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Bogdanski E, Viveiros MD, Kaffenberger J. Frequency of infections during rituximab treatment of autoimmune blistering diseases. Arch Dermatol Res 2024; 316:136. [PMID: 38676739 DOI: 10.1007/s00403-024-02865-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 02/21/2024] [Accepted: 04/07/2024] [Indexed: 04/29/2024]
Abstract
This study investigates the frequency of infections in autoimmune blistering disease (AIBD) patients treated with rituximab and evaluates the difference in infectious complications in patients on concomitant antibiotic and/or antiviral prophylaxis. The study retrospectively reviewed 43 AIBD patients who received rituximab over a five-year interval. The patients were categorized based on prophylaxis type (antibiotic, antiviral, or both) and concomitant immunosuppression status, which we defined as treatment with an immunosuppressive medication during the time frame they were given Rituximab. Our findings suggest that concomitant immunosuppression alongside rituximab did not significantly increase the risk of developing infectious complications compared to rituximab monotherapy. Results revealed that 34.4% of patients with concomitant immunosuppression had a secondary bacterial infection, defined as bacterial complications requiring hospitalization, consistent with prior studies. Moreover, antibiotic prophylaxis did not significantly reduce infection risk in patients on rituximab, with 45.1% of these patients experiencing bacterial complications. There was an absence of pneumocystis pneumonia in the study population. Despite the small sample size and limited timeline, this study suggests that antibiotic prophylaxis may not significantly mitigate the risk of infections in AIBD patients receiving rituximab, and the risk of infection with concomitant immunosuppression with rituximab requires additional investigation for definitive causal risk.
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Affiliation(s)
- Emily Bogdanski
- College of Medicine, The Ohio State University, 370 W 9th Ave, Columbus, OH, 43210, USA
| | - Matthew D Viveiros
- College of Medicine, The Ohio State University, 370 W 9th Ave, Columbus, OH, 43210, USA
| | - Jessica Kaffenberger
- Department of Dermatology, The Ohio State University Wexner Medical Center, 540 Officenter Place, Suite 240, Gahanna, OH, 43230, USA.
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2
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Caplan AS, Mecoli CA, Micheletti RG. Prophylaxis Against Pneumocystis Pneumonia. JAMA 2023; 330:1908-1909. [PMID: 37988097 DOI: 10.1001/jama.2023.18862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2023]
Affiliation(s)
- Avrom S Caplan
- Ronald O. Perelman Department of Dermatology, NYU Grossman School of Medicine, New York, New York
| | - Christopher A Mecoli
- Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Robert G Micheletti
- Departments of Dermatology and Medicine, University of Pennsylvania, Philadelphia
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3
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Hsu HC, Huang PW, Cho YT, Chu CY. Cotrimoxazole as a Preventative Intervention for Pneumocystis Pneumonia in Pemphigus Patients Treated with Rituximab: A Retrospective Study. Dermatol Ther (Heidelb) 2023:10.1007/s13555-023-00953-9. [PMID: 37322166 DOI: 10.1007/s13555-023-00953-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 05/30/2023] [Indexed: 06/17/2023] Open
Abstract
INTRODUCTION Pneumocystis jirovecii pneumonia (PJP) is a severe, life-threatening complication in patients treated with rituximab. However, there is no consensus on the primary prophylaxis for it in rituximab-treated pemphigus patients. Therefore, we sought to investigate the prophylactic efficacy and safety profile of cotrimoxazole for reducing the risk of developing PJP in pemphigus patients receiving rituximab. METHODS This single-center retrospective study investigated 148 pemphigus patients undergoing a first cycle of rituximab between 2008 and 2021 at a tertiary referral center in northern Taiwan. Patients were divided into the prophylaxis group (N = 113) and the control group (N = 35) according to whether or not cotrimoxazole was administered. The primary outcome was the 1-year incidence of PJP in the two groups, while the secondary outcome was the incidence of cotrimoxazole-related adverse events. RESULTS Of the 148 patients enrolled in this study, three patients, all in the control group, developed PJP during the 1-year follow-up. The incidence of PJP (8.6%) in the control group was significantly higher than that in the prophylaxis group (0%) (p = 0.012). The incidence of cotrimoxazole-related adverse events was 2.7%, and none of the cases were associated with life-threatening conditions. In addition, the cumulative prednisolone dose was associated with a trend of a higher risk of PJP (p = 0.0483). CONCLUSIONS Prophylactic cotrimoxazole significantly reduces the risk of PJP in a certain high-risk population and has a tolerable safety profile.
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Affiliation(s)
- Hao-Chen Hsu
- Department of Dermatology, National Taiwan University Hospital and National Taiwan University College of Medicine, No. 7, Chung-Shan South Road, Taipei, Taiwan
| | - Po-Wei Huang
- Department of Dermatology, National Taiwan University Hospital and National Taiwan University College of Medicine, No. 7, Chung-Shan South Road, Taipei, Taiwan
- Department of Surgery and Section of Dermatology, National Taiwan University Cancer Center, Taipei, Taiwan
| | - Yung-Tsu Cho
- Department of Dermatology, National Taiwan University Hospital and National Taiwan University College of Medicine, No. 7, Chung-Shan South Road, Taipei, Taiwan
| | - Chia-Yu Chu
- Department of Dermatology, National Taiwan University Hospital and National Taiwan University College of Medicine, No. 7, Chung-Shan South Road, Taipei, Taiwan.
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4
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Qiu T, Li Y, Gong X, Zhou J, Yang K, Zhang X, Zhang Z, Lan Y, Hu F, Peng Q, Zhang Y, Kong F, Chen S, Ji Y. Oral antibiotic prophylaxis for infection in patients with vascular anomalies receiving sirolimus treatment: a multicenter retrospective study. Orphanet J Rare Dis 2023; 18:121. [PMID: 37221564 DOI: 10.1186/s13023-023-02740-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 05/18/2023] [Indexed: 05/25/2023] Open
Abstract
OBJECTIVES Patients with vascular anomalies (VAs) who receive oral sirolimus may be at high risk of infectious complications. Antibiotic prophylaxis with trimethoprim-sulfamethoxazole (TMP-SMZ) has been advocated. However, there have been few evidence-based analyses on this topic. This study assessed the effect of prophylactic TMP-SMZ on the incidence of infections in VA patients receiving sirolimus monotherapy. METHODS A retrospective, multicenter chart review was performed on all VA patients receiving sirolimus treatment from August, 2013 to January, 2021. RESULTS Before January 2017, 112 patients were treated with sirolimus without antibiotic prophylaxis. In the subsequent period, 195 patients were treated with TMP-SMZ for at least 12 months during sirolimus therapy. The percentage of patients with at least one serious infection during the initial 12 months of sirolimus treatment did not differ between the groups (difference, 1.1%; 95% CI - 7.0-8.0%). We observed no difference in the incidence of individual infection or total adverse events between the groups. The rate of sirolimus discontinuation due to adverse events did not differ significantly between groups. CONCLUSIONS We demonstrated that prophylactic TMP-SMZ does not decrease the incidence of infection or improve tolerance in VA patients receiving sirolimus monotherapy.
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Affiliation(s)
- Tong Qiu
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, 610041, China
- Med-X Center for Informatics, Sichuan University, Chengdu, 610041, China
| | - Yanan Li
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, 610041, China
- Med-X Center for Informatics, Sichuan University, Chengdu, 610041, China
| | - Xue Gong
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Jiangyuan Zhou
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Kaiying Yang
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Xuepeng Zhang
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Zixin Zhang
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Yuru Lan
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Fan Hu
- Department of Vascular and Interventional Radiology, West China Second University Hospital, Sichuan University, Chengdu, 610041, China
| | - Qiang Peng
- Department of Pediatric Surgery, Chengdu Women and Children's Central Hospital, Chengdu, 610031, China
| | - Yongbo Zhang
- Department of Pediatric Surgery, Chengdu Women and Children's Central Hospital, Chengdu, 610031, China
| | - Feiteng Kong
- Department of Pediatric Surgery, Sichuan Provincial Maternity and Child Health Care Hospital, Chengdu, 610045, China
| | - Siyuan Chen
- Pediatric Intensive Care Unit, Department of Critical Care Medicine, West China Hospital of Sichuan University, 37# Guo-Xue-Xiang, Chengdu, 610041, China.
| | - Yi Ji
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, 610041, China.
- Med-X Center for Informatics, Sichuan University, Chengdu, 610041, China.
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5
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Rosi-Schumacher M, Baker J, Waris J, Seiffert-Sinha K, Sinha AA. Worldwide epidemiologic factors in pemphigus vulgaris and bullous pemphigoid. Front Immunol 2023; 14:1159351. [PMID: 37180132 PMCID: PMC10166872 DOI: 10.3389/fimmu.2023.1159351] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Accepted: 04/03/2023] [Indexed: 05/15/2023] Open
Abstract
Autoimmune blistering diseases such as bullous pemphigoid (BP) and pemphigus vulgaris (PV) are complex, multifactorial, and polygenic diseases, whose exact pathogenesis is difficult to pinpoint. Research aimed at elucidating the associated epidemiologic risk factors of these two diseases has been hampered by their rare disease status. Further, a lack of centralization and standardization of available data makes the practical application of this information challenging. In order to collate and clarify the available literature we comprehensively reviewed 61 PV articles from 37 different countries and 35 BP articles from 16 different countries addressing a range of disease relevant clinical parameters including age of onset, sex, incidence, prevalence, and HLA allele association. The reported incidence of PV ranged from 0.098 to 5 patients per 100,000 people, while BP ranged from 0.21 to 7.63 patients per 100,000. Prevalence of PV ranged from 0.38 to 30 per 100,000 people and BP ranged from 1.46 to 47.99 per 100,000. The mean age of onset in patients ranged from 36.5 to 71 years for PV and 64 to 82.6 years for BP. Female-to-male ratios ranged from 0.46 to 4.4 in PV and 1.01 to 5.1 in BP. Our analysis provides support for the reported linkage disequilibrium of HLA DRB1*0402 (an allele previously shown to be associated with PV) and DQB1*0302 alleles in Europe, North America, and South America. Our data also highlight that HLA DQB1*0503 (also known to be associated with PV) appears in linkage disequilibrium with DRB1*1404 and DRB1*1401, mainly in Europe, the Middle East, and Asian countries. The HLA DRB1*0804 allele was only associated with PV in patients of Brazilian and Egyptian descent. Only two HLA alleles were reported as associated with BP more than twice in our review, DQB1*0301 and DQA1*0505. Collectively, our findings provide detailed insights into the variation of disease parameters relevant to PV and BP that can be expected to inform future work aimed at unraveling the complex pathogenesis of these conditions across the globe.
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Affiliation(s)
| | | | | | | | - Animesh A. Sinha
- Department of Dermatology, University at Buffalo, Buffalo, NY, United States
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6
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Varghese JA, Guhan S, Zheng L. Emerging Fungal Infections and Cutaneous Manifestations in Immunosuppressed Patients. CURRENT DERMATOLOGY REPORTS 2023. [DOI: 10.1007/s13671-023-00386-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
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7
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Retrospective analysis of risks and benefits of trimethoprim/sulfamethoxazole as prophylaxis for Pneumocystis jiroveci pneumonia in patients with dermatologic disease. J Am Acad Dermatol 2023:S0190-9622(23)00194-9. [PMID: 36796726 DOI: 10.1016/j.jaad.2023.01.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 12/07/2022] [Accepted: 01/15/2023] [Indexed: 02/17/2023]
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Lugat A, Lasolle H, François M, Benhenda N, Bricaire L, Cornu E, Cristante J, Gitton A, Hadoux J, Kerlan V, Le Bras M, Mezzaroba V, Puerto M, Storey C, Ouzounian S, Donadille B, Raverot G, Drui D, Haissaguerre M. Pneumocystis pneumonia in patients with Cushing's syndrome: A French multicenter retrospective study. ANNALES D'ENDOCRINOLOGIE 2023; 84:37-44. [PMID: 36183804 DOI: 10.1016/j.ando.2022.09.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 09/02/2022] [Accepted: 09/05/2022] [Indexed: 10/14/2022]
Abstract
OBJECTIVE Pneumocystis pneumonia (PcP) is an opportunistic infection occurring in immunocompromised patients. Cushing's syndrome (CS) impairs the immune system, and several authors have reported PcP in patients with CS. The present study aimed to characterize PcP occurring in a CS context and its management in French tertiary centers, in order to highlight the similarities in clinical presentation and treatment according to whether prophylaxis is implemented or not. METHODS This was a multicenter retrospective study conducted in several French University Hospitals and Cancer Centers. Patients with PcP and confirmed CS regardless of etiology were included. We excluded patients with other known causes of acquired immunodeficiency with increased risk of PcP. RESULTS Twenty-five patients were included. CS etiology was neoplastic in 84.0% of cases. CS clinical presentation associated predominant catabolic signs (76.0%), hypokalemia (91.7%) and lymphopenia (89.5%). CS was intense in most patients, with mean plasma cortisol levels at diagnosis of 2.424±1.102nmol/L and urinary free cortisol>10× the upper limit of normal in 85.0%. In all patients, PcP onset followed introduction of cortisol blockers, at a median 5.5 days. Patients were treated with 1 to 3 cortisol blockers, mainly metyrapone (88%), which significatively lowered plasma cortisol levels to 667±541nmol/L at the onset of PcP (P<0.001). PcP occurred in 7 patients despite prophylaxis. Finally, 60.0% patients were admitted to intensive care, and 20.0% died of PcP. CONCLUSION High mortality in patients with PcP implies that clinicians should be better informed about this rare infectious complication. Prophylaxis remains controversial, requiring comparative studies.
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Affiliation(s)
- Alexandre Lugat
- Medical Oncology Department, CHU de Nantes, 44000 Nantes, France; Nantes Université, Inserm 1307, CNRS 6075, Université d'Angers, CRCI2NA, Nantes, France
| | - Hélène Lasolle
- Endocrinology Department, Reference Centre for Rare Pituitary Diseases HYPO, "Groupement Hospitalier Est", Hospices Civils de Lyon, Bron, France; Lyon 1 University, Villeurbanne, France; INSERM U1052, CNRC UMR5286, Cancer Research Centre of Lyon (CRLC), Lyon, France
| | - Maud François
- Endocrinology, Diabetology and Nutrition, Centre Hospitalier Universitaire de Reims, Reims, France
| | | | - Léopoldine Bricaire
- Department of Endocrinology and National Reference Center for Rare Adrenal Disorders, Hôpital Cochin, Assistance publique-Hôpitaux de Paris, 75014 Paris, France
| | - Erika Cornu
- Hypertension Unit, Hôpital Européen George-Pompidou, Paris, France
| | | | - Anne Gitton
- Endocrinology, Diabetology and Nutrition, Centre Hospitalier Universitaire de Reims, Reims, France
| | - Julien Hadoux
- Department of Endocrine Oncology and Nuclear Medicine, Gustave-Roussy and University Paris-Saclay, Villejuif, France
| | - Véronique Kerlan
- Department of Endocrinology, Diabetes and Metabolic Diseases, Hôpital de la Cavale-Blanche, Brest, France
| | - Maëlle Le Bras
- Department of Endocrinology, Diabetology and Nutrition, l'institut du thorax, CHU Nantes, Nantes, France
| | - Vincent Mezzaroba
- Endocrinology Department, Reference Centre for Rare Pituitary Diseases HYPO, "Groupement Hospitalier Est", Hospices Civils de Lyon, Bron, France; Lyon 1 University, Villeurbanne, France; INSERM U1052, CNRC UMR5286, Cancer Research Centre of Lyon (CRLC), Lyon, France
| | - Marie Puerto
- Department of Endocrinology, Haut Levêque University Hospital, Bordeaux, France
| | - Caroline Storey
- Department of Paediatric Endocrinology and Diabetology, Robert-Debré Teaching Hospital, Assistance publique-Hôpitaux de Paris, Paris, France
| | - Sophie Ouzounian
- Endocrinology Department, Saint-Antoine Hospital, Sorbonne Université, Assistance publique-Hôpitaux de Paris, Paris, France
| | - Bruno Donadille
- Endocrinology Department, Saint-Antoine Hospital, Sorbonne Université, Assistance publique-Hôpitaux de Paris, Paris, France
| | - Gérald Raverot
- Endocrinology Department, Reference Centre for Rare Pituitary Diseases HYPO, "Groupement Hospitalier Est", Hospices Civils de Lyon, Bron, France; Lyon 1 University, Villeurbanne, France; INSERM U1052, CNRC UMR5286, Cancer Research Centre of Lyon (CRLC), Lyon, France
| | - Delphine Drui
- Department of Endocrinology, Diabetology and Nutrition, l'institut du thorax, CHU Nantes, Nantes, France
| | - Magalie Haissaguerre
- Department of Endocrinology, Haut Levêque University Hospital, Bordeaux, France.
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9
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Pemphigus for the Inpatient Dermatologist. CURRENT DERMATOLOGY REPORTS 2022. [DOI: 10.1007/s13671-022-00369-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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10
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Borojevic B, Johns E, Raju N, Sycamnias LA. Pneumocystis pneumonia with respiratory failure in a HIV-negative patient following short course of low-dose to moderate-dose prednisolone for a dermatological condition. BMJ Case Rep 2022; 15:e249346. [PMID: 35675962 PMCID: PMC9185496 DOI: 10.1136/bcr-2022-249346] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/30/2022] [Indexed: 12/15/2022] Open
Abstract
A woman in her 80s was admitted with 5 days of progressive dyspnoea and hypoxic respiratory failure, in the setting of receiving a 3-week course of low-dose to moderate-dose prednisolone for a pruritic skin rash. Her medical history was not significant for major medical comorbidities or any other clear risk factors for secondary immunosuppression apart from advanced age. CT revealed widespread small-airway and parenchymal disease with ground-glass opacities consistent with atypical respiratory infection. Sputum PCR confirmed Pneumocystis jirovecii She was diagnosed with Pneumocystis jirovecii pneumonia (PJP) in the context of her clinical presentation, radiological features and PCR result. Her HIV status was negative. The patient was treated with 4 weeks of trimethoprim-sulfamethoxazole and 3 weeks of adjunctive prednisolone. She initially required high-dependency unit support with non-invasive ventilation. In this case report, we review the literature regarding PJP in the dermatology setting.
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Affiliation(s)
- Branko Borojevic
- General Medicine, Austin Health, Heidelberg, Victoria, Australia
| | - Esther Johns
- General Medicine, Austin Health, Heidelberg, Victoria, Australia
| | - Nihal Raju
- General Medicine, Austin Health, Heidelberg, Victoria, Australia
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11
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Tsai YJ, Cho YT, Chu CY. Clinical Effectiveness and Safety of Initial Combination Therapy with Corticosteroids and Rituximab in Bullous Pemphigoid: A Retrospective Cohort Study. Am J Clin Dermatol 2022; 23:571-585. [PMID: 35579853 DOI: 10.1007/s40257-022-00688-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Rituximab is a potential initial adjuvant therapy for bullous pemphigoid, yet clinical experience is scarce. OBJECTIVE We aimed to examine the clinical outcomes and safety of initial combination therapy with systemic corticosteroids and adjuvant rituximab for the treatment of bullous pemphigoid. METHODS A retrospective cohort study was performed on 84 patients with bullous pemphigoid, who received systemic corticosteroids with or without initial adjuvant rituximab therapy (defined as rituximab use within 12 weeks after initiation of systemic corticosteroids). RESULTS Among the 84 patients included (37 received systemic corticosteroids with rituximab and 47 were treated with systemic corticosteroids without rituximab), the median time to complete remission on minimal therapy or off therapy was 215 days (95% confidence interval 176.9-253.1) in patients receiving rituximab vs 529 days (95% confidence interval 338.6-719.4) in those not receiving rituximab. A Cox regression analysis showed an increased probability of reaching complete remission on minimal therapy or off therapy with the combined therapy (hazard ratio = 2.28 [1.28-4.07], p = 0.005) after age, Bullous Pemphigoid Disease Activity Index score, and underlying diseases were controlled. In multivariate logistic/linear regressions, initial adjuvant rituximab therapy was associated with a higher complete remission rate (odds ratio = 6.63 [2.09-21.03]) and lower cumulative prednisolone (mg)/body weight (kg) (B = -24.86 [-44.06 to -8.29]) within 48 weeks. Risk of hospitalization for infection was not elevated in the group treated with adjuvant rituximab. CONCLUSIONS Rituximab use as adjuvant therapy within 12 weeks after initiation of systemic corticosteroids was associated with a faster and higher rate of achieving complete remission on minimal therapy or off therapy, as well as a significant corticosteroid-sparing effect and a comparable safety profile in this retrospective study. Hence, initial combination therapy with corticosteroids and adjuvant rituximab could serve as an effective treatment option for bullous pemphigoid, but this requires confirmation in randomized controlled studies.
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Affiliation(s)
- Yun-Ju Tsai
- Department of Dermatology, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan
- Department of Dermatology, National Taiwan University Hospital and National Taiwan University College of Medicine, 15F, No. 7, Chung-Shan South Road, Taipei, Taiwan
| | - Yung-Tsu Cho
- Department of Dermatology, National Taiwan University Hospital and National Taiwan University College of Medicine, 15F, No. 7, Chung-Shan South Road, Taipei, Taiwan
| | - Chia-Yu Chu
- Department of Dermatology, National Taiwan University Hospital and National Taiwan University College of Medicine, 15F, No. 7, Chung-Shan South Road, Taipei, Taiwan.
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12
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Faraji H, Daneshpazhooh M, Ehsani AH, Mahmoudi H, Tavakolpour S, Aryanian Z, Aslani S, Khodaveisi H, Balighi K. Evaluating the risk-to-benefit ratio of using cotrimoxazole as a pneumocystis pneumonia preventative intervention among pemphigus patients treated with rituximab: A retrospective study with 494 patients. Dermatol Ther 2021; 35:e15257. [PMID: 34890103 DOI: 10.1111/dth.15257] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 11/27/2021] [Accepted: 12/04/2021] [Indexed: 11/28/2022]
Abstract
Rituximab is widely used as the first-line treatment for pemphigus patients. Since it depletes the B cells, it increases the risk of infections. Here, we evaluated the prophylactic efficacy of cotrimoxazole in decreasing the risk of pneumocystis pneumonia (PCP) infection in the pemphigus patients treated with rituximab. The medical records of confirmed pemphigus patients receiving rituximab were evaluated in two groups; those who received cotrimoxazole as a prophylactic after rituximab and patients who only received rituximab without any prophylaxis. The occurrence of PCP infection was determined in each group and compared. Medical records of 494 patients, including 301 women and 193 men, with the mean age of 46.74 years were analyzed. The phenotypes of the disease were mucocutaneous (n = 364), mucosal (n = 88), and cutaneous (n = 42). Among them, 235 cases had received cotrimoxazole as a prophylaxis and 259 patients did not. The incidence of PCP in total patients was 2 (0.4%), one in each group. Accordingly, no significant difference was observed in the incidence of PCP between two groups (p = 0.84). Also, no cotrimoxazole-related side effect was observed in the treated group. It seems that due to the low incidence of PCP in pemphigus patients treated with rituximab, prophylactic cotrimoxazole therapy is not necessary and it only increases the overall therapy cost and might cause cotrimoxazole-related adverse effects in some patients. However, regarding its probable beneficial effect in patients with long-term history of immunosuppressive therapy, more studies are required.
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Affiliation(s)
- Hannaneh Faraji
- Department of Dermatology, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran.,Autoimmune Bullous Diseases Research Center, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Daneshpazhooh
- Department of Dermatology, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran.,Autoimmune Bullous Diseases Research Center, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Amir Hooshang Ehsani
- Department of Dermatology, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran.,Autoimmune Bullous Diseases Research Center, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Hamidreza Mahmoudi
- Department of Dermatology, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran.,Autoimmune Bullous Diseases Research Center, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Soheil Tavakolpour
- Department of Dermatology, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran.,Autoimmune Bullous Diseases Research Center, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran.,Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Zeinab Aryanian
- Department of Dermatology, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran.,Autoimmune Bullous Diseases Research Center, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran.,Department of Dermatology, Babol University of Medical Sciences, Babol, Iran
| | - Saeed Aslani
- Department of Immunology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Hamidreza Khodaveisi
- Department of Dermatology, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran.,Autoimmune Bullous Diseases Research Center, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Kamran Balighi
- Department of Dermatology, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran.,Autoimmune Bullous Diseases Research Center, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran
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13
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Malik AM, Tupchong S, Huang S, Are A, Hsu S, Motaparthi K. An Updated Review of Pemphigus Diseases. Medicina (B Aires) 2021; 57:medicina57101080. [PMID: 34684117 PMCID: PMC8540565 DOI: 10.3390/medicina57101080] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 09/26/2021] [Accepted: 09/28/2021] [Indexed: 01/19/2023] Open
Abstract
Clinicians may encounter a variety of skin conditions that present with vesiculobullous lesions in their everyday practice. Pemphigus vulgaris, pemphigus foliaceus, IgA pemphigus, and paraneoplastic pemphigus represent the spectrum of autoimmune bullous dermatoses of the pemphigus family. The pemphigus family of diseases is characterized by significant morbidity and mortality. Considering the risks associated with a delayed diagnosis or misdiagnosis and the potential for overlap in clinical features and treatment, evaluation for suspected pemphigus disease often requires thorough clinical assessment and laboratory testing. Diagnosis is focused on individual biopsies for histopathology and direct immunofluorescence. Additional laboratory methods used for diagnosis include indirect immunofluorescence and enzyme-linked immunosorbent assay. Recent advancements, including anti-CD20 therapy, have improved the efficacy and reduced the morbidity of pemphigus treatment. This contribution presents updates on the pathophysiology, clinical features, diagnostic work-up, and medical management of pemphigus. Improved strategies for diagnosis and clinical assessment are reviewed, and newer treatment options are discussed.
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Affiliation(s)
- Ali M. Malik
- College of Medicine, University of Florida, Gainesville, FL 32606, USA; (A.M.M.); (A.A.)
| | - Sarah Tupchong
- Lewis Katz School of Medicine, Temple University, Philadelphia, PA 19140, USA;
| | - Simo Huang
- Department of Dermatology, Lewis Katz School of Medicine, Temple University, Philadelphia, PA 19140, USA; (S.H.); (S.H.)
| | - Abhirup Are
- College of Medicine, University of Florida, Gainesville, FL 32606, USA; (A.M.M.); (A.A.)
| | - Sylvia Hsu
- Department of Dermatology, Lewis Katz School of Medicine, Temple University, Philadelphia, PA 19140, USA; (S.H.); (S.H.)
| | - Kiran Motaparthi
- Department of Dermatology, College of Medicine, University of Florida, Gainesville, FL 32606, USA
- Correspondence:
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14
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Tabassum S, Rahman A, Nasir N. Response to letter by Payal M. Patel and Kyle T. Amber on "Pemphigus management guidelines: A life-saving perspective". J Am Acad Dermatol 2021; 85:e291-e292. [PMID: 34271031 DOI: 10.1016/j.jaad.2021.06.888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 06/24/2021] [Accepted: 06/30/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Saadia Tabassum
- Department of Medicine, The Aga Khan University Hospital, Karachi, Pakistan.
| | - Atiya Rahman
- Department of Dermatology, Combined Military Hospital (CMH) & CMH Lahore Medical College, Lahore Cantonment, Pakistan
| | - Nosheen Nasir
- Section of Adult Infectious Diseases, Department of Medicine, The Aga Khan University Hospital, Karachi, Pakistan
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15
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The risk of Pneumocystis pneumonia in patients of autoimmune blistering disease-reply to letter entitled "Pemphigus management guidelines: A life-saving perspective". J Am Acad Dermatol 2021; 85:e289. [PMID: 34271032 DOI: 10.1016/j.jaad.2021.04.106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 04/19/2021] [Accepted: 04/20/2021] [Indexed: 11/22/2022]
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16
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Kushner CJ, Wang S, Tovanabutra N, Tsai DE, Werth VP, Payne AS. Factors Associated With Complete Remission After Rituximab Therapy for Pemphigus. JAMA Dermatol 2021; 155:1404-1409. [PMID: 31642878 DOI: 10.1001/jamadermatol.2019.3236] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Importance Rituximab has emerged as a front-line therapy for pemphigus, but prognostic factors for achieving complete remission off therapy (CROT) with oral systemic agents remain unknown. Objectives To describe rates of CROT and relapse and identify prognostic factors for achieving CROT after rituximab therapy for pemphigus. Design, Setting, and Participants A single-center, retrospective, cohort study was conducted at the University of Pennsylvania including 112 patients with pemphigus treated with rituximab with at least 12 months' clinical follow-up after the start of rituximab therapy. Multivariate regression analysis of factors predictive of CROT and Kaplan-Meier analysis of disease relapse were conducted. The study included patients treated with rituximab from March 15, 2005, until December 19, 2016. Data analysis was performed from December 2017 to June 2018. Main Outcomes and Measures The primary study outcome was CROT after 1 cycle. Secondary study outcomes included rate of CROT or the composite end point of CROT or complete remission on minimal therapy after 1 or more cycle, and median time to relapse. Multivariate regression analysis for prognostic variables for CROT, including age, sex, pemphigus subtype, body mass index (BMI) (calculated as weight in kilograms divided by height in meters squared), disease duration, and dosing regimen, was performed. Results A total of 112 patients with pemphigus with median 37.8 months (range, 12.1-130.7) follow-up after rituximab therapy were identified. Of these, 65 were women (58.0%). At the time of first rituximab infusion, median age was 52.3 years (range, 20.0-89.3). Including patients who received multiple cycles of rituximab, 79 patients (70.5%) achieved CROT after a median time of 10.5 months (range, 2.0-49.8), and 36 of 72 patients (50.0%) subsequently experienced relapse after a median of 23.3 months (interquartile range, 10.8-50.4 months). Considering only the first cycle of rituximab, 54 patients (48.2%) achieved CROT. Controlling for age, sex, pemphigus subtype, BMI, and disease duration, patients who received lymphoma vs rheumatoid arthritis dosing were 2.70-fold more likely to achieve CROT (odds ratio [OR], 2.70; 95% CI, 1.03-7.12; P = .04). Increasing age was associated with significant increases in achieving CROT (Wald test for trend, P = .01), whereas BMI greater than or equal to 35 was associated with a 0.14 OR (95% CI, 0.03-0.63; P = .01) for achieving CROT, regardless of the dosing regimen. In multivariate analysis, there was no significant difference in CROT rates with sex (OR, 1.01; 95% CI, 0.42-2.50; P = .97), pemphigus subtype (OR, 0.37; 95% CI, 0.09-1.51; P = .17), or disease duration (OR, 0.99; 95% CI, 0.98-1.00; P = .09). Conclusions and Relevance Lymphoma dosing and older age may be associated with CROT and BMI greater than or equal to 35 may be a negative prognostic factor for CROT after rituximab therapy for pemphigus. These findings help inform clinical expectations and merit evaluation in future prospective clinical trials.
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Affiliation(s)
- Carolyn J Kushner
- Department of Dermatology, University of Pennsylvania, Philadelphia.,Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Shiyu Wang
- Department of Dermatology, University of Pennsylvania, Philadelphia
| | - Napatra Tovanabutra
- Department of Dermatology, University of Pennsylvania, Philadelphia.,Division of Dermatology, Department of Internal Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Donald E Tsai
- Division of Hematology Oncology, Department of Internal Medicine, University of Pennsylvania, Philadelphia
| | - Victoria P Werth
- Department of Dermatology, University of Pennsylvania, Philadelphia.,Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Aimee S Payne
- Department of Dermatology, University of Pennsylvania, Philadelphia
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17
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Individual patients' risk factors impact guidelines for prophylactic agents used in pemphigus patients treated with rituximab. J Am Acad Dermatol 2021; 85:e47-e48. [PMID: 33713786 DOI: 10.1016/j.jaad.2021.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 03/03/2021] [Indexed: 11/24/2022]
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18
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Kridin K, Ahmed AR. The evolving role of rituximab in the treatment of pemphigus vulgaris: a comprehensive state-of-the-art review. Expert Opin Biol Ther 2021; 21:443-454. [PMID: 33455475 DOI: 10.1080/14712598.2021.1874915] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
INTRODUCTION Pemphigus vulgaris (PV) is a life-threatening autoimmune mucocutaneous blistering disease. Systemic corticosteroids (CS), while life-saving, have several serious side effects. To improve treatment and prognosis, recently rituximab (RTX), a chimeric monoclonal antibody against CD20 molecule on B cells, has become popular. This Expert Opinion discusses clinical and scientifically relevant aspects of RTX treating PV. AREA COVERED This presentation describes the mechanism of action, clinical efficacy, safety, adverse events, protocols used, and clinical outcomes. Concerns for infection, reactivation of latent or previous infections, and high relapse rate are discussed. EXPERT OPINION Use of RTX in PV is still a work in progress. There are many unanswered questions. FDA did not provide a protocol or guidelines. Whenever RTX is used, systemic corticosteroids are simultaneously used, albeit for a shorter duration and lower dose. Used in these doses for these durations they can cause immunosuppression. Would it be more appropriate if instead of 'First Line Therapy' it would be more advisable to use the term 'First Adjunctive Immunosuppressive Agent'?
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Affiliation(s)
- Khalaf Kridin
- Department of Dermatology, Rambam Health Care Campus, Haifa, Israel
| | - A Razzaque Ahmed
- Department of Dermatology, Tufts University School of Medicine, and the Center for Blistering Diseases, USA
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19
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Nosrati A, Hodak E, Mimouni T, Oren-Shabtai M, Levi A, Leshem YA, Mimouni D. Treatment of Pemphigus with Rituximab: Real-Life Experience in a Cohort of 117 Patients in Israel. Dermatology 2021; 237:450-456. [PMID: 33567432 DOI: 10.1159/000513515] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 12/02/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND A combined regimen of rituximab with corticosteroids for the treatment of pemphigus was effective in a prospective randomized controlled trial. OBJECTIVE To assess real-life response to rituximab in patients with pemphigus. METHODS A retrospective cohort of patients with pemphigus treated with ≥1 rituximab cycles (1,000 mg on days 0 and 14). The primary outcome was remission rate after 1 cycle. For efficacy analyses, a minimal 6-month follow-up was required. Adverse events were assessed in all patients. RESULTS The cohort included 117 patients for safety analysis, 108 for efficacy analysis (median follow-up of 33 months). All but one received concomitant corticosteroids, a third also received adjuvants. Overall, 80/108 patients (74%) achieved remission after the first rituximab cycle at a median of 5.5 months. Relapses occurred in 39 patients (49%) at a median of 18 months. Repeating treatment in relapsed patients increased remission rates to 75 and 88% after the second and third cycles, respectively. Adverse events were similar to those of previous publications. Two elderly patients died of infections attributable to rituximab combined with high-dose corticosteroids. CONCLUSION In a large real-life long-term cohort, rituximab with corticosteroids ± adjuvants induced remission in most patients with pemphigus, with relatively favorable safety. Repeating treatment following relapse or remission failure was beneficial.
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Affiliation(s)
- Adi Nosrati
- Division of Dermatology, Rabin Medical Center, Petah Tiqva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Emmilia Hodak
- Division of Dermatology, Rabin Medical Center, Petah Tiqva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tomer Mimouni
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Meital Oren-Shabtai
- Division of Dermatology, Rabin Medical Center, Petah Tiqva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Assi Levi
- Division of Dermatology, Rabin Medical Center, Petah Tiqva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yael A Leshem
- Division of Dermatology, Rabin Medical Center, Petah Tiqva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Daniel Mimouni
- Division of Dermatology, Rabin Medical Center, Petah Tiqva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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20
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Kokubu H, Kato T, Nishikawa J, Tanaka T, Fujimoto N. Adverse effects of trimethoprim–sulfamethoxazole for the prophylaxis of
Pneumocystis
pneumonia in dermatology. J Dermatol 2021; 48:542-546. [DOI: 10.1111/1346-8138.15724] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 11/10/2020] [Accepted: 11/21/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Hiraku Kokubu
- Department of Dermatology Shiga University of Medical Science Otsu Shiga Japan
| | - Takeshi Kato
- Department of Dermatology Shiga University of Medical Science Otsu Shiga Japan
| | - Junko Nishikawa
- Department of Dermatology Shiga University of Medical Science Otsu Shiga Japan
| | - Toshihiro Tanaka
- Department of Dermatology Shiga University of Medical Science Otsu Shiga Japan
| | - Noriki Fujimoto
- Department of Dermatology Shiga University of Medical Science Otsu Shiga Japan
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21
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Bohelay G, Caux F, Musette P. Clinical and biological activity of rituximab in the treatment of pemphigus. Immunotherapy 2021; 13:35-53. [PMID: 33045883 DOI: 10.2217/imt-2020-0189] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
B-cells are major effector cells in autoimmunity since they differentiate into plasmocytes that produce pathogenic auto-antibody such as anti-desmoglein antibodies in pemphigus patients. Major advances were obtained using whole B-cell depleting therapies including anti-CD20 antibodies in refractory pemphigus patients that lead to rituximab approval in pemphigus patients in EU and USA. This review summarizes the data supporting the efficacy of rituximab in pemphigus and provides an overview of the reported immunological changes underlying its therapeutic action. Short and long-term remission in pemphigus is explained by the removal of autoreactive B-cells involved in the production of pathogenic IgG auto-antibodies and by enhancement of the appearance of regulatory B-cells that could maintain long term immune tolerance.
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Affiliation(s)
- Gérôme Bohelay
- Department of Dermatology, Groupe Hospitalier Paris Seine-Saint-Denis, AP-HP & INSERM UMR1125, Bobigny, France
| | - Frédéric Caux
- Department of Dermatology, Groupe Hospitalier Paris Seine-Saint-Denis, AP-HP & INSERM UMR1125, Bobigny, France
| | - Philippe Musette
- Department of Dermatology, Groupe Hospitalier Paris Seine-Saint-Denis, AP-HP & INSERM UMR1125, Bobigny, France
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22
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Patel PM, Jones VA, Amber KT. Disease-dependent Risk of Pneumocystis Pneumonia: The Case of Autoimmune Blistering Disease. Chest 2020; 158:2704-2705. [PMID: 33280759 DOI: 10.1016/j.chest.2020.06.081] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 06/24/2020] [Accepted: 06/27/2020] [Indexed: 11/19/2022] Open
Affiliation(s)
- Payal M Patel
- Department of Dermatology, University of Illinois at Chicago, Chicago, IL
| | - Virginia A Jones
- Department of Dermatology, University of Illinois at Chicago, Chicago, IL
| | - Kyle T Amber
- Department of Dermatology, University of Illinois at Chicago, Chicago, IL.
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23
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Abstract
Pemphigus is a rare autoimmune disease of the skin, characterized by autoantibodies targeting adhesion proteins of the epidermis, in particular desmoglein 3 and desmoglein 1, that cause the loss of cell-cell adhesion and the formation of intraepidermal blisters. Given that these autoantibodies are both necessary and sufficient for pemphigus to occur, the goal of pemphigus therapy is the elimination of autoreactive B-cells responsible for autoantibody production. Rituximab, an anti-CD20 monoclonal antibody, was the first targeted B-cell therapy approved for use in pemphigus and is now considered the frontline therapy for new onset disease. One limitation of this treatment is that it targets both autoreactive and non -autoreactive B-cells, which accounts for the increased risk of serious infections in treated patients. In addition, most rituximab-treated patients experience disease relapse, highlighting the need of new therapeutic options. This review provides a concise overview of rituximab use in pemphigus and discusses new B-cell and antibody-directed therapies undergoing investigation in clinical studies.
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Affiliation(s)
- Roberto Maglie
- Department of Health Sciences, Section of Dermatology, University of Florence, Florence, Italy -
| | - Emiliano Antiga
- Department of Health Sciences, Section of Dermatology, University of Florence, Florence, Italy
| | - Aimee S Payne
- Department of Dermatology, University of Pennsylvania, Philadelphia, PA, USA
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24
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Chen J, Mao X, Zhao W, Zhang B, Chen X, Yu C, Zheng Z, Jin H, Li L. Assessment of the Characteristics and Associated Factors of Infectious Complications in Bullous Pemphigoid. Front Immunol 2020; 11:1607. [PMID: 32793235 PMCID: PMC7390841 DOI: 10.3389/fimmu.2020.01607] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 06/16/2020] [Indexed: 12/13/2022] Open
Abstract
Objectives: The clinical outcome of bullous pemphigoid appears worse in patients with infectious complications, and assessment of the prevalence and risk factors of infectious complications could be necessary to plan preventative strategies and to instruct the treatment plans. We sought to determine the risk factors of infection and compare associated factors in inpatients and outpatients with different system infections. Design: This is a single-centered retrospective study on the medical records of 252 patients from 2010 to 2018 at the dermatology department, Peking Union Medical College. Medical profiles of medical history, diagnosis, infectious complications, and treatment plans were analyzed. The associated factors were compared between the subgroups, including inpatients and outpatients, different body sites of infection. Results: Of the total 252 patients with bullous pemphigoid (BP), 81 patients (81/252, 32.1%) had infectious complications. Forty-eight patients died from pulmonary infections (11/48, 22.9%), cardiovascular diseases (6/48, 12.5%), and other diseases. Infections were most frequently found in skin/mucosa (44/252, 17.5%), respiratory system (32/252, 12.7%), and blood (10/252, 4.0%). On multivariate analysis, risk factors of infections in BP were maximal control dose of corticosteroids (OR 2.539, 95% CI 1.456-4.430, p = 0.001), low serum albumin level (OR 2.557, 95% CI 1.283, 5.092, p = 0.007), hospitalization (OR 4.025, 95% CI 2.289, 7.079, p < 0.001), comorbidities including respiratory disease (OR 4.060, 95% CI, 1.861, 8.858, p < 0.001), eye disease (OR 4.431, 95% CI 1.864, 10.532, p < 0.001), and diabetes (OR 2.667, 95% CI 1.437, 4.949, p = 0.002). The rate of infection was significantly higher in inpatients compared to that in outpatients (54.0 vs. 20.6%, p < 0.001), with diverse risk factors. Mucocutaneous infections were associated with a maximal control dose of corticosteroid and other dermatoses. Respiratory infections were related to respiratory disease and old age, and hematologic infection was associated with low serum hemoglobin levels and mucosal involvement of BP. Both of them were associated with mucosal involvement of BP and high titer anti-BP180 antibody. Conclusions: Infectious complications of bullous pemphigoid are common and are associated with mucosal involvement of BP, more comorbidities, the higher dose of corticosteroids, and the lower level of serum albumin.
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Affiliation(s)
- Jia Chen
- Department of Dermatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xuming Mao
- Department of Dermatology, University of Pennsylvania, Philadelphia, PA, United States
| | - Wenling Zhao
- Department of Dermatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Department of Dermatology, Shunyi Maternal and Children's Hospital of Beijing Children's Hospital, Beijing, China
| | - Bingjie Zhang
- Department of Dermatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xinyi Chen
- Department of Dermatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chenyang Yu
- Department of Dermatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zehui Zheng
- Department of Dermatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hongzhong Jin
- Department of Dermatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Li Li
- Department of Dermatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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25
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Inpatient Management of Autoimmune Blistering Diseases: an Update, Review, and Practical Guide. CURRENT DERMATOLOGY REPORTS 2019. [DOI: 10.1007/s13671-019-00272-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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26
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White PL, Price JS, Backx M. Pneumocystis jirovecii Pneumonia: Epidemiology, Clinical Manifestation and Diagnosis. CURRENT FUNGAL INFECTION REPORTS 2019. [DOI: 10.1007/s12281-019-00349-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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27
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Maglie R, Hertl M. Assessment of serious infections in pemphigus and pemphigoid by a national registry. J Eur Acad Dermatol Venereol 2019; 32:1623-1624. [PMID: 30303304 DOI: 10.1111/jdv.15237] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- R Maglie
- Department of Dermatology, Philipps University, Marburg, Germany.,Department of Surgery and Translational Medicine, Section of Dermatology, University of Florence, Florence, Italy
| | - M Hertl
- Department of Dermatology, Philipps University, Marburg, Germany
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28
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Kneiber D, Kowalski EH, Kridin K, Yale ML, Grando SA, Amber KT. Gastrointestinal symptoms, gastrointestinal bleeding and the role of diet in patients with autoimmune blistering disease: a survey of the International Pemphigus and Pemphigoid Foundation. J Eur Acad Dermatol Venereol 2019; 33:1935-1940. [PMID: 31169928 DOI: 10.1111/jdv.15731] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 05/07/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Autoimmune blistering diseases are a group of severe mucocutaneous conditions that typically require the use of prolonged corticosteroids and immunosuppression. Properly managing associated comorbidities is an integral part of these patients' care. The frequency of gastrointestinal symptoms, particularly gastrointestinal bleeding in these patients, is not known. Likewise, the effect of diet on disease is unknown. OBJECTIVE To determine the incidence of gastrointestinal comorbidities and the role of diet in patients with autoimmune blistering disease. METHODS We distributed an e-survey to patients with autoimmune blistering disease utilizing the International Pemphigus and Pemphigoid Foundation's listserv. The incidence of gastrointestinal symptoms and gastrointestinal bleeding were recorded, as were foods avoided and those noted to be beneficial in patients' disease. Historical incidences in the general population were used as controls. RESULTS A total of 200 responses were collected. 30.3% of patients experienced gastroesophageal reflux following treatment of their autoimmune blistering disease, with 51.7% utilizing some form of gastrointestinal symptomatic treatment. The incidence of gastrointestinal bleeding following an autoimmune blistering diagnosis was 2.1%, which remained significant despite correction for non-steroidal anti-inflammatory use (NSAID), but not corticosteroid use. 65.2% of patients reported dietary limitations because of their autoimmune blistering disease. Significant intolerances after correction for multiple comparisons included alcohol, citrus and spicy foods. Greater than 10% of patients reported improvements in their disease with vegetables and dairy. CONCLUSIONS Gastrointestinal comorbidities are common in patients with autoimmune blistering diseases, with gastrointestinal bleeding occurring in 2.1% of patients following a diagnosis of autoimmune blistering disease. While further work is needed to determine the relative risk of routine gastrointestinal prophylaxis in this population, gastrointestinal bleeding prophylaxis should be considered in patients receiving corticosteroids, particularly those taking NSAIDs. Dietary limitations are additionally frequent in this population. Patients should be cautious of alcohol, citrus and spicy foods.
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Affiliation(s)
- D Kneiber
- Department of Dermatology, University of Illinois at Chicago, Chicago, IL, USA
| | - E H Kowalski
- Department of Dermatology, University of Illinois at Chicago, Chicago, IL, USA
| | - K Kridin
- Department of Dermatology, Rambam Healthcare Campus, Haifa, Israel
| | - M L Yale
- International Pemphigus and Pemphigoid Foundation, Sacramento, CA, USA
| | - S A Grando
- Department of Dermatology, University of California Irvine, Irvine, CA, USA
| | - K T Amber
- Department of Dermatology, University of Illinois at Chicago, Chicago, IL, USA.,Department of Dermatology, University of California Irvine, Irvine, CA, USA
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29
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Rekhtman S, Strunk A, Garg A. Incidence of pneumocystosis among patients exposed to immunosuppression. J Am Acad Dermatol 2019; 80:1602-1607. [DOI: 10.1016/j.jaad.2018.12.052] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 12/20/2018] [Accepted: 12/27/2018] [Indexed: 11/29/2022]
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30
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Siscos SM, Neill BC, Tarantino IS, Aires DJ, Rajpara A. Response: Dapsone advantages over trimethoprim-sulfamethoxazole for Pneumocystis pneumonia prophylaxis in immunobullous patients. J Am Acad Dermatol 2019; 85:e371-e372. [PMID: 31015010 DOI: 10.1016/j.jaad.2019.04.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 04/15/2019] [Indexed: 10/27/2022]
Affiliation(s)
- Spyros M Siscos
- Division of Dermatology, University of Kansas Medical Center, Kansas City, Kansas
| | - Brett C Neill
- Division of Dermatology, University of Kansas Medical Center, Kansas City, Kansas
| | - Isadore S Tarantino
- Division of Dermatology, University of Kansas Medical Center, Kansas City, Kansas
| | - Daniel J Aires
- Division of Dermatology, University of Kansas Medical Center, Kansas City, Kansas
| | - Anand Rajpara
- Division of Dermatology, University of Kansas Medical Center, Kansas City, Kansas.
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Dapsone, 2 birds with 1 stone: A response to “Dapsone advantages over trimethoprim-sulfamethoxazole for Pneumocystis pneumonia prophylaxis in immunobullous patients”. J Am Acad Dermatol 2019; 85:e369. [DOI: 10.1016/j.jaad.2019.03.093] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 03/15/2019] [Accepted: 03/19/2019] [Indexed: 11/18/2022]
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Abstract
BACKGROUND Pemphigus diseases are a heterogeneous group of potentially life-threatening autoimmune bullous disorders. Therefore, rapidly acting and effective therapeutic approaches are essential. OBJECTIVES In this review, current therapeutic options in line with available guidelines are presented and new therapeutic approaches are discussed. METHODS A literature search was performed using PubMed. RESULTS Treatment of pemphigus is based on systemic glucocorticosteroids, frequently combined with potentially corticosteroid-sparing immunosuppressants such as azathioprine and mycophenolate mofetil/mycophenolic acid. Recently, the impressive efficacy of the anti-CD20 antibody rituximab has been shown in a prospective randomized trial. In severe or treatment-refractory cases, immunoadsorption or high-dose intravenous immunoglobulins (IVIG) are recommended. Adjuvant immunoadsorption also seems to be useful within the first 8-12 weeks of therapy in patients with very high autoantibody levels. A variety of new therapeutic approaches is currently evaluated in phase IIa studies. CONCLUSION Therapy of pemphigus has been greatly improved by the employment of rituximab. The use of glucocorticosteroids, associated with a high number of adverse events and elevated mortality, could be reduced by the additional use of rituximab. After approval of rituximab for the treatment of pemphigus by the US Food and Drug Administration in 2018, licensing in Europe is expected in 2019.
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Affiliation(s)
- N van Beek
- Klinik für Dermatologie, Allergologie und Venerologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Deutschland.
| | - D Zillikens
- Klinik für Dermatologie, Allergologie und Venerologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Deutschland
| | - E Schmidt
- Klinik für Dermatologie, Allergologie und Venerologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Deutschland.,Lübecker Institut für Experimentelle Dermatologie (LIED), Universität zu Lübeck, Lübeck, Deutschland
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Abstract
Bullous pemphigoid is the most frequent autoimmune bullous disease and mainly affects elderly individuals. Increase in incidence rates in the past decades has been attributed to population aging, drug-induced cases and improvement in the diagnosis of the nonbullous presentations of the disease. A dysregulated T cell immune response and synthesis of IgG and IgE autoantibodies against hemidesmosomal proteins (BP180 and BP230) lead to neutrophil chemotaxis and degradation of the basement membrane zone. Bullous pemphigoid classically manifests with tense blisters over urticarial plaques on the trunk and extremities accompanied by intense pruritus. Mucosal involvement is rarely reported. Diagnosis relies on (1) the histopathological evaluation demonstrating eosinophilic spongiosis or a subepidermal detachment with eosinophils; (2) the detection of IgG and/or C3 deposition at the basement membrane zone using direct or indirect immunofluorescence assays; and (3) quantification of circulating autoantibodies against BP180 and/or BP230 using ELISA. Bullous pemphigoid is often associated with multiple comorbidities in elderly individuals, especially neurological disorders and increased thrombotic risk, reaching a 1-year mortality rate of 23%. Treatment has to be tailored according to the patient's clinical conditions and disease severity. High potency topical steroids and systemic steroids are the current mainstay of therapy. Recent randomized controlled studies have demonstrated the benefit and safety of adjuvant treatment with doxycycline, dapsone and immunosuppressants aiming a reduction in the cumulative steroid dose and mortality.
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Affiliation(s)
- Denise Miyamoto
- Division of Dermatology, Hospital das Clínicas,
Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP),
Brazil
| | - Claudia Giuli Santi
- Division of Dermatology, Hospital das Clínicas,
Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP),
Brazil
| | - Valéria Aoki
- Department of Dermatology, Faculdade de Medicina,
Universidade de São Paulo, São Paulo (SP), Brazil
| | - Celina Wakisaka Maruta
- Department of Dermatology, Faculdade de Medicina,
Universidade de São Paulo, São Paulo (SP), Brazil
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Ren Z, Narla S, Hsu DY, Silverberg JI. Association of serious infections with pemphigus and pemphigoid: analysis of the Nationwide Inpatient Sample. J Eur Acad Dermatol Venereol 2018; 32:1768-1776. [PMID: 29575160 DOI: 10.1111/jdv.14961] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 03/06/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Pemphigus and pemphigoid are blistering disorders associated with barrier disruption, immune dysregulation and use of immunosuppressing systemic therapy, all of which may predispose towards serious infections. OBJECTIVES To determine whether pemphigus and pemphigoid are associated with increased likelihood of serious infections and the impact of such infections on mortality and cost of care. METHODS We analysed data from the 2002 to 2012 Nationwide Inpatient Sample, including a representative 20% sample of all hospitalizations in the US (total n = 72 108 077 adults). RESULTS Overall, 54.6% (95% CI: 53.6-55.6%) and 50.4% (49.0-51.8%) of inpatients with either pemphigoid or pemphigus had a diagnosis of serious infection, respectively, compared with 25.4% (25.2-25.6%) in those without either diagnosis. In multivariable logistic regression models controlling for gender, age, race/ethnicity and insurance status, pemphigoid or pemphigus was associated with 26 or 21 of 48 infections examined, respectively. In particular, both pemphigoid and pemphigus were associated with higher odds of infections of the skin, bones, respiratory, gastrointestinal, genitourinary and central nervous system, septicaemia and antibiotic-resistant infections. Pemphigus was also associated with aspergillus, pharyngitis and Pneumocystis Carinii pneumonia. Associations of any serious infection in both pemphigoid and pemphigus patients were older age, non-White race, lower median household income, government or no insurance, higher number of chronic conditions, and those with a diagnosis of Cushing's syndrome, diabetes, cancer or autoimmune disease. The diagnosis of any serious infection vs. no infection was associated with increased inpatient mortality and costs in both pemphigoid (mortality: 7.85% vs. 2.84%; cost: $16 115 vs. $10 653) and pemphigus (mortality: 6.78% vs. 1.88%; cost: $17 707 vs. $11 545) inpatients (P < 0.0001 for all). CONCLUSIONS Adults with pemphigus or pemphigoid had increased cutaneous, respiratory, multi-organ and systemic infections, which were associated with considerable inpatient mortality and cost burden. Moreover, there were significant clinical and healthcare disparities with respect to infections in patients with pemphigus or pemphigoid.
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Affiliation(s)
- Z Ren
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - S Narla
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - D Y Hsu
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - J I Silverberg
- Departments of Dermatology, Preventive Medicine and Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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35
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Abstract
Pemphigus vulgaris (PV) is a life-threatening disease belonging to the pemphigus group of autoimmune intra-epidermal bullous diseases of the skin and mucosae. The therapeutic management of PV remains challenging and, in some cases, conventional therapy is not adequate to induce clinical remission. The cornerstone of PV treatment remains systemic corticosteroids. Although very effective, long-term corticosteroid administration is characterized by substantial adverse effects. Corticosteroid-sparing adjuvant therapies have been employed in the treatment of PV, aiming to reduce the necessary cumulative dose of corticosteroids. Specifically, immunosuppressive agents such as azathioprine and mycophenolate mofetil are widely used in PV. More recently, high-dose intravenous immunoglobulins, immunoadsorption, and rituximab have been established as additional successful therapeutic options. This review covers both conventional and emerging therapies in PV. In addition, it sheds light on potential future treatment strategies for this disease.
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Affiliation(s)
- Khalaf Kridin
- Department of Dermatology, Rambam Health Care Campus, Haifa, Israel
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