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Addisonian Pigmentation of the Oral Mucosa

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Addisonian Pigmentation of the Oral Mucosa PEDIATRIC DERMATOLOGY Series Editor: Camila K. Janniger, MD Addisonian Pigmentation of the Oral Mucosa Samir S. Shah, MD; Catherine H. Oh, MD; Susan E. Coffin, MD, MPH; Albert C. Yan, MD Cutaneous pigmentation is a hallmark of Addison Free thyroxine and thyrotropin levels were within disease. When present, the hyperpigmentation reference range. generally localizes to sun-exposed surfaces. This case highlights a less well-recognized Comment cutaneous feature that is pathognomonic for the Addison disease, a chronic primary insufficiency of disease: oral mucous membrane hyperpigmenta- the adrenal glands, results in both glucocorticoid and tion. We describe this unique type of discolor- mineralocorticoid deficiency. Historically, tuberculo- ation in detail and contrast it with other forms of sis accounted for most cases of Addison disease.1 oral pigmentation. Autoimmune destruction of the adrenal glands, also Cutis. 2005;76:97-99. known as autoimmune adrenalitis, is now the most common cause of Addison disease in both children and adults.2,3 Autoimmune destruction of other Case Report endocrine tissues can occur concurrently. These A 9-year-old girl presented with a 4-month history polyglandular autoimmune syndromes are associated of painless black patches on the tongue and gingiva. with hypoparathyroidism, pernicious anemia, and The patches had persisted despite treatment with chronic mucocutaneous candidiasis (type 1); diabetes oral fluconazole, which had been prescribed empiri- mellitus (type 2); or thyroiditis (type 3).4 Type 3, cally for presumed oral candidiasis. Results of a phys- however, consists of an autoimmune thyroiditis ical examination revealed scattered, asymptomatic, syndrome in the absence of Addison disease.5 bluish-black macules on the dorsal surface of the Although most children (75%) presenting with isolated tongue, the mucosal surface of the lower lip, and the Addison disease are boys,6 type 1 autoimmune poly- hard palate (Figure). No cervical lymphadenopathy glandular syndrome occurs equally in boys and girls.2 was noted. The patient’s medical history was notable Other causes of Addison disease in children include for a recent diagnosis of primary adrenal insuffi- trauma and adrenocortical hemorrhage, which is most ciency and Addison disease. commonly associated with meningococcemia.4 Significant laboratory evaluation results included Most of the symptoms arising from primary findings consistent with primary adrenal insuffi- adrenal insufficiency result in cortisol deficiency. ciency: a nocturnal plasma cortisol level of 0.3 µg/dL Symptoms include fatigue, weakness, orthostasis, (reference range, 2–10 µg/dL) and a corticotropin nausea, vomiting, weight loss, and anorexia. Com- level of 1300 pg/mL (reference range, 9–52 pg/mL). mon presenting symptoms seen in children include hypoglycemia, gastrointestinal disturbances, and Accepted for publication November 1, 2004. progressive peripheral weakness. Hyperpigmenta- Drs. Shah, Coffin, and Yan are from the Department of Pediatrics, tion of the skin and mucosal surfaces, the most spe- Children’s Hospital of Philadelphia, Pennsylvania. Dr. Oh is from cific sign of Addison disease, occurs in up to 92% of the Department of Pediatrics, Jefferson University School of patients.7 This dyspigmentation may precede other Medicine, Philadelphia. manifestations by up to 10 years.8 The authors report no conflict of interest. Reprints: Albert C. Yan, MD, Pediatric Dermatology, Children’s Pigmentation of the oral mucosa is considered Hospital of Philadelphia, 34th St and Civic Center Blvd, pathognomonic for Addison disease. This distinc- Philadelphia, PA 19104 (e-mail: [email protected]). tive finding can aid in distinguishing Addison VOLUME 76, AUGUST 2005 97 Pediatric Dermatology disease from other endocrin- opathies that also may present with hyperpigmentation, such as hyperthyroidism.9 The oral hyper- pigmented macules of Addison disease can be found diffusely on the tongue, gingiva, buccal mucosa, and hard palate. The macules tend to be blue-black or brown and can be spotty or streaked in configuration. The pattern of pigmentation is usually patchy and can occasionally alter- nate with leukodermic patterns. The hyperpigmentation of Addison disease tends to produce a generalized bronze appearance that is more easily detectable in fair-skinned children. In dark- skinned children, a similar increase in color may be mistaken for a tan. Hyperpigmentation occurs most prominently at the flexures, sites of pressure and friction, palmar and plantar creases, and A sun-exposed areas. It also may result in intensification of nor- mally pigmented areas such as the genitalia and areolae mammae.6 Scars also can exhibit hyperpig- mentation, which only appears in scars acquired after the onset of the disease. Coexistence of pig- mented and uncolored scars may aid in the precise dating of the destructive process found in the adrenals.8 Paradoxically, vitiligo also may be seen in patients with Addison disease and may occur concurrently with hyperpigmen- tation. Pigmentation of the vagi- B nal mucosae and conjunctivae also are frequently observed in Pigmentation of the tongue (A) and lower lip (B) in Addison disease. affected patients.1 Hyperpigmentation associated with Addison disease presumably occurs secondary familial adrenocorticotropin unresponsiveness syn- to overproduction of the pro-opiomelanocortin drome (familial glucocorticoid deficiency),12 thymic byproduct ␤-lipotropin, which is secreted in excess carcinoids,13 and paraneoplastic corticotropin pro- amounts concomitantly with corticotrophin from duction in the setting of underlying malignancy14; the pituitary gland because of the lack of feedback however, oral pigmentation has not been specifically inhibition seen in adrenal insufficiency states.10 reported in these cases. Other conditions that lead to increased cortico- Adequate hormone replacement therapy typi- tropin production also may present with similar cally results in a decrease in the degree of cutaneous cutaneous hyperpigmentation, as seen in adreno- pigmentation, though oral pigmentation persists leukodystrophy (Siemerling-Creutzfeldt disease),11 indefinitely.15 In this particular case, the patient’s 98 CUTIS® Pediatric Dermatology oral pigmentation did show modest improvement 3. Myhre AG, Undlien DE, Løvås K, et al. Autoimmune with good hormonal control; however, when the adrenocortical failure in Norway. autoantibodies and patient was noncompliant with hormonal therapy, human leukocyte antigen class II associations related her pigmentation worsened clinically. In some to clinical features. J Clin Endocrinol Metab. affected younger children, the skin color may even- 2002;87:618-623. tually return to normal with therapy. 4. Baker JR Jr. Autoimmune endocrine disease. JAMA. 1997;278:1931-1937. Differential Diagnosis 5. Spinner MW, Blizzard RM, Childs B. Clinical and Diagnoses that may mimic the oral pigmentation genetic heterogeneity in idiopathic Addison’s disease of Addison disease include: oral “black tongue” and hypoparathyroidism. J Clin Endocrinol Metab. candidiasis, ethnic pigmentation, and reactions to 1968;28:795-804. certain drugs. Black hairy tongue and black tongue 6. Oelkers W. Current concepts: adrenal insufficiency. N Engl candidiasis are disorders believed to be caused by J Med. 1996;335:1206-1212. Candida albicans and occasionally Aspergillus 7. Hurwitz S. Clinical Pediatric Dermatology: A Textbook of species. These conditions are associated with long- Skin Disorders of Childhood and Adolescence. 2nd ed. term use of antibiotics. Characterized by dense, Philadelphia, Pa: WB Saunders Co; 1993. black, bluish-black, or brown “matted” areas of the 8. Forest MG. Adrenal steroid deficiency states. In: dorsal surface of the tongue, black tongue candidi- Brook CGD, ed. Clinical Paediatric Endocrinology. 3rd asis can be successfully eliminated by discontinua- ed. Cambridge, England: Blackwell Science; tion or minimization of antibiotics, gentle 1995:453-498. brushing of the tongue surface, and use of an oral 9. Banba K, Tanaka N, Fujioka A, et al. Hyperpigmenta- antifungal agent.16 tion caused by hyperthyroidism: differences from the pig- The most common pattern of ethnic or racial pig- mentation of Addison disease. Clin Exp Dermatol. mentation is a band of pigment at the junction of 1999;24:196-198. attached and alveolar mucosa. In contrast to Addison 10. Wiebke A, Allolio B. Adrenal insufficiency. Lancet. disease, pigmentation on the tongue of those with skin 2003;361:1881-1893. of color is typically localized to the tips of isolated groups 11. Ropers HH, Burmeister P, Petrykowski W, et al. of filiform papillae.17 Such pigmentation, usually found Leukodystrophy, skin hyperpigmentation, and adrenal only in persons with dark skin, also can be found as atrophy: Siemerling-Creutzfeldt disease. transmission isolated pigmented patches in 5% of Caucasians. through several generations in two families. Am J Hum Drug-induced pigmentation can range from Genet. 1975;27:547-553. brown (seen with oral contraceptives, cytotoxic 12. Berberoglu M, Aycan Z, Ocal G, et al. Syndrome of con- agents, and some anticonvulsants) to yellow or genital adrenocortical unresponsiveness to ACTH. blue-black (as seen with the antimalarial drugs report of six patients. J Pediatr Endocrinol Metab. quinacrine, chloroquine, and hydroxychloro- 2001;14:1113-1118. quine).18 Long-term use of minocycline has been 13. Gartner LA, Voorhess ML. Adrenocorticotrophic hormone- associated with a blue-gray
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