Interleukin-37 inhibits desmoglein-3 endocytosis and keratinocyte dissociation via upregulation of Caveolin-1 and inhibition of the STAT3 pathway

BACKGROUND

Pemphigus vulgaris (PV) is a potentially fatal autoimmune bullous disease primarily caused by acantholysis of keratinocytes attributed to pathogenic desmoglein-3 (Dsg3) autoantibodies. Interleukin-37 (IL-37) reportedly plays important roles in a variety of autoimmune diseases, but its role in PV is not clear.

OBJECTIVES

To investigate whether IL-37 plays a role in the occurrence and progression of PV.

METHODS

HaCaT keratinocytes were stimulated with anti-Dsg3 antibody to establish an in vitro PV model, which was defined as anti-Dsg3 group. Cells incubated with medium without anti-Dsg3 treatment were used as control. IL-37 was cultured with these cells infected with or without lentiviral vector shRNA-Caveolin-1 (sh-Cav-1-LV). Cell dissociation assay and immunocytofluorescence were performed to assess keratinocyte dissociation, keratin retraction and Dsg3 endocytosis. Real-time PCR was used to detect the mRNA level of Cav-1, and western blot was used to determine the protein expression of Cav-1, Dsg3, STAT3 and phosphorylated-STAT3 (p-STAT3).

RESULTS

The anti-Dsg3 group showed more cell debris, increased keratin retraction, increased Dsg3 endocytosis, reduced Cav-1 expression and co-localization than the control group, while IL-37 treatment neutralized all of these changes. Interestingly, Cav-1 knockdown supressed the inhibitory effect of IL-37 on keratinocyte dissociation and Dsg3 internalization. The protein expression of p-STAT3 was increased in keratinocytes of the PV model but decreased by IL-37. Re-activation of the STAT3 pathway by colivelin supressed the inhibitory effect of IL-37 on keratinocyte dissociation and Dsg3 internalization, along with upregulation of Cav-1 and Dsg3.

CONCLUSIONS

IL-37 inhibited keratinocyte dissociation and Dsg3 endocytosis in an in vitro PV model through the upregulating Cav-1 and inhibiting STAT3 pathway.

The human skin organ culture model as an optimal complementary tool for murine pemphigus models

Pemphigus is a severe autoimmune bullous disease of the skin and/or mucous membranes caused by autoantibodies that mainly target the adhesion proteins desmoglein (Dsg) 3 and/or Dsg1. Clinically, pemphigus is characterized by flaccid blistering, leading to severe water and electrolyte loss. Before the introduction of corticosteroid treatment, the disease turned out to be fatal in many cases. Despite recent therapeutic improvements, treatment of pemphigus patients is centred on prolonged systemic immunosuppression and remains challenging. Current drug development for pemphigus has a strong focus on disease-causing B cells and autoantibodies and, more recently, also on modulating autoantibody-induced tissue pathology and keratinocyte signalling. This drug development requires reliable pre-clinical model systems replicating the pathogenesis of the human disease. Among those are neonatal and adult mouse models based on the transfer of Dsg3, Dsg1/3 or Dsg1-specific autoantibodies. To reduce the number of animal experiments, we recently established a standardized human skin organ culture (HSOC) model for pemphigus. This model reproduces the clinical phenotype of autoantibody-induced tissue pathology in pemphigus vulgaris. For induction of blistering, a recombinant single-chain variable fragment (scFv) targeting both Dsg1 and 3 is injected into pieces of human skin (obtained from plastic surgeries). Further characterization of the HSOC model demonstrated that key morphologic, molecular and immunologic features of pemphigus are being replicated. Thus, the pemphigus HSOC model is an excellent alternative to pemphigus animal model systems that are based on the transfer of (auto)antibodies.

cAMP: A master regulator of cadherin-mediated binding in endothelium, epithelium and myocardium

Regulation of cadherin-mediated cell adhesion is crucial not only for maintaining tissue integrity and barrier function in the endothelium and epithelium but also for electromechanical coupling within the myocardium. Therefore, loss of cadherin-mediated adhesion causes various disorders, including vascular inflammation and desmosome-related diseases such as the autoimmune blistering skin dermatosis pemphigus and arrhythmogenic cardiomyopathy. Mechanisms regulating cadherin-mediated binding contribute to the pathogenesis of diseases and may also be used as therapeutic targets. Over the last 30 years, cyclic adenosine 3',5'-monophosphate (cAMP) has emerged as one of the master regulators of cell adhesion in endothelium and, more recently, also in epithelial cells as well as in cardiomyocytes. A broad spectrum of experimental models from vascular physiology and cell biology applied by different generations of researchers provided evidence that not only cadherins of endothelial adherens junctions (AJ) but also desmosomal contacts in keratinocytes and the cardiomyocyte intercalated discs are central targets in this scenario. The molecular mechanisms involve protein kinase A- and exchange protein directly activated by cAMP-mediated regulation of Rho family GTPases and S665 phosphorylation of the AJ and desmosome adaptor protein plakoglobin. In line with this, phosphodiesterase 4 inhibitors such as apremilast have been proposed as a therapeutic strategy to stabilize cadherin-mediated adhesion in pemphigus and may also be effective to treat other disorders where cadherin-mediated binding is compromised.

Pemphigus Vulgaris: More Than Just a Skin Disease

INTRODUCTION

Pemphigus is a group of autoimmune diseases of the skin and mucous membranes that is characterized by multiple bullae formation. It is caused by autoantibodies directed against the cell surface of keratinocytes, resulting in the loss of cell-cell adhesion of keratinocytes. This disease can be very debilitating and difficult to treat if large surface areas are involved.

METHODS

We performed a retrospective review of a complex case of pemphigus vulgaris in a 24-year-old man who develop partial-thickness skin lesions distributed throughout the entire body with a total body surface of 80% short after an episode of strep throat treated with amoxicillin.

RESULTS

The patient had a complicated hospital course in which the standard treatment of the disease led to adverse effects that were successfully managed at our busy burn center.

CONCLUSIONS

Pemphigus vulgaris is a complex skin disease in which treatment techniques carry their risk and must be tailored to the patient's specific needs. Treatment of this conditions at a burn center would be beneficial as demonstrated with conditions like Stevens-Johnson syndrome and toxic epidermal necrolysis.

[Senear-Usher syndrome (seborrheic pemphigus): An exceptional case]

BACKGROUND

Among the autoimmune diseases causing erosive lesions and blisters on skin and mucous membranes is pemphigus. Within this is a rare subtype known as seborrheic pemphigus or Senear-usher syndrome which is characterized by broken blisters and crusts involving the seborrheic areas.

CASE REPORT

A 40-year-old female patient, initially treated in a first level unit for a condition of 45 days of evolution, characterized by thick scabby lesions with an erythematous base, pruritic and painful, located in the center of the face, with posterior extension towards the abdomen, thorax, and extremities. Treatment consisted of prednisolone, with favorable evolution. The biopsy of the lesions with the diagnosis of seborrheic pemphigus.

CONCLUSIONS

Senear-usher syndrome is a rare disease of multifactorial origin. Early diagnosis and adequate treatment are decisive factors to avoid the evolution and advanced forms of the disease.

Histopathological Spectrum And Role Of Clinicopathological Correlation In The Diagnosis Of Vesiculobullous Lesions

BACKGROUND

Histopathology is an important diagnostic modality for vesiculobullous lesions, however the diagnosis may at times require use of Immunofluorescence techniques which are expensive and not widely available. The aim of this study was to determine the histopathological spectrum of vesiculobullous diseases and to determine the role of clinic-pathological correlation in diagnosing bullous lesions.

METHODS

This was cross sectional validation study conducted in a tertiary care hospital, over a period of 18 months. All the clinically diagnosed cases of bullous diseases were included and examined as histological sections by three histopathologists.

RESULTS

Out of 58 total cases, the most frequently diagnosed lesions included Pemphigus vulgaris (27%), Bullous pemphigoid (13.8%) and Pemphigus foliaceous (12.1%). Females comprised 55% of cases, age distribution was wide but most patient were in age bracket of 20-39 years.

CONCLUSION

There was 89.6% correlation between clinical and histopathological diagnosis. Only 2 cases were sent for Immunofluorescence studies, as histopathology was inconclusive in those cases. Therefore, we conclude that histopathological examination along with clinical correlation is a very useful way of diagnosing vesiculobullous disorders.

Role of ADAM10 and ADAM17 in the Regulation of Keratinocyte Adhesion in Pemphigus Vulgaris

The severe autoimmune blistering disease Pemphigus vulgaris (PV) is mainly caused by autoantibodies (IgG) against desmoglein (Dsg) 3 and Dsg1. The mechanisms leading to the development of blisters are not fully understood, but intracellular signaling seems to play an important role. Sheddases ADAM10 and ADAM17 are involved in the turnover of the desmosomal cadherin Dsg2 and ADAM10 has been shown to contribute to acantholysis in a murine pemphigus model. In the present study, we further examined the role of ADAM10 and ADAM17 both in keratinocyte adhesion and in the pathogenesis of PV. First, we found that inhibition of ADAM10 enhanced adhesion of primary human keratinocytes but not of immortalized keratinocytes. In dissociation assays, inhibition of ADAM10 shifted keratinocyte adhesion towards a hyperadhesive state. However, ADAM inhibition did neither modulate protein levels of Dsg1 and Dsg3 nor activation of EGFR at Y1068 and Y845. In primary human keratinocytes, inhibition of ADAM10, but not ADAM17, reduced loss of cell adhesion and fragmentation of Dsg1 and Dsg3 immunostaining in response to a PV1-IgG from a mucocutaneous PV patient. Similarly, inhibition of ADAM10 in dissociation assay decreased fragmentation of primary keratinocytes induced by a monoclonal antibody against Dsg3 and by PV-IgG from two other patients both suffering from mucosal PV. However, such protective effect was not observed in both cultured cells and ex vivo disease models, when another mucocutaneous PV4-IgG containing more Dsg1 autoantibodies was used. Taken together, ADAM10 modulates both hyperadhesion and PV-IgG-induced loss of cell adhesion dependent on the autoantibody profile.

In Vitro, Ex Vivo, and In Vivo Models for the Study of Pemphigus

Pemphigus is a life-threatening autoimmune disease. Several phenotypic variants are part of this family of bullous disorders. The disease is mainly mediated by pathogenic autoantibodies, but is also directed against two desmosomal adhesion proteins, desmoglein 1 (DSG1) and 3 (DSG3), which are expressed in the skin and mucosae. By binding to their antigens, autoantibodies induce the separation of keratinocytes, in a process known as acantholysis. The two main Pemphigus variants are Pemphigus vulgaris and foliaceus. Several models of Pemphigus have been described: in vitro, ex vivo and in vivo, passive or active mouse models. Although no model is ideal, different models display specific characteristics that are useful for testing different hypotheses regarding the initiation of Pemphigus, or to evaluate the efficacy of experimental therapies. Different disease models also allow us to evaluate the pathogenicity of specific Pemphigus autoantibodies, or to investigate the role of previously not described autoantigens. The aim of this review is to provide an overview of Pemphigus disease models, with the main focus being on active models and their potential to reproduce different disease subgroups, based on the involvement of different autoantigens.

Relapse of pemphigus foliaceus initiating at the site of irradiation in an elderly male with laryngeal carcinoma: Illustrating the concept of immunocompromised cutaneous district

Radiotherapy-induced or -aggravated pemphigus is not a common occurrence with only a few cases reported so far. The radiation disrupts the local immune regulation and alters the antigenicity of keratinocytes, but the exact etiology is not clear. We report a case of an elderly man operated for laryngeal carcinoma who presented with recurrence of pemphigus foliaceus lesions starting at the irradiation site. The appearance of vesiculobullous lesions at the site of irradiation should be evaluated thoroughly to rule out immunobullous diseases.

Antibody-Negative Paraneoplastic Autoimmune Multiorgan Syndrome (PAMS) in a Patient with Follicular Lymphoma Accompanied by an Excess of Peripheral Blood CD8+ Lymphocytes

Paraneoplastic autoimmune multiorgan syndrome (PAMS) is a life-threatening autoimmune disease associated with malignancies. Here, we present a patient initially misdiagnosed with “chronic” Stevens–Johnson syndrome. Over a year later, the patient was diagnosed with stage IV follicular lymphoma and treated with an anti-CD20 antibody. At this time, his skin condition had significantly worsened, with erythroderma and massive mucosal involvement, including in the mouth, nose, eyes, and genital region. Histopathology revealed lichenoid infiltrates with interface dermatitis, dyskeratoses, necrotic keratinocytes, and a dense CD8+ infiltrate with strong epidermotropism. Direct and indirect immunofluorescence tests for autoantibodies were negative. Remarkably, we retrospectively discovered a chronic increase in peripheral CD8+ lymphocytes, persisting for over a year. Consequently, the patient was diagnosed with antibody-negative PAMS. Three weeks later, he succumbed to respiratory failure. This dramatic case highlights the challenges in diagnosing PAMS, particularly in cases where immunofluorescence assays are negative. Importantly, we observed, for the first time, a chronic excess of CD8+ peripheral blood lymphocytes, associated with PAMS, consistent with the systemic, autoreactive T-cell-driven processes that characterize this condition.

Chronic exposure to the anti-m3 muscarinic acetylcholine receptor autoantibody in pemphigus vulgaris contributes to disease pathophysiology

Pemphigus vulgaris (PV) is a potentially lethal autoimmune mucocutaneous blistering disease characterized by binding of IgG autoantibodies (AuAbs) to keratinocytes (KCs). In addition to AuAbs against adhesion molecules desmogleins 1 and 3, PV patients also produce an AuAb against the M3 muscarinic acetylcholine (ACh) receptor (M3AR) that plays an important role in regulation of vital functions of KCs upon binding endogenous ACh. This anti-M3AR AuAb is pathogenic because its adsorption eliminates the acantholytic activity of PV IgG; however, the molecular mechanism of its action is unclear. In the present study, we sought to elucidate the mode of immunopharmacologic action of the anti-M3AR AuAb in PV. Short-term exposures of cultured KCs to PV IgG or the muscarinic agonist muscarine both induced changes in the expression of keratins 5 and 10, consistent with the inhibition of proliferation and upregulated differentiation and in keeping with the biological function of M3AR. In contrast, long-term incubations induced a keratin expression pattern consistent with upregulated proliferation and decreased differentiation, in keeping with the hyperproliferative state of KCs in PV. This change could result from desensitization of the M3AR, representing the net antagonist-like effect of the AuAb. Therefore, chronic exposure of KCs to the anti-M3AR AuAb interrupts the physiological regulation of KCs by endogenous ACh, contributing to the onset of acantholysis. Since cholinergic agents have already demonstrated antiacantholytic activity in a mouse model of PV and in PV patients, our results have translational significance and can guide future development of therapies for PV patients employing cholinergic drugs.

Punctate Pattern and Pemphigus: Is There Any Evidence of Punctate Pattern Among Iranian Patients?

AIM

To examine the prevalence of this novel pattern among Iranian patients with pemphigus and peruse the relationship between the presence of a punctate pattern with clinical severity of disease and histopathological findings.

METHODS

One hundred recently diagnosed patients with pemphigus were enrolled. DIF evaluation and routine light microscopy were performed on their biopsy specimens. Disease severity was determined using the Pemphigus Disease Area Index. Serum samples were collected to measure autoantibody titers using enzyme-linked immunosorbent assay.

RESULTS

All the samples evaluated by DIF showed a continuous linear pattern of intercellular IgG deposition, whereas none of them had a punctate pattern. Despite a significant correlation between the Pemphigus Disease Area Index score and autoantibody values, no association between histopathological findings and disease severity has been found.

CONCLUSION

We could not detect any punctate pattern among Iranian patients with pemphigus. The importance of this pattern in the diagnosis of pemphigus might be different among patients with different ethnic and genetic factors.

[Pemphigus vulgaris with exclusive affectation in the esophagus: a case report]

Background

Pemphigus vulgaris comprises a group of heterogeneous blistering autoimmune diseases of the skin and mucosa. Esophageal involvement within pemphigus vulgaris is rare with an uncertain prevalence that requires a detailed diagnostic and a therapeutic approach.

Clinical case

37-year-old female, with a history of treatment with Cox-2 inhibitors due to herniated disc. She is sent to the Gastroenterology Service for weight loss of approximately 5 kilos in a month, with the presence of dysphagia, odynophagia and retrosternal pain with poor tolerance to the oral route. Endoscopy was performed, which reported esophagitis dissecans superficialis (EDS), erythematous gastropathy of the antrum and normal duodenum. Findings were correlated with the diagnosis of pemphigus vulgaris with exclusive involvement of the esophagus. The evaluation did not identify lesions on the skin, oral cavity or other mucous membranes. A new endoscopy was performed as a control and it was found immunofluorescence of the esophageal biopsy reactive to IgG 2. Initial management was given with glucocorticoids, anti-inflammatories and immunosuppressants.

Conclusions

The importance of the study of pemphigus lies not only in the high associated morbidity and mortality, but also in its intrinsic rarity and the complexity of its detection, given that patients usually take several months to have an accurate diagnosis and even more time to achieve therapeutic goals. It is a priority the dissemination of the study of pemphigus among health professionals involved in its detection.

Desmogleins 1, 3, and E-cadherin immunohistochemical expression within mucocutaneous pemphigus vulgaris

Introduction

pemphigus vulgaris (PV) is an autoimmune condition characterized by the loss of adhesion between the epithelial cells and blister formation. The production of autoantibodies against desmosomal proteins, namely, desmoglein (DSG) 1 and DSG3, is considered a main event of PV. A full understanding of the role of adhesion molecules in the pathogenesis of PV is not fully elucidated yet. This study aimed to evaluate and correlate the immunohistochemical expression of E-cadherin (E-cad), DSG1, and DSG3 proteins in oral and skin PV.

Methods

this study was a retrospective analysis study. Positive PV cases were stained with anti-E-cad, anti-DSG1, and anti-DSG3 antibodies. The expression of each marker was determined by two pathologists according to an established scoring system: (E-cad: negative, weak, moderate, and strong), (DSG1: negative, weak, and strong), and (DSG3: negative and positive). The Chi-square and Pearson´s correlation tests were used to statistically analyze the data.

Results

forty-three biopsies (26 skin and 17 oral tissue samples) from 22 males and 21 female PV patients were included. The median age was 40.50 years. In total, the immunohistochemical expression was negative for DSG3, E-cad, and DSG1 in 81.4%, 18.5%, and 16.4%, respectively. DSG1 expression was significantly higher in males than females. A statistically significant correlation was found between E-cad and DSG3 expressions.

Conclusion

a significant difference in the expression of markers of both oral and skin PV was absent. Downregulation of DSG3 expression was the hallmark feature that also showed a positive correlation with E-cad expression.

RETROSPECTIVE CHART ANALYSIS OF PATIENTS DIGNOSED WITH ACANTHOLYTIC PEMPHIGUS FOR THE PERIOD 2008-2018

OBJECTIVE

The aim: Determine the clinical and anamnestic criteria that cause the аcantholytic pemphigus (AP) morbidity in the course of the treatment.

PATIENTS AND METHODS

Materials and methods: Analysis of medical histories of patients who underwent the therapy on the basis of the clinic for 10 years. In the analysis of 174 medical case histories were determined the factors provoking the onset and exacerbation of the disease. The disease severity was assessed using the IKEDA index.

RESULTS

Results: During the analysis, patients were divided into two groups. The I group - patients who required combination therapy - systemic glucocorticosteroids (SGCs) and immunosuppressant (azathioprine (AZA)). For patients of group II used SGCs - according to the indications. The presence of intoxication and signs of pyoderma were more common in patients of group I. The number of exacerbations per year for an unknown reason in group I was almost 3 times higher. The ineffectiveness of high starting doses of SGCs was 20.2% of cases compared with those in group II.

CONCLUSION

Conclusions: According to clinical and anamnestic data, during the retrospective analysis of case histories, the criteria determining the severity of acantholytic pemphigus during treatment were determined: the age of patients, the diagnosis period, the prevalence of lesions and severity of dermatosis according to the IKEDA index, the selection of adequate treatment tactics, taking into the complications caused as a result of the systemic glucocorticosteroids therapy.

[The study of microbiota in patients with bullous lesions of the oral mucosa]

THE AIM OF THE STUDY

The study by the method of tissue polymerase chain reaction of the species composition of the microbiota of lesions of the oral mucosa in patients with bullous lesions.

MATERIAL AND METHODS

Biopsy specimens of the oral mucosa of 51 patients were studied by the polymerase chain reaction method, of which 14 patients with pemphigus vulgaris, 17 patients with pemphigoid bullosa, and 20 patients with the bullous form of ruber lichen planus. 4 types of microorganisms have been identified - Fusobacterium, Streptococcus pneumoniae, Candida albicans, Ureaplasma spp. and viruses - Human Papillomavirus 16, Epstein-Barr virus and Citomegalovirus.

RESULTS

In the study of the microbiota of bullous lesions, associations of microorganisms and viruses were established in a significant number of cases. Associations of Str.pneumoniae and C. albicans were quite common in patients with pemphigus vulgaris in 26.3%, pemphigoid bullosa in 20.0%, and in patients with the bullous form of ruber lichen planus in 14.3% of cases. In patients with pemphigus vulgaris, the association of Str.pneumoniae, C. albicans and EBV was noted in 31.6% of cases. In patients with the bullous form of ruber lichen planus in a high percentage of cases (28.6%), the associations of Str. pneumoniae, EBV and CMV.

CONCLUSION

Identification at earlier stages of management of patients with bullous lesions Str. pneumoniae, Candida albicans, and Fusobacterium associated with herpes viruses should be regarded as one of the triggering mechanisms of an autoimmune conflict, which subsequently causes a specific clinical picture of these diseases.

[Diagnostically difficult case of pemphigus vulgaris isolated manifestation in the oral cavity]

A clinical example of the manifestation of vulgar pemphigus on the oral mucosa in the form of a single mildly painful erosion at the border of the soft and hard palate with extensive erosive lesions that existed in the patient for a long time is presented. The detection of a false positive reaction to syphilis led to an increase in the time of diagnosis. Only the appointment of a repeated full examination of the patient in accordance with clinical standards (cytological analysis, histological examination and indirect immunofluorescence method) allowed to establish the correct diagnosis, prescribe adequate therapy to the patient in a hospital setting and get a positive result.

Immunohistochemical Expression of Galectin-3 in Pemphigus Vulgaris

ABSTRACT

Pemphigus vulgaris (PV) is an autoimmune bullous disorder related to immunoglobulin-G autoantibodies against desmoglein-3. Galectin-3 is one of the main elements of the immunoglobulin-E group which is essential in the cell-cell or cell-matrix adhesion. Although the presence of immunoglobulin-E autoantibodies in PV has been observed, no studies have been performed to describe the role of galectin-3 in PV. We evaluated galectin-3 expression in PV as a first step in assessing its impact in the pathogenesis of this autoimmune blistering process. In a retrospective study, 56 specimens from 45 patients diagnosed with PV were stained with antibodies to galectin-3. The percentages of nuclear and cytoplasmic galectin-3 expression as well as staining intensity were evaluated around blisters and adjacent unaffected skin. We observed a significant decrease in galectin-3 cytoplasmic and nuclear expression as well as stain intensity around blisters compared with adjacent unaffected skin. Although autoantibodies against desmogleins trigger the blister formation in PV patients, loss of galectin-3 may play a role in the extension of blister formation by initiating cell-cell disassembly at the level of the intercellular keratinocyte desmosome. We demonstrated a lower expression of galectin-3 around the blisters in PV. The pathogenesis of the blister formation may be related to lower expression of galectin-3. Additional studies are necessary to clarify the result of this outcome and determine the accurate pathogenesis of blister formation in PV.

Histopathology of Pemphigus Vulgaris Revisited

ABSTRACT

Pemphigus vulgaris (PV) is a severe, potentially life-threatening autoimmune blistering disease, which is common in India. Although there is abundant literature on clinical and immunologic features, comprehensive studies on its histopathology are lacking. The aim of this study was to describe the histopathologic and immunofluorescence features as well as discuss various diagnostic pitfalls of PV. Histopathologic and immunofluorescence (DIF/IIF) findings were reviewed for 169 biopsies from 2007 to 2017 (11 years). The 169 samples included 152 skin, 16 oral mucosal, and 1 corneal biopsy. Maximum prevalence was noted in the fifth decade (57%) with a slight male preponderance. Vesicles were seen in 149 cases (88%), the level of which was suprabasal in 91(61%) and both suprabasal and intraepidermal in 50 cases (33.5%). Acantholytic cells were present in 142 cases (95%). Acantholytic keratinocytes showed rounded and polygonal acantholysis. 86 (51%) cases showed evidence of regeneration. Adnexal involvement was seen in 92 cases, commonest in the hair follicles. Unusual histologic findings included: intraepidermal bulla, absence of dermal inflammation, free floating hair shafts, multinucleated epithelial cells, eosinophil predominance; all of which are discussed. DIF was performed in 166 cases, of which 163 were positive (98%), and IgG was the commonest immunoreactant (96%). IIF was performed in 11 cases, of which 9 cases were positive for Dsg3. Although the diagnosis of PV rests on combined clinical, histologic, and IF features, histopathology as the sole means is also a powerful tool. It is important to be aware of the diagnostic pitfalls to optimize its utility.

Castleman disease and paraneoplastic pemphigus in a pregnant woman: A case report

RATIONALE

Orogenital ulcers can be observed in various conditions, such as Behcet disease, infection and also paraneoplastic pemphigus (PNP). Castleman disease (CD), which is a rare cause of paraneoplastic pemphigus represents a heterogenous lymphoproliferative disorder of unknown etiology. Paraneoplastic pemphigus associated with CD in pregnancy is rare and has not been reported yet.

PATIENT CONCERNS

We report a rare case of CD in a 26-year-old pregnant woman with orogenital ulcers. The patient suffered from mucosal erosions and uveitis at 23 weeks of gestation. A retroperitoneal mass (9.7×7.3×11.8 cm) was identified by CT scan.

DIAGNOSES

According to histological and immunohistological findings, a diagnosis of unicentric CD, hyaline vascular type, and PNP was formulated.

INTERVENTION

High dose methylpredisonlone was given for the therapy. Pancreatic uncinatectomy, portal vein and superior mesenteric vein repair, pancreaticojejunostomy, and caesarean section were performed on the patient to remove the tumor and the fetus.

OUTCOMES

The fetus did not survive after surgery. The patient did not achieve remission and she died from epidermolysis and sepsis several months later.

LESSONS

PNP associated with CD is a rare lymphoproliferative disorder and needs to be differentiated from other orogenital diseases by histological features.

ETHICS AND DISSEMINATION

Written informed consent was obtained from the patient for publication of this case report and accompanying images. Ethical approval of this study was granted by the Ethics Committee of West China Hospital of Sichuan University. (Ethics Reference No: 2021143).

Deep pemphigus (pemphigus vulgaris, pemphigus vegetans and paraneoplastic pemphigus) in dogs, cats and horses: a comprehensive review

Pemphigus is the term used to describe a group of rare mucocutaneous autoimmune bullous diseases characterized by flaccid blisters and erosions of the mucous membranes and/or skin. When the autoantibodies target desmosomes in the deep layers of the epidermis, deep pemphigus variants such as pemphigus vulgaris, pemphigus vegetans and paraneoplastic pemphigus develop. In this article, we will review the signalment, clinical signs, histopathology and treatment outcome of pemphigus vulgaris, pemphigus vegetans and paraneoplastic pemphigus in dogs, cats and horses; where pertinent, we compare the animal diseases to their human homologue. Canine, feline and equine pemphigus vulgaris, pemphigus vegetans and paraneoplastic pemphigus have many features similar to the human counterpart. These chronic and often relapsing autoimmune dermatoses require aggressive immunosuppressive therapy. In animals, the partial-to-complete remission of pemphigus vulgaris and pemphigus vegetans has been achieved with high dose glucocorticoid therapy, with or without adjunct immunosuppressants; the prognosis is grave for paraneoplastic pemphigus.

Hallopeau type of pemphigus vegetans, an unusual clinical presentation of an infrequent disease

Pemphigus vegetans is a rare variant of pemphigus vulgaris, characterized by vegetative lesions that develop mainly in flexural areas. Herein, we present a middle-aged woman who presented to the emergency department with a rare cutaneous finding of bilateral axillary pustules that progressed over months to vegetant and malodorous plaques associated with subsequent painful erosions.