Case 1 A 9-year-old girl born to second-degree consanguineous parents was brought to the outpatient department with a history of pain in the feet and pigmentary changes on the skin of 4 years' duration. Cutaneous examination revealed large symmetrical areas of mottled pigmentation (both hypo and hyper) with atrophy over the face, flexures, hands, and feet. There were multiple, small, keratotic papules (Fig. 1) over the back, joints, palms, and soles. Scalp examination revealed widened suture lines and multiple, soft, nodular swellings on the occipital region with sparse and short hair. There was also a small nodule on the scalp which discharged cheesy material and was suggestive of calcinosis cutis. The right index finger showed a broad terminal phalanx. Gynecologic examination revealed a small infantile uterus. The patient had normal dentition. Cases 2 and 3 two brothers, aged 6 and 3 years, who were brought to the clinic for screening, also revealed similar skeletal and cutaneous changes, but with less intense pigmentation. Both had normal development of the genitalia. Case 4 After 4 years, another girl of 15 years of age was referred to us with complaints of inability to walk due to pain in the feet. The patient was born to second- degree consanguineous parents and showed the same clinical features as those of Case 1, except for short stature (height, 138 cm) and a broad terminal phalanx on the left middle finger. This female patient also had an infantile uterus. All four patients were subjected to routine investigations, which were found to be within normal limits. Examination of the hair under potassium hydroxide mOUnt did not reveal any abnormality. Skeletal surveys were performed for all patients. In Case 1, an X-ray of the skull anteroposterior (AP) and lateral view (Fig. 2) revealed frontal bossing of the cranial vault, Coronal, lambdoid, and sagittal sutures were widened, measuring 5, 5, and 7 mm, respectively. The cranial vault had a ground glass appearance and did not show outer and inner table differentiation. The metopic and mendosal sutures were seen. The sutures were seen as straight lines instead of serrated interdigitations. The occipital area showed only a sea of membranes with islands of ossified bones (Wormian bones). Platybasia was seen. The mandible was hypoplastic. A chest X-ray revealed a narrow chest cavity with normal clavicles. An X-ray of the spine was normal. An X-ray of the pelvis ShOwed increased acetabular angles, collapsed head of femur, and reduced shaft neck angle. An X-ray of the hand showed popcorn calcification in the soft tissues. There was hypoplasia of the distal part of the terminal phalanx of the left index finger. An X-ray of the foot also showed Similar soft tissue calccification of the left big and little toes. Skeletal surveys of the two other siblings revealed Wormian bones and widened suture lines, but were otherwise normal. A skeletal survey of the fourth case also reflected the same changes as in Case 1, except that hypoplasia of the terminal phalanx of the left middle finger was observed. Histopathology of the scalp nodule of Case 1 and of the keratotic papules of Cases 1 and 4 (Fig. 3) revealed calcified deposits in the mid and lower dermis which stained positive with Von Kossa.
