of the final version of the manuscript&#59; drafting and editing of the manuscript&#59; critical review of the literature&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">M&#244;nica Vannucci Nunes Lipay&#58; Approval of the final version of the manuscript&#59; drafting and editing of the manuscript&#59; critical review of the literature&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Glaucos Ricardo Paraluppi&#58; Approval of the final version of the manuscript&#59; critical review of the manuscript&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied case&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">C&#233;lia Ant&#244;nia Xavier de Moraes Alves&#58; Approval of the final version of the manuscript&#59; critical review of the manuscript&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied case&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conflicts of interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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ISSN: 03650596
Idioma original: Inglês
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