Detection of apoptosis in pemphigus vulgaris by TUNEL technique

BACKGROUND

Pemphigus is part of a group of blistering diseases that affect the skin and mucous membranes. Based on its autoimmune origin, autoantibodies develop in pemphigus that are directed toward cell surface components of keratinocytes. However, some data cannot be explained, such as the lack of a relationship between autoantibody levels and the severity of clinical manifestations, treatment resistance, the presence of inflammatory infiltrates and the potential occurrence of apoptosis as determinants of vesicle formation.

OBJECTIVE

To examine the presence of apoptosis in pemphigus vulgaris by TUNEL technique.

METHODS

In this cross-sectional study, we selected 15 paraffin-embedded tissues from subjects who were diagnosed with pemphigus vulgaris by hematoxylin and eosin staining. The samples were subjected to TUNEL assay and examined under an Olympus BX61 fluorescence microscope. Positivity was categorized dichotomously, and the statistical analysis was performed using the X2 test.

RESULTS

Positivity was observed in basal layer cells in 14 (93.3%) cases. In 13 (86.7%) of the positive cases, we noted espinosum and granular layers that formed the blister roof, and in 12 cases (80%), positive acantholytic cells were observed.

CONCLUSIONS

TUNEL positivity was observed in pemphigus vulgaris, implicating apoptosis in the pathophysiology of this condition, which can help guide the development of apoptotic blockers as therapeutics.

Pemphigus foliaceus exacerbated by radiation, in association with myasthenia gravis

Pemphigus foliaceus (PF) is a sporadic autoimmune blistering disease of unknown etiology. The production of immunoglobulin G4 antibodies against desmoglein-1 is responsible for the clinical manifestation of PF. We present a case of a woman with a recent diagnosis of myasthenia gravis (MG), who was also recently treated with radiation therapy for breast cancer. The clinical exam, supported by biopsy and direct immunofluorescence, were consistent with PF. We present this case to increase the awareness of the potential exacerbation or induction of PF with radiation, and of the association of PF and myasthenia gravis. Only five prior cases of radiation-exacerbated or radiation-induced PF have been reported in the literature to date. Furthermore, the co-existence of the autoimmune entities of myasthenia gravis and PF has been reported in the literature in only 9 cases and was also noted in this patient.

Radiation-induced pemphigus or pemphigoid disease in 3 patients with distinct underlying malignancies

The cutaneous lesions of radiation-induced pemphigus or pemphigoid disease may resemble other skin diseases, including recurrent underlying cancer. We performed a computerized search of Mayo Clinic (Rochester, Minnesota) archives and identified 3 cases of pemphigus or pemphigoid disease that occurred after radiation therapy for breast, cervical, and metastatic malignancies, respectively. In 2 of these patients, the disease was initially confined to the irradiated field but subsequently disseminated to other parts of the patients' bodies, including mucosal surfaces. In all 3 patients, the blistering disease occurred 5 to 14 months after the onset of radiation therapy. All 3 were treated with corticosteroids and demonstrated complete recovery of the skin eruption after radiotherapy was discontinued. Although the precise mechanism of this cutaneous eruption is unknown, clinicians should be alert for this potentially serious complication and evaluate all cutaneous eruptions developing during and after radiotherapy.

Oral Pemphigus Vulgaris: Case Report

BACKGROUND

Pemphigus is a potentially life threatening autoimmune disease that causes blisters and erosions of the skin and the mucous membrane. The epithelial lesions are a result of auto-antibodies that react with desmosomal glycoproteins that are present on the cell surface of the keratinocyte. The autoimmune reaction against these glycoproteins causes a loss of cell to cell adhesion, resulting in the formation of intraepithelial bullae. Eighty to ninety percent of patients with pemphigus vulgaris develop oral lesions and in 60% of cases oral lesions are the first sign. Timely recognition and therapy of oral lesion is critical as it may prevent skin involvement. If treatment is instituted during this time, the disease is easier to control and the chance for an early remission of the disorder is enhanced.

CASE DETAILS

This case report describes the case of a patient who complained of ulcers of the mouth and difficulty in swallowing since 20 days, who was diagnosed as having Pemphigus vulgaris. Due to early diagnosis, lower doses of medication for a shorter period of time could control the disease.

CONCLUSION

Dental professionals must be sufficiently familiar with the clinical manifestations of pemphigus vulgaris to ensure early diagnosis and treatment which in turn determines the prognosis and course of the disease.

Influence of cell dissociation on normal epidermal cells in Hailey-Hailey's disease and Darier's disease

The effects of cell dissociation in HHD and DD on normal outgrown epidermal cells in explant culture were investigated, and the results were obtained as follows: The outgrown epidermal cells from skin fragments of patients with HHD or DD reveal characteristic dissociative behavior in explant culture. This phenomenon is considered to be "acantholysis" at the level of tissue culture. The outgrown epidermal cells from the normal skin fragments can dissociate when they are cultured together with those from patients with HHD or DD. The latter exhibits distinct dissociative behavior. These cell dissociations can be stopped by changing the medium to a new one. These dissociations reappear by decreasing the amount of the medium to a certain low level. The dissociation of outgrown epidermal cells from normal skin fragments occurs on transference of the medium in which the cell dissociations were observed.

Tissue culture of epidermal cells in some acantholytic dermatoses

The explant culture of small skin specimens is a good model of in vivo epidermal growth. In this model epidermal cells are not dislodged and remain in vitro under the influences of the original mesenchyme, at least during early growth. Recently we attempted to grow epidermal cells from the skin lesions of some acantholytic dermatoses (Darier's disease [DD], Hailey-Hailey's disease [HHD], and pemphigus vulgaris [PV]) in explant culture, and we observed the behavior of outgrown epidermal cells for a relatively short time after explantation. The cell outgrowth from the skin of a patient with PV, which seemed to be apparently normal but showed positive Nikolsky's sign, formed a well organized flat sheet 48 to 96 hours after explantation, as seen in cultures of normal human adult skin. In contrast, the outgrown cells from the skin lesions of three patients with DD, as well as those from three patients with HHD, showed a characteristic disorganized outgrowth. They did not form the well-organized flat sheet, but showed a marked cell dissociation and conspicuously increased locomotive ability. These findings seems to clearly exhibit the processes of "acantholysis" in vitro and strongly suggest that the cells from these 2 latter dermatoses have a genetically determined insufficiency or defect in cell adhesion. From these results the authors conclude that the mechanism of cell dissociation in DD and HHD is fundamentally different from that in PV.

Preclinical studies identify non-apoptotic low-level caspase-3 as therapeutic target in pemphigus vulgaris

The majority of pemphigus vulgaris (PV) patients suffer from a live-threatening loss of intercellular adhesion between keratinocytes (acantholysis). The disease is caused by auto-antibodies that bind to desmosomal cadherins desmoglein (Dsg) 3 or Dsg3 and Dsg1 in mucous membranes and skin. A currently unresolved controversy in PV is whether apoptosis is involved in the pathogenic process. The objective of this study was to perform preclinical studies to investigate apoptotic pathway activation in PV pathogenesis with the goal to assess its potential for clinical therapy. For this purpose, we investigated mouse and human skin keratinocyte cultures treated with PV antibodies (the experimental Dsg3 monospecific antibody AK23 or PV patients IgG), PV mouse models (passive transfer of AK23 or PVIgG into adult and neonatal mice) as well as PV patients' biopsies (n=6). A combination of TUNEL assay, analyses of membrane integrity, early apoptotic markers such as cleaved poly-ADP-ribose polymerase (PARP) and the collapse of actin cytoskeleton failed to provide evidence for apoptosis in PV pathogenesis. However, the in vitro and in vivo PV models, allowing to monitor progression of lesion formation, revealed an early, transient and low-level caspase-3 activation. Pharmacological inhibition confirmed the functional implication of caspase-3 in major events in PV such as shedding of Dsg3, keratin retraction, proliferation including c-Myc induction, p38MAPK activation and acantholysis. Together, these data identify low-level caspase-3 activation downstream of disrupted Dsg3 trans- or cis-adhesion as a major event in PV pathogenesis that is non-synonymous with apoptosis and represents, unlike apoptotic components, a promising target for clinical therapy. At a broader level, these results posit that an impairment of adhesive functions in concert with low-level, non-lethal caspase-3 activation can evoke profound cellular changes which may be of relevance for other diseases including cancer.

Pemphigus foliaceus

A 55-year-old woman presented after a four-year history of impetiginized eczema that was distributed over her face, scalp, chest, and back and a recent diagnosis of breast cancer. A skin biopsy specimen for direct immunofluorescence demonstrated intercellular IgG4. Anti-desmoglein 1 and 3 antibodies were present. Indirect immunofluorescence testing was positive on monkey but not rat esophagus. These findings were consistent with a diagnosis of pemphigus foliaceus in association with a malignant condition. After many years of the use of topical glucocorticoids and oral antibiotics, the patient's disease was ultimately managed with methotrexate and a small dose of prednisone. Increasing data supports a role for a steroid-sparing effect of methotrexate in pemphigus vulgaris and likely pemphigus foliaceus.

Pemphigus vulgaris presenting with multiple lesion morphologies

Pemphigus vulgaris is an uncommon intraepidermal blistering disorder that typically presents with flaccid bullae or erosions. We report a patient with pemphigus vulgaris who presented with several unusual clinical features: tense bullae with dependently layered pus, true target lesions coalescing into annular configurations, and diffuse desquamation that initially raised concern for toxic epidermal necrolysis. We discuss the differential diagnosis and implications of these morphological findings.

Gender-based variability in disease presentation in pemphigus vulgaris

Pemphigus vulgaris is a chronic autoimmune blistering disorder of the skin. As with many autoimmune diseases, a female predominance in pemphigus vulgaris is well established. The genetic and physiological basis for this gender bias is not well understood. Moreover, it is unclear whether the affect of gender extends beyond disease susceptibility to influence disease presentation. To address this issue, we performed a comprehensive analysis of 72 male and 125 female pemphigus vulgaris patients across a set of defined demographic (HLA type, ethnicity) and clinical (age at disease onset, anti-desmoglein antibody levels, site of lesions, and history of autoimmune disease) factors. We find that male patients are more likely to present with disease onset before age 40 than females. Additionally, we find that males have increased cutaneous involvement and display greater co-expression of anti-Dsg1 and anti-Dsg3 antibodies, while females tend to have mucosal predominance and stronger personal and family histories of autoimmunity. We do not find any differences in the distribution of HLA type or ethnicity between male and female pemphigus vulgaris patients. Our findings establish that gender does influence disease presentation in pemphigus vulgaris, supporting a role for genetic and hormonal factors in immune dysregulation and perpetuation of the autoimmune phenotype.

Updates on the management of autoimmune blistering diseases

Autoimmune blistering diseases are rare, but potentially debilitating cutaneous disorders characterized by varying degrees of mucosal and cutaneous bullae formation. Topical therapy is appropriate for mild and even some moderate disease activity, but systemic treatment can be considered for more extensive involvement. Corticosteroids remain the first-line systemic therapy for patients with moderate to severe bullous pemphigoid and pemphigus vulgaris. While the use of systemic steroids has dramatically reduced mortality from these two autoimmune blistering disorders, treatment is also associated with multiple side effects, especially when used long-term. Steroid sparing agents, therefore, are invaluable in inducing long-term remission while minimizing steroid associated side effects. Treatment must be tailored to the individual patient's condition, and several other factors must be carefully considered in choosing appropriate therapy: 1) diagnosis, 2) severity of the condition and body site affected, 3) presence of comorbidities, and 4) ability to tolerate systemic therapy.

The expanding spectrum of IgA pemphigus: a case report and review of the literature

IgA pemphigus (IGAP) is a rare, distinct variant of pemphigus, currently classified, depending upon the histological features, immunofluorescence staining pattern and autoantibody profile, into two types: subcorneal pustular dermatosis (SPD) and intraepidermal neutrophilic IgA dermatosis. In a patient with a widespread blistering disease of the skin resembling SPD-type IGAP, we demonstrate the coexistence of IgA reactivity to both epidermal (desmocollins 2 and 3) and basement membrane-associated (BP180) proteins, suggesting the coexistence of atypical IGAP and linear IgA bullous dermatosis, respectively. This case, together with 20 previous reports of atypical IGAP, underscores the limitations of current classification schemes. Therefore, we suggest reclassifying these cases under the general term 'IGAP spectrum'.

A Case of Herpetiform Pemphigus with Anti-Desmoglein 3 IgG Autoantibodies

Herpetiform pemphigus (HP) is a rare variant of pemphigus characterized by a unique clinical phenotype of erythematous or urticarial plaques and vesicles that present in a herpetiform arrangement. Most HP cases have circulating anti-desmoglein 1 (Dsg1) IgG autoantibodies, but some HP cases have anti-desmoglein 3 (Dsg3) IgG. A 92-year-old Japanese woman presented with severely pruritic annular erythema and vesicles in a herpetiform arrangement on the trunk. No oral mucosal lesions were present. Histopathologically, these vesicles showed eosinophilic spongiosis as well as suprabasilar acantholysis. Direct immunofluorescence showed in vivo IgG deposition on keratinocyte cell surfaces, and indirect immunofluorescence showed circulating IgG autoantibodies against keratinocyte cell surfaces at a titer of 1:30. Enzyme-linked immunosorbent assay using recombinant Dsg1 and Dsg3 revealed the presence of anti-Dsg3 IgG but no anti-Dsg1 IgG autoantibodies. The lack of oral mucosal involvement and the unique clinical features favored the diagnosis of HP. It remains to be clarified why the anti-Dsg3 IgG autoantibodies in this patient induced this unique features of HP, rather than the mucosal dominant type of pemphigus vulgaris.

Paraneoplastic Pemphigus Associated with Pelvic Inflammatory Fibrosarcoma: A Case Report

A 36-year-old African-American woman presented with an extensive stomatitis and pigmented cutaneous macules on the neck, axillae and hands. Subsequently she developed violaceus papules on the dorsa of the hands, histologically consistent with an interface dermatitis. After 18 months of progressive disease, paraneoplastic pemphigus was suspected and a search for an underlying neoplasm was initiated. An exploratory laparotomy revealed a pelvic mass and the histologic examination showed an inflammatory fibrosarcoma. The evidence of acantholysis on new cutaneous lesions and the positivity of indirect immunofluorescence with rodent urinary bladder epithelium reinforced the diagnostic criteria for paraneoplastic pemphigus, which is confirmed by the identification of strong protein bands at 210, 190 and 170 kd by immunoprecipitation. Paraneoplastic pemphigus should be considered when investigating atypical mucocutaneous manifestations of pemphigus vulgaris and lichen planus. Diagnostic screening for paraneoplastic pemphigus and a search for an underlying tumor should be performed.

Two Brazilian Cases of IgA Pemphigus

IgA pemphigus is a rare, neutrophilic, acantholytic skin disorder with approximately 70 cases described in the literature. We report two patients with the subcorneal pustular dermatosis (SPD) type of IgA pemphigus. Initially, both patients were misdiagnosed as subcorneal pustular dermatosis of Sneddon and Wilkinson. The correct diagnosis was only made after detecting intercellular IgA depositions in the epidermis by direct immunofluorescence. Immunoblotting (IB) of normal human epidermal extracts, performed on both sera, was negative for Dsg 1, Dsg 3, BP 230, BP 180, 210 kDa envoplakin, and 190 kDa periplakin. ELISA for desmogleins (Dsg 1 and Dsg 3) showed that neither of the cases had IgA antibodies to Dsg. The c-DNA transfection test for desmocollins (Dsc) revealed that the IgA antibodies of both patients reacted with desmocollin 1. This result supports the hypothesis that the autoantigen in SPD type IgA pemphigus is desmocollin 1.

Pemphigus in Korea: Clinical Manifestations and Treatment Protocol

Pemphigus, a rare, chronic blistering disease of the skin and mucous membranes with severe morbidity and occasional mortality, is the most common autoimmune bullous disease in Korea. The purpose of this study was to evaluate the clinical features and propose a treatment strategy for patients with pemphigus. A retrospective analysis was conducted of 51 pemphigus patients seen between 1993 and 2001. Pemphigus vulgaris (PV) was the most common type with 32 cases, followed by 19 cases of pemphigus foliaceus (PF). The male to female ratio was 1:1.3, with females predominating, particularly among PV patients (PV, 1:1.5; PF, 1:1.1). The average ages at onset of PV and PF were 44.3 and 51.0 years old, respectively. Mucosal involvement was noted in 27 cases (84.4%) of PV but in only 3 cases (15.8%) of PF. Most patients initially received relatively low to intermediate doses (0.3-1.0 mg/kg/day) of prednisolone, and 23 (71.9%) PV patients and 10 (52.6%) PF patients also received immunosuppressive agents. Oral prednisolone and azathioprine (100 mg/day) formed the mainstay of treatment for our patients (47.1%). At the time of writing, 25.5% (13/51) of patients are in complete remission, and 72.5% (37/51) are undergoing maintenance therapy. One patient died due to sepsis during the treatment. For the treatment of pemphigus, a course of the lowest possible corticosteroid dosage in combination with immunosuppressive agents appears to be effective and less toxic than a high corticosteroid dosage.

[Pemphigus in pregnancy. A case report and literature review]

Pemphigus vulgaris is a bullous, autoimmune, mucocutaneous and potentially fatal disease. Association between pemphigus vulgaris and pregnancy is little frequent. Evolution of this autoimmune disease is different, because of the hormone and immunological disorders related to pregnancy. Adverse effects on fetus should be taken into account, by drugs administered to the mother and by the transference of antibodies by transplacentary route. This paper reports the case of a 21-year-old female patient with diagnosis of pemphigus vulgaris since 14 years old, who assisted to consultation due to a pregnancy of three-months and exacerbation of the disease.

Histopathology of the nail unit

In this report, we review several inflammatory infectious and tumoral conditions of the nail unit. We emphasize the anatomic peculiarities of such pathologies of the nail unit and provide some required diagnostic criteria.