PENS hamartoma or “papular epidermal nevus with "skyline" basal cell layer” is a congenital epidermal hamartoma, which is characterized by specific histopathological features. We report a diagnosis of PENS hamartoma that was made in an 18-month-old girl.

Initially described by Torrelo et al. in 2011 (1), PENS hamartoma exhibits particular clinical features consisting of coalescent, verrucous, and light brown polygonal papules (2). The diagnosis is confirmed by histological examination, which, in the majority of cases, shows an alignment of epidermal basal cells and palissadic disposition of nuclei evoking a "skyline". In 2012, the term PENS Syndrome was retained, owing to new clinical descriptions associating light neurological abnormalities with these cutaneous lesions (2). PENS syndrome is a rare neuro-cutaneous syndrome, which involves one or more congenital epidermal hamartomas of PENS type, as well as non-specific neurological abnormalities (1-3). Neurological manifestations begin to occur during the first two years of life (1). A review of the literature identified 27 reported cases of PENS hamartomas (1-12), including some familial cases and other cases associated with neurological abnormalities (PENS syndrome). The physiopathology of PENS hamartoma and PENS syndrome remains unclear, whereas several hypotheses have been advanced (7).

Antenatal hydronephrosis is the most common congenital abnormality. The post-natal management is, however, still controversial, specifically concerning further testing, as well as and benefit of antibiotic prophylaxis. The systematic indication of performing a voiding cystourethrogram for vesicoureteral reflux screening and of prescribing antibiotic prophylaxis for preventing urinary tract infections has been increasingly questioned by recent study data. A less aggressive approach is discussed here, which is essentially based on post-natal ultrasound findings.

We herein propose an algorithm that is based on these study data.

The systematic use of opioids has made us lose sight of their significant adverse effects, including respiratory distress, hyperalgesia, as well as postoperative nausea and vomiting. Sub-Saharan African countries are currently facing the issue of post-interventional surveillance, with post-operative respiratory problems being rather common. Similarly, these countries experience difficulties in managing pain, nausea, and vomiting. At times, opioid ruptures may occur, which may lead to postponing surgical procedures, in a context where access to surgery is already a obstacle. The opioid-free anesthesia could be an interesting alternative for these countries, especially when using accessible drugs with simple protocols. Therefore, anesthesiologists from these countries should focus their interest on such anesthesia techniques, in the aim to better define their place in their daily practice and share their potential benefits in a limited-resource setting.