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| SHORT COMMUNICATION |
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| Year : 2017 | Volume
: 5
| Issue : 1 | Page : 133-135 |
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Absent skin at birth with blistering: Bart's Syndrome?
Amina Asfiya M Iqbal, Manjunath Mala Shenoy, Malcolm Pinto, Vishal B Amin, Spandana P Hegde
Department of Dermatology, Yenepoya Medical College, Yenepoya University, Mangalore, Karnataka, India
| Date of Web Publication | 16-Jun-2017 |
Correspondence Address:
Amina Asfiya M Iqbal
Department of Dermatology, Yenepoya Medical College, Yenepoya University, University Road, Deralakatte, Mangalore - 575 018, Karnataka
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/amhs.amhs_31_17
Bart's Syndrome is a disorder characterised by aplasia cutis congenita and epidermolysis bullosa. We report a case of a 4-day-old baby who had absent skin over the legs along with blistering and nail dystrophy. The diagnosis of Bart's Syndrome was made based on history and clinical examination. However, detailed investigations and histopathological confirmation is needed for final diagnosis. The management is conservative and needs multidisciplinary support.
Keywords: Aplasia cutis congenita, Bart's syndrome, epidermolysis bullosa
How to cite this article:
Iqbal AM, Shenoy MM, Pinto M, Amin VB, Hegde SP. Absent skin at birth with blistering: Bart's Syndrome?. Arch Med Health Sci 2017;5:133-5 |
| Introduction | |  |
Bart's syndrome was first described by Bart et al. in 1966.[1] It consists of any one or a combination of the following three characteristics: congenital absence of skin, blistering, and associated nail abnormalities.[2] It is considered as a variant of aplasia cutis congenita (ACC) with epidermolysis bullosa (EB). Hereby, we report a rare case of Bart's syndrome.
| Case Report | | |
A 4-day-old male presented with a history of skin abnormalities and blisters over the body since birth. The baby was the third offspring born to a nonconsanguineous couple. The parents were healthy and had no similar abnormalities of skin. The first child had similar skin abnormality and died within two weeks after birth. The second child was however normal. The baby was normal in terms of weight, length, head circumference, and vital signs.
On examination, there was a well-defined area covered with a red translucent membrane over the anterior and medial aspect of the left leg extending onto the medial part of the sole and involving the great toe. The defect extended proximally up to the thigh and distally involved medial one-third of sole [Figure 1]. In addition, absence of skin was noted over the distal half of fingers of the left hand [Figure 2]. A few discrete blisters were distributed over the extremities. Oral cavity showed erosions over the hard palate [Figure 3]. Nails were dystrophic. Systemic examination appeared normal clinically but imaging studies were not done.
Skin biopsy and immunofluorescence studies could not be done as the patient was lost to follow-up. However, it was later learnt that the child succumbed to death within a few days. The cause of death was unknown.
| Discussion | | |
Bart's syndrome was first observed in a family with congenital absence of skin on the lower leg and widespread blistering of skin, mucous membrane, and nail dystrophy.[2] Bart et al. reported a kinship consisting of 103 direct descendants from one proband over four subsequent generations.[1] The family had 26 affected members and penetrance was complete; father-son transmission was noted.[2] Clinical findings suggested that the Bart syndrome may be any of the three subtypes of EB: epidermal, junctional, or dermal. However, Bart was unable to classify the disease since advanced investigations were not available during his time.[3] Although a rare disease, Bart's syndrome has been reported from India.[4] Even though Bart's syndrome has been classified as Type VI ACC by Frieden, it is a misnomer since ACC denotes failure of skin development, whereas in Bart's syndrome, skin is present initially and lost subsequently. The skin in ACC appears ulcerated, with superficial erosions, scarring, or bulla formation and heals with hypertrophic scarring.[5]
Although several hypotheses have been proposed regarding its etiology and pathophysiology, they are still ill understood. The inheritance pattern is autosomal dominant; however, isolated cases have been reported. Abnormalities of anchoring fibrils (Type VII collagen) have been described at the dermo-epidermal junction.[6] Duran-McKinster et al. suggested that congenital absence of skin in Bart's syndrome may follow the lines of Blaschko due to physical trauma in utero.[7] Chiaverini et al. identified a mutation leading to a glycine-to-arginine substitution at Type VII collagen. The genetic abnormality has been associated with chromosome 3. Sporadic cases are associated with mutations of the triple helix domain of collagen VII gene.[8] Differential diagnosis of Bart's syndrome includes ACC, EB, Adams-Oliver syndrome, and congenital bullous poikiloderma (Kindler syndrome).[6]
Skin lesions in Bart's syndrome appear on extremities as sharply demarcated, glistening red ulceration that extend upward from the dorsal and the medial surface of the foot to the shin. They are usually unilateral.[2] Skin around the oral cavity, nose, and ears can be affected owing to friction and trauma. Nail changes include nail dystrophy or progressive loss of nails.[9] Other associated anomalies include pyloric atresia, rudimentary ear development, flattened nose, broad nasal root, and wide-set eyes.[6] A case of Bart's syndrome associated with corpus callosum agenesis and choanal atresia has also been described.[3] The above case had no associated anomalies clinically, but a detailed evaluation was not done.
The above case of Bart's syndrome was diagnosed clinically. Prenatal diagnosis can be done by fetoscopies; fetal skin biopsy specimens for ultrastructural analysis are obtained through transmission electron microscopy. Recently, DNA-based diagnostic screening using fetal DNA from amniotic fluid cells or chorionic villi samples is being done. Postnatal diagnosis depends on skin biopsy which should be examined for ultrastructural and antigenic features by transmission electron microscopy, immunofluorescence antigenic mapping, and EB-related monoclonal antibody investigations.[9]
Management of Bart's syndrome is basically conservative. It is important to prevent infection of the denuded area and to allow the affected portion to heal adequately. The goal of treatment is to accelerate healing and reduce the risk of scarring. Furthermore, a close watch on complications such as hemorrhage, infection, hypothermia, and hypoglycemia is important. With good treatment the prognosis is good.[6] In the above case, the cause of death may have been an undiagnosed anomaly associated with Bart's syndrome.
The inheritance pattern in this case looks to be autosomal dominant since another sibling was also affected. The presence of mucosal involvement, blistering, and nail dystrophy suggests that the above case could have been a dominant dystrophic EB. However, a definite conclusion would be possible only with skin biopsy, immunofluorescence, and electron microscopy.
Limitations
- The case needs several investigations including immunofluorescence studies for confirmation of Bart's syndrome
- Cause of death is not explainable.
| Conclusion | | |
This case is being reported for its rarity. We have reported this case to create awareness that a differential diagnosis of Bart's syndrome should be considered when a neonate presents with the absence of skin at birth and blistering. Genetic counseling of affected families should be done and prenatal diagnosis should be attempted in families at risk of Bart's syndrome.[4] A multidisciplinary team consisting of a dermatologist, neonatologist, neurologist, plastic surgeon, geneticist, and gastroenterologist are needed for comprehensive care of the affected neonate.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Kim DY, Lim HS, Lim SY. Bart syndrome. Arch Plast Surg 2015;42:243-5.  |
| 2. | Rajpal A, Mishra R, Hajirnis K, Shah M, Nagpur N. Bart's syndrome. Indian J Dermatol 2008;53:88-90. [ PUBMED] [Full text] |
| 3. | Saeed M, Haq AU, Qadir K. Bart's syndrome associated corpus callosum agenesis and Choanal atresia. Iran J Child Neurol 2014;8:76-9. |
| 4. | Mittal RR, Singh SP, Gill SS; Dimple. Bart syndrome. Indian J Dermatol Venereol Leprol 1996;62:266-7. [ PUBMED] [Full text] |
| 5. | Moss C, Shahidullah H. Naevi and other developmental defects. In: Burns T, Breathnach S, Cox N, Griffiths C, editors. Rook's Textbook of Dermatology. 8 th ed., Vol. 2. Edinburgh: Wiley-Blackwell; 2010. p. 18.98. |
| 6. | Kulali F, Bas AY, Kale Y, Celik IH, Demirel N, Apaydin S. Type VI aplasia cutis congenita: Bart's syndrome. Case Rep Dermatol Med 2015;2015:549825. |
| 7. | Duran-McKinster C, Rivera-Franco A, Tamayo L, de la Luz Orozco-Covarrubias M, Ruiz-Maldonado R. Bart syndrome: The congenital localized absence of skin may follow the lines of Blaschko. Report of six cases. Pediatr Dermatol 2000;17:179-82. |
| 8. | Chiaverini C, Charlesworth A, Fernandez A, Barbarot S, Bessis D, Bodemer C, et al. Aplasia cutis congenita with dystrophic epidermolysis bullosa: Clinical and mutational study. Br J Dermatol 2014;170:901-6. |
| 9. | Omran A, Elimam D, Mobarak RA, Ibrahim M, El-Sharkawy S. Bart syndrome with ear malformation. Sultan Qaboos Univ Med J 2015;15:e143-5. |
[Figure 1], [Figure 2], [Figure 3]
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