Paraneoplastic pemphigus triggered by radiotherapy

Paraneoplastic pemphigus is a recently described autoimmune disease characterized by painful mucosal ulceration and polymorphous skin lesions in association with an underlying neoplasm. Distinct autoantibodies bind desmoplakin I, desmoplakin II, bullous pemphigoid antigen and an uncharacterized 190 kDa antigen. A case is presented of paraneoplastic pemphigus that developed after radiotherapy for non-Hodgkin's lymphoma in a 53 year old man. Multiple skin biopsies showed a lichenoid reaction without acantholysis. Immunofluorescence and mucosal biopsies were required to establish the correct diagnosis. Corneal opacities resembling lichenoid graft-versus-host disease and retinal haemorrhages, which developed in the patient, have not been previously documented. Despite high doses of immunosuppressive agents and plasmaphoresis, the patient eventually died from respiratory failure.

A case of autoimmune bullous dermatosis with features of pemphigus vulgaris and bullous pemphigoid

Pleomorphic blisters, including tense bullae and annularly arranged vesicles around the erythema as well as erosive eruptions in the oral cavity, appeared on a 61-year-old woman 5 years after surgery for cholangiocellular carcinoma. A biopsy specimen from the oral cavity showed intraepidermal blisters, and those from skin lesions showed subepidermal blisters with infiltrates of eosinophils and neutrophils. The early-stage vesicles showed infiltrates along the epidermal-dermal junction, where electron microscopy disclosed disruption of the lamina densa, basal cells remaining on the dermis, and acantholytic keratinocytes among the infiltrates, but there was no cleavage of the epidermal-dermal junction at the lamina lucida. Direct immunofluorescence studies showed immune deposition at the intercellular space (ICS) and along the basement membrane zone (BMZ). Indirect immunofluorescence studies confirmed coexistence of IgG class anti-ICS and anti-BMZ antibodies. Although this case showed immunohistochemical features of bullous pemphigoid, the presence of suprabasal cleavage in the oral mucosa, acantholytic cells in the blister cavity, the deposition of IgG at the ICS of the perilesional epidermis, and circulating anti-ICS antibodies strongly suggested that this case was primarily pemphigus. The strong inflammation along the epidermal-dermal junction due to unknown factors may have modified the clinical appearance and the histopathology.

Use of corticosteroids and aurothioglucose in a pygmy goat with pemphigus foliaceus

Pemphigus foliaceus was diagnosed in a 20-month-old female pygmy goat. The goat had a 3-month history of chronic exfoliative dermatitis and was examined after developing alopecia and severe, asymmetric, diffuse flakes of dry, nonadherent skin scales. Pemphigus foliaceus was diagnosed on the basis of dermatohistologic findings and was confirmed by analysis of results of direct immunofluorescence testing of perilesional specimens obtained by use of a punch biopsy. The goat was successfully treated with prednisolone (immunosuppressive induction dosage; 1 mg/kg of body weight, IM, q 12 h). Remission was achieved in 1 week and was maintained by use of prednisolone (immunosuppressive maintenance dosage; 1 mg/kg, IM, q 48 h). Treatment with aurothioglucose (1 mg/kg, IM, q 7 d) that was initiated during administration of prednisolone and was continued after discontinuation of corticosteroid administration failed to prevent redevelopment of pemphigus foliaceus.

A case of bullous pemphigoid with antibodies against intercellular 130 kd antigen

Pemphigus and bullous pemphigoid are two typical autoimmune bullous diseases that involve circulating autoantibodies directed against the epidermal cell surface and the epidermal basement membrane zone, respectively. The coexistence of pemphigus and bullous pemphigoid is rare. We describe a case of a 79-year-old man who had tense bullae and erythematous, erosive lesions on his trunk and four extremities. Histopathology revealed subepidermal blister formation without any evidence of intraepidermal acantholytic changes. Direct immunofluorescence study demonstrated deposition of IgG on the epidermal intercellular spaces, as well as along the basement membrane zone; C3 was detected only on the latter. Indirect immunofluorescence study using monkey esophagus as a substrate demonstrated the presence of circulating antibodies against both junctional and intercellular antigens. In order to analyze the precise nature of this patient's antibodies, indirect immunofluorescence study using cultured human keratinocytes and immunoblot analyses were performed. Pemphigus vulgaris sera showed smooth and uniform staining on intercellular spaces. The patient's serum showed a granular and uneven staining pattern. Immunoblot analysis showed that the patient's serum reacted with the typical 230 kd (bullous pemphigoid) antigen and 130 kd antigen, which is close to the pemphigus vulgaris antigen.

Immunofluorescence study of pemphigus from north India

Both serum studies by indirect immunofluorescence (IIF) tests and skin biopsy examination by direct immunofluorescence (DIF) were performed on 22 cases of pemphigus with clinically active lesions. Twenty cases had pemphigus vulgaris and two, pemphigus foliaceus. The majority of cases (70%) were between 21 and 60 years old; the mean age was 39.5 +/- 12.7 years. There was no sex predilection. DIF showed the positive fluorescence of intercellular cement substance (ICS) of the epidermis in all 22 cases (100%). IgG was positive in 77.2%, followed sequentially by C3C (50%), IgA (45.45%), and IgM (36.36%). Six cases (27.27%) also showed granular immunoglobulin and/or complement deposits at the dermoepidermal junction. IIF detected serum antiepithelial antibodies in 18 cases (81.81%) using human esophagus as substrate. Most of these cases (88.88%) showed IgG type of antibodies; the other 11.11% exhibited IgA and IgM in low concentrations. 1+ titer positivity was observed in 15 cases. This study demonstrates the value of DIF for a definitive diagnosis of pemphigus. However, it is also important to appreciate that immunofluorescence is not a substitute for histopathology, but rather complementary to it.

Coexistence of myasthenia gravis and pemphigus foliaceus

Myasthenia gravis and pemphigus are both considered to have an autoimmune basis. Although immunological and clinical studies have been performed on large numbers of patients with myasthenia gravis, the coexistence of myasthenia gravis and pemphigus foliaceus has rarely been described. We recently have the opportunity to study a 33-year-old female patient having both of these autoimmune diseases confirmed by various diagnostic methods. This rare coexistence of myasthenia gravis and pemphigus foliaceus has not been previously documented in Korea.

[Unusual radiation reaction after soft roentgen radiotherapy in a patient with pemphigus vulgaris]

A 71-year-old woman suffered from pronounced erosion of her nose after soft X-ray therapy (total dose 28 Gy, half dose depth 10.5-11.5 mm). 5 weeks after the end of the irradiation no healing tendency was observed. This unusual clinical course was caused by a simultaneously existing pemphigus vulgaris that worsened after radiotherapy, presumably as a consequence of the release of epidermal antigens. In this case it is improbable that the pemphigus was induced by the radiotherapy, as has been reported on several occasions in the literature. However, this possibility cannot be entirely excluded.

Endemic pemphigus foliaceus (fogo selvagem) in native Americans from Brazil

BACKGROUND

Fogo selvagem (FS) is an autoimmune disease that is endemic in certain regions of Brazil and appears to be precipitated by an environmental factor.

OBJECTIVE

Our purpose was to confirm the occurrence and prevalence of FS in a population of Xavante Indians living in an endemic region of central Brazil.

METHODS

Clinical, anthropologic, and immunologic studies were carried out in patients and in normal inhabitants of the Pimentel Barbosa Indian Reservation, Mato Grosso, Brazil.

RESULTS

FS was identified and confirmed in 10 patients from a patient pool of 295 with various skin diseases. The Xavante settlement has a total population of 746. Anti-desmoglein 1 autoantibodies were detected in all patients with FS and were absent from more than 300 serum samples collected from randomly selected unaffected persons.

CONCLUSION

FS is strongly linked to outdoor activities and is largely restricted to immunogenetically predisposed persons. FS appears to have been endemic in certain regions of South America for several centuries.

Diagnosis of dermatitis herpetiformis by an avidin-biotin-peroxidase method

BACKGROUND AND DESIGN

Immunofluorescence detection of stippled IgA in dermal papillae has been considered the gold standard in the diagnosis of dermatitis herpetiformis (DH). We have developed an immunohistochemical technique using the avidin-biotin-peroxidase complex that is equally effective as direct immunofluorescence in detecting IgA. We retrospectively studied 43 paraffin-embedded biopsy specimens obtained from patients with DH and a variety of other diseases for the presence of IgA along the basement membrane zone.

RESULTS

Eleven immunofluorescence-proved cases of DH were found positive for IgA with the avidin-biotin-peroxidase method. One biopsy specimen originally classified as DH was identified and reclassified as linear IgA bullous disease based on the immunoperoxidase findings. All the samples that were positive on direct immunofluorescence were positive with the avidin-biotin-peroxidase method. Control samples of bullous pemphigoid, discoid lupus erythematosus, pemphigus vulgaris, and dermatitis were all negative for IgA deposition.

CONCLUSION

The diagnosis of DH on formalin-fixed tissue is possible with the use of an avidin-biotin-peroxidase method, which is convenient and cost-effective.

Accuracy of indirect immunofluorescence testing in the diagnosis of paraneoplastic pemphigus

BACKGROUND

Paraneoplastic pemphigus (PNP) is an autoimmune disease defined in part by autoantibodies with unique specificity. Initial reports suggested that indirect immunofluorescence with rodent bladder epithelium was highly reliable in detecting these autoantibodies.

OBJECTIVE

We compared the sensitivity and the specificity of indirect immunofluorescence in the diagnosis of PNP in a large number of cases.

METHODS

Indirect immunofluorescence was performed on stratified squamous epithelium of monkey esophagus and mouse tongue, bladder, liver, and myocardium. Sera were obtained from 28 patients with PNP and from 29 control subjects with autoimmune blistering diseases.

RESULTS

The sensitivity of murine bladder as a substrate was 75%, with a specificity of 83%. Indirect immunofluorescence on liver was specific (96.5%) but insensitive (43%). Sensitivity and specificity with myocardium were intermediate.

CONCLUSION

Indirect immunofluorescence on murine bladder epithelium is an adequate screening test for PNP but is negative or indeterminate in as many as one fourth of patients. Negative indirect immunofluorescence does not exclude the diagnosis of PNP, and immunochemical techniques such as immunoprecipitation must be performed.

Treatment with alpha interferon associated with the development of paraneoplastic pemphigus

The use of interferon (INF) is usually considered safe, the major side-effect being a flu-like syndrome. However, with its ability to alter immune responsiveness, INF has been associated with the induction of autoimmune diseases. We report a patient with Waldenström's macroglobulinaemia who developed a generalized blistering eruption after treatment with systemic INF-alpha 2A (INF) for multiple skin cancers. The patient's skin showed histological features, immunofluorescence findings, and immunoprecipitation diagnostic of paraneoplastic pemphigus. Despite aggressive treatment the patient died. In our patient, the use of INF was temporally related to the development of paraneoplastic pemphigus. Although interferon has been shown to induce other autoimmune diseases, to our knowledge this is only the second report of a patient treated with an interferon who subsequently developed a fatal autoimmune blistering disorder. Paraneoplastic pemphigus is a recently described autoimmune bullous disorder with a poor prognosis. The mechanism by which INF triggered the paraneoplastic pemphigus is not known.

Environmental factors influencing the biologic behavior of patterns of pemphigus vulgaris: epidemiologic approach

BACKGROUND

Pemphigus vulgaris is an autoimmune disorder, in which environmental factors seem to play a role, both in the pathogenesis and the activity of the disease. The purpose of the study was to correlate the biologic activity of pemphigus vulgaris with sun exposure and air temperature.

METHODS

An epidemiologic study was carried out, analyzing results of serology, skin involvement, and proportional morbidity rates, related to sun exposure and air temperature. The study was based on retrospective and prospective series of patients. All data were evaluated in a yearly seasonal distribution.

RESULTS

Strong correlations were shown between climatologic data and pemphigus activity in the populations studied.

CONCLUSIONS

Environmental factors have a significant impact on the disease expression. This stresses the necessity of preventive measures against exposure to sun and high temperature.

Atypical pemphigus associated with monoclonal IgA gammopathy

We describe a 60-year-old woman with atypical pemphigus and IgA-lambda monoclonal gammopathy. Histopathologic study of vesiculopustular lesions showed intraepidermal acantholytic and neutrophilic blisters. Direct immunofluorescence revealed intercellular IgG deposition with concurrent deposits of IgA and C3. Indirect immunofluorescence and immunoblotting studies revealed that the patient had circulating IgG anti-intercellular antibodies that recognized the 150 kd desmoglein (pemphigus foliaceus antigen) in bovine desmosome preparation. Immunoblot studies with human epidermal extract showed that the IgG of this patient exclusively reacted with the 140 kd protein (between the 150 kd human desmoglein and the 130 kd human pemphigus vulgaris antigen), the nature of which is currently unknown. The patient also had IgA anti-intercellular autoantibodies, which reacted with the desmoglein in the bovine desmosome sample but did not show any reactivity in human epidermal extract.

Coexistence of pemphigus and bullous pemphigoid

Widespread tense blisters developed on a 60-year-old Japanese man who had been diagnosed with pemphigus 11 years earlier, because of a history of pruritic erythema and erosions on his face, chest, and back, mild supra-basal layer blister formation found in a biopsy specimen, and a positive direct immunofluorescence test showing IgG deposition in the intercellular space. The histological findings showed subepidermal blister, and the immunoblot study detected 180kD bullous pemphigoid antigen. Direct immunofluorescence test revealed intercellular staining for IgG, and indirect immunofluorescence tests repeatedly demonstrated the presence of circulating antibodies to the intercellular space. From these observations, this case suggests the coexistence of pemphigus and bullous pemphigoid.

Paraneoplastic pemphigus with clinical features of erosive lichen planus associated with Castleman's tumor

A patient with Castleman's tumor is reported in whom painful mucosal erosions and a maculopapular eruption developed. Complete remission occurred 1 year after surgical tumor resection. The clinical, histological and immunological features were consistent with the syndrome described as paraneoplastic pemphigus.

Adhesion molecules. I: Keratinocyte-keratinocyte interactions; cadherins and pemphigus

During the last few years, considerable progress has been made in our understanding of the structure and function of cadherins and of the pathophysiology of pemphigus. Cadherins are a multiple gene family of Ca(++)-dependent cell adhesion molecules with a typical single-spanning transmembrane structure. Cadherins have two major subfamilies, classic cadherin and desmosomal cadherin. Classic cadherins, including E-, P-, and N-cadherins, are characterized by a homophilic binding specificity. They localize at adherens junctions and mediate physiologic interaction with the involvement of cytoplasmic anchoring molecules, catenins, and the actin-based cytoskeleton network. Desmosomal cadherins, the desmocollins and desmogleins, localize at desmosomes and are linked to the intermediate keratin filaments network via plakoglobin and desmoplakin. Molecular cloning has demonstrated that the autoantigens of both pemphigus vulgaris and pemphigus foliaceus are members of the desmoglein subfamily of the cadherin supergene family. Thus, pemphigus is characterized as an anti-cadherin autoimmune disease. Furthermore, a baculovirus recombinant protein of pemphigus vulgaris antigen was capable of absorbing out the pathogenic autoantibodies from patients' sera, providing a possibility of antigen-specific therapeutic strategies for pemphigus.

Paraneoplastic pemphigus: the first case report from Japan

Paraneoplastic pemphigus is a rare skin disease characterized by painful mucosal ulcerations and polymorphous skin lesions in association with an underlying neoplasm. A 54-year-old Japanese man, who had received chemotherapy and radiation therapy due to a diagnosis of non-Hodgkin's lymphoma, developed marked stomatitis, conjunctivitis and blisters. Histologic examination showed suprabasal cleft formation with acantholysis and keratinocyte necrosis. Direct immunofluorescence revealed the deposition of IgG at the cell surface of the keratinocytes and C3 at the basement membrane zone. Indirect immunofluorescence on normal human skin and rat bladder sections revealed circulating autoantibodies to the cell surface of both keratinocytes and transitional epithelia. Immunoprecipitation disclosed antibodies reactive to the 250-kD, 230-kD, 210-kD and 170-kD proteins. From these results, a diagnosis of paraneoplastic pemphigus was made. This is the first report of paraneoplastic pemphigus from Japan.

Changes in clinical features, histologic findings, and antigen profiles with development of pemphigus foliaceus from pemphigus vulgaris

BACKGROUND AND DESIGN

Several articles have described patients with pemphigus who showed a transition from pemphigus vulgaris (PV) to pemphigus foliaceus (PF) or vice versa. However, there have been no adequate reports in the literature on the association between transition in disease type and change in autoantibody reactivity against the pemphigus antigens. We investigated the antigen profiles of the serum samples obtained from two patients with pemphigus who were demonstrated to shift from PV to PF with evidence from clinical, histologic, and immunohistologic findings. Western blot technique was performed using normal human epidermal extracts as an antigen source.

RESULTS

The serum samples of both cases at the PV stage reacted with the 130-kd antigen and the serum samples at the PF stage reacted with the 150-kd antigen. Accordingly, the dermatologic, histologic, and immunohistologic findings before and after the transition from PV to PF were clearly related to changes in the serum reactivity with the pemphigus antigens.

CONCLUSIONS

This was the first investigation completely demonstrating changes in antigen profiles at the molecular level consistent with transition from the PV to the PF form of the disease. Moreover, the findings of this study confirmed the existence of a close correlation between the 130- and the 150-kd antigens, with the onset of each form of the disease.

Angiotensin-converting enzyme inhibitor-induced pemphigus: three case reports and literature review

OBJECTIVE

To identify patients examined in the Mayo Clinic Department of Dermatology whose pemphigus was attributable to an angiotensin-converting enzyme inhibitor and to compare these cases with previously reported cases of drug-induced pemphigus.

RESULTS

A retrospective review of medical records revealed two cases of captopril-induced pemphigus and one of enalapril-induced pemphigus. Our patients had substantially increased circulating IgG autoantibodies to intercellular substance, as detected on monkey esophagus substrate.

CONCLUSION

Our findings contrast those of other reports of drug-induced pemphigus in which circulating autoantibodies are implied to be low or absent.