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Caux F, Patsatsi A, Karakioulaki M, Antiga E, Baselga E, Borradori L, Caproni M, Cardones AR, Chandran NS, Dräger S, Drenovska K, Goebeler M, Günther C, Hofmann SC, Ioannides D, Joly P, Marinović B, Mariotti EB, Marzano AV, Morel KD, Murrell DF, Prost C, Sárdy M, Setterfield J, Skiljevic D, Uzun S, Vassileva S, Zambruno G, Schmidt E. S2k guidelines on diagnosis and treatment of linear IgA dermatosis initiated by the European Academy of Dermatology and Venereology. J Eur Acad Dermatol Venereol 2024; 38:1006-1023. [PMID: 38421060 DOI: 10.1111/jdv.19880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 01/19/2024] [Indexed: 03/02/2024]
Abstract
INTRODUCTION Linear IgA dermatosis (LAD) is a rare subepidermal autoimmune bullous disease (AIBD) defined by predominant or exclusive immune deposits of immunoglobulin A at the basement membrane zone of skin or mucous membranes. This disorder is a rare, clinically and immunologically heterogeneous disease occurring both in children and in adults. The aim of this project is to present the main clinical features of LAD, to propose a diagnostic algorithm and provide management guidelines based primarily on experts' opinion because of the lack of large methodologically sound clinical studies. METHODS These guidelines were initiated by the European Academy of Dermatology and Venereology (EADV) Task Force Autoimmune Bullous Diseases (AIBD). To achieve a broad consensus for these S2k consensus-based guidelines, a total of 29 experts from different countries, both European and non-European, including dermatologists, paediatric dermatologists and paediatricians were invited. All members of the guidelines committee agreed to develop consensus-based (S2k) guidelines. Prior to a first virtual consensus meeting, each of the invited authors elaborated a section of the present guidelines focusing on a selected topic, based on the relevant literature. All drafts were circulated among members of the writing group, and recommendations were discussed and voted during two hybrid consensus meetings. RESULTS The guidelines summarizes evidence-based and expert opinion-based recommendations (S2 level) on the diagnosis and treatment of LAD. CONCLUSION These guidelines will support dermatologists to improve their knowledge on the diagnosis and management of LAD.
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Affiliation(s)
- Frédéric Caux
- Department of Dermatology and Referral Center for Autoimmune Bullous Diseases, Groupe Hospitalier Paris Seine-Saint-Denis, AP-HP and University Paris 13, Bobigny, France
| | - Aikaterini Patsatsi
- Autoimmune Bullous Diseases Unit, 2nd Department of Dermatology, Aristotle University School of Medicine, Papageorgiou General Hospital, Thessaloniki, Greece
| | - Meropi Karakioulaki
- Department of Dermatology and Venereology, Medical Center, University Hospital Freiburg, Freiburg, Germany
| | - Emiliano Antiga
- Department of Health Sciences, Section of Dermatology, Azienda USL Toscana Centro, Rare Diseases Unit, European Reference Network-Skin Member, University of Florence, Florence, Italy
| | - Eulalia Baselga
- Department of Dermatology, Hospital Sant Joan de Deu, Barcelona, Spain
| | - Luca Borradori
- Department of Dermatology, University of Bern, Inselspital, Berne, Switzerland
| | - Marzia Caproni
- Department of Health Sciences, Section of Dermatology, Azienda USL Toscana Centro, Rare Diseases Unit, European Reference Network-Skin Member, University of Florence, Florence, Italy
| | - Adela R Cardones
- Division of Dermatology, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Nisha Suyien Chandran
- Division of Dermatology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Sören Dräger
- Department of Dermatology, Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Kossara Drenovska
- Department of Dermatology and Venereology, University Hospital "Alexandrovska", Medical University-Sofia, Sofia, Bulgaria
| | - Matthias Goebeler
- Department of Dermatology, Venereology and Allergology, University Hospital Würzburg, Würzburg, Germany
| | - Claudia Günther
- Department of Dermatology, University Hospital, Technical University Dresden, Dresden, Germany
| | - Silke C Hofmann
- Department of Dermatology, Allergy and Dermatosurgery, Helios University Hospital Wuppertal, University Witten-Herdecke, Wuppertal, Germany
| | - Dimitrios Ioannides
- 1st Department of Dermatology, Aristotle University School of Medicine, Hospital of Skin and Venereal Diseases, Thessaloniki, Greece
| | - Pascal Joly
- Department of Dermatology, Rouen University Hospital, INSERM 1234, Normandie University, Rouen, France
| | - Branka Marinović
- Department of Dermatology and Venereology, University Hospital Centre Zagreb, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Elena Biancamaria Mariotti
- Department of Health Sciences, Section of Dermatology, Azienda USL Toscana Centro, Rare Diseases Unit, European Reference Network-Skin Member, University of Florence, Florence, Italy
| | - Angelo Valerio Marzano
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Kimberly D Morel
- Departments of Dermatology and Pediatrics at Columbia University Medical Center, Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Dedee F Murrell
- Department of Dermatology, St George Hospital, University of New South Wales, Sydney, New South Wales, Australia
| | - Catherine Prost
- Department of Dermatology and Referral Center for Autoimmune Bullous Diseases, Groupe Hospitalier Paris Seine-Saint-Denis, AP-HP and University Paris 13, Bobigny, France
| | - Miklós Sárdy
- Department of Dermatology, Venereology and Dermatooncology, Semmelweis University, Budapest, Hungary
- Department of Dermatology and Allergy, University Hospital, LMU, Munich, Germany
| | - Jane Setterfield
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Centre for Host-Microbiome Interactions, King's College London Faculty of Dentistry, Oral & Craniofacial Sciences, London, UK
| | - Dusan Skiljevic
- Department of Dermatovenereology, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Soner Uzun
- Department of Dermatology, Akdeniz University Faculty of Medicine, Antalya, Turkey
| | - Snejina Vassileva
- Department of Dermatology and Venereology, University Hospital "Alexandrovska", Medical University-Sofia, Sofia, Bulgaria
| | - Giovanna Zambruno
- Genodermatosis Unit, Translational Pediatrics and Clinical Genetics Research Division, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Enno Schmidt
- Department of Dermatology, Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
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Opelka B, Schmidt E, Goletz S. Type XVII collagen: Relevance of distinct epitopes, complement-independent effects, and association with neurological disorders in pemphigoid disorders. Front Immunol 2022; 13:948108. [PMID: 36032160 PMCID: PMC9400597 DOI: 10.3389/fimmu.2022.948108] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 07/07/2022] [Indexed: 11/13/2022] Open
Abstract
Pemphigoid diseases (PD) are autoimmune skin blistering diseases characterized by autoantibodies directed against proteins of the cutaneous basement membrane zone (BMZ). One of the major antigens is type XVII collagen (BP180), a transmembrane glycoprotein, which is targeted in four PDs: bullous pemphigoid, mucous membrane pemphigoid, linear IgA dermatosis, and pemphigoid gestationis. To date, different epitopes on BP180 have been described to be recognized by PD disease patients’ autoantibodies. Different BP180 epitopes were associated with distinct clinical phenotypes while the underlying mechanisms are not yet fully understood. So far, the main effects of anti-BP180 reactivity are mediated by Fcγ-receptors on immune cells. More precisely, the autoantibody–antigen interaction leads to activation of complement at the BMZ and infiltration of immune cells into the upper dermis and, by the release of specific enzymes and reactive oxygen species, to the degradation of BP180 and other BMZ components, finally manifesting as blisters and erosions. On the other hand, inflammatory responses independent of Fcγ-receptors have also been reported, including the release of proinflammatory cytokines and internalization and depletion of BP180. Autoantibodies against BP180 can also be found in patients with neurological diseases. The assumption that the clinical expression of PD depends on epitope specificity in addition to target antigens, autoantibody isotypes, and antibody glycosylation is supported by the observation that epitopes of PD patients differ from those of PD patients. The aim of the present review is to describe the fine specificities of anti-BP180 autoantibodies in different PDs and highlight the associated clinical differences. Furthermore, the direct effects after binding of the autoantibodies to their target are summarized.
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Affiliation(s)
- Bianca Opelka
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Enno Schmidt
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Stephanie Goletz
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
- *Correspondence: Stephanie Goletz,
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Arès S, Lim D, Jung S, Bouffard D, Mereniuk A. Annular bullous pemphigoid: A case report and review of literature. SAGE Open Med Case Rep 2022; 10:2050313X221093128. [PMID: 35495292 PMCID: PMC9039429 DOI: 10.1177/2050313x221093128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Bullous pemphigoid is an autoimmune blistering disease that primarily affects the geriatric population. It often presents as urticarial erythematous plaques, which evolve into subepidermal blisters accompanied by pruritus. Although rare, clinical variants of bullous pemphigoid have been documented. We present a rare case of annular bullous pemphigoid in a 50-year-old male and offer a brief review of the literature. Only five other case reports, including three in adults, have described this unusual presentation, which can mimic other autoimmune blistering diseases, including linear IgA bullous dermatosis and pemphigus herpetiformis. Therefore, histopathology and immunologic studies were essential in properly diagnosing this patient. Our case supports that annular blistering lesions can be a clinical variant of bullous pemphigoid.
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Affiliation(s)
- Steffie Arès
- Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Darosa Lim
- Division of Dermatology, Hôpital du Sacré-Cœur de Montréal, Université de Montréal, Montreal, QC, Canada
| | - Sungmi Jung
- Department of Pathology, McGill University Health Centre, McGill University, Montreal, QC, Canada
| | - Danielle Bouffard
- Department of Pathology, Centre hospitalier de l’Université de Montréal, Université de Montréal, Montreal, QC, Canada
| | - Alexandra Mereniuk
- Division of Dermatology, Hôpital du Sacré-Cœur de Montréal, Université de Montréal, Montreal, QC, Canada
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Becker M, Schumacher N, Schmidt E, Zillikens D, Sadik CD. Evaluation and Comparison of Clinical and iLaboratory Characteristics of Patients With IgA Epidermolysis Bullosa Acquisita, Linear IgA Bullous Dermatosis, and IgG Epidermolysis Bullosa Acquisita. JAMA Dermatol 2021; 157:917-923. [PMID: 34160564 DOI: 10.1001/jamadermatol.2021.0762] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Immunoglobulin A (IgA) epidermolysis bullosa acquisita (EBA) is an autoimmune skin blistering disease with IgA autoantibodies directed against type VII collagen. There is debate whether it should be considered part of the clinical spectrum of linear IgA bullous dermatosis (LABD) or a separate disease entity. Objective This cohort study aimed to define the clinical features and treatment responses of IgA EBA and anti-BP180-driven LABD, and to compare the prevalences of IgA EBA anti-BP180 LABD and classic IgG-mediated EBA in an autoimmune diagnostic laboratory database. Design, Setting, and Participants This retrospective cohort study and case series study included demographic, immunopathologic, and serologic data from 300 patients diagnosed with IgA EBA, IgG EBA, or LABD. Furthermore, clinical features and treatment responses of IgA EBA were analyzed in a case series including 4 patients with IgA EBA. All patients from the database of the autoimmune diagnostic laboratory at the Department of Dermatology, University of Lübeck, Germany, who were diagnosed with IgA EBA, LABD, or IgG EBA between October 2010 and July 2019 were included. Four patients diagnosed with IgA EBA between October 2015 and January 2018 are described in detail. Main Outcomes and Measures The clinical course of IgA EBA was observed before and during different treatments. Results The database search yielded 21 cases of IgA EBA (12 females [57%]/9 males [43%]), 222 cases of LABD (111 females [51%]/106 males [49]), and 57 cases of IgG EBA (29 females [50%]/28 males [48%]). The median (range) age of each cohort was 64 (4-81) years for IgA EBA, 56 (3-92) years for IgG EBA, and significantly older compared with IgG EBA (P = .002) for those with LAPD (median [range], 70 [1-94] years). The patients with IgA EBA exhibited heterogeneous clinical presentations that significantly differed from those of anti-BP180 LABD. All 4 patients with IgA EBA described in detail were first treated with dapsone, but only 1 responded to this treatment. The others required treatment with high-dose dexamethasone, rituximab, and/or intravenous immunoglobulins to achieve partial clinical remission. Conclusions and Relevance Overall, the findings of this cohort study and small case series suggest that IgA EBA may be more common than expected and may require more intensive systemic treatment than LABD, suggesting it should be considered a separate disease entity.
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Affiliation(s)
- Mareike Becker
- Department of Dermatology, Allergy, and Venereology, University of Lübeck, Lübeck, Germany.,Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
| | - Nina Schumacher
- Department of Dermatology, Allergy, and Venereology, University of Lübeck, Lübeck, Germany
| | - Enno Schmidt
- Department of Dermatology, Allergy, and Venereology, University of Lübeck, Lübeck, Germany.,Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany.,Center for Research on Inflammation of the Skin
| | - Detlef Zillikens
- Department of Dermatology, Allergy, and Venereology, University of Lübeck, Lübeck, Germany.,Center for Research on Inflammation of the Skin
| | - Christian D Sadik
- Department of Dermatology, Allergy, and Venereology, University of Lübeck, Lübeck, Germany.,Center for Research on Inflammation of the Skin
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Perandones-González H, Alonso-Alonso T, Medina-Valdivieso S, Linares-Navarro R, Sáez-Álvarez S, Montanchez-Mateo J. Linear IgA/IgG bullous dermatosis after nivolumab therapy. Int J Dermatol 2021; 60:1007-1009. [PMID: 33900624 DOI: 10.1111/ijd.15627] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 02/23/2021] [Accepted: 04/06/2021] [Indexed: 11/30/2022]
Affiliation(s)
| | | | | | | | - Samuel Sáez-Álvarez
- Pathology Department, Complejo Asistencial Universitario de León, Leon, Spain
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6
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Lim GH, Cai SCS, Lee JSS, Chen Q. Rare case of linear IgA bullous dermatosis showing IgA, IgG and IgM reactivity. Australas J Dermatol 2021; 62:e361-e362. [PMID: 33729542 DOI: 10.1111/ajd.13558] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 12/17/2020] [Accepted: 12/19/2020] [Indexed: 12/12/2022]
Affiliation(s)
- Gim Hui Lim
- Duke NUS Medical School, Singapore, Singapore
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7
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Nätynki A, Tuusa J, Hervonen K, Kaukinen K, Lindgren O, Huilaja L, Kokkonen N, Salmi T, Tasanen K. Autoantibodies Against the Immunodominant Bullous Pemphigoid Epitopes Are Rare in Patients With Dermatitis Herpetiformis and Coeliac Disease. Front Immunol 2020; 11:575805. [PMID: 33072118 PMCID: PMC7544946 DOI: 10.3389/fimmu.2020.575805] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 08/25/2020] [Indexed: 12/11/2022] Open
Abstract
Dermatitis herpetiformis (DH) is an extraintestinal manifestation of coeliac disease (CD). Patients with DH have an elevated risk of development of another autoimmune blistering skin disease, bullous pemphigoid (BP). In this study we investigated whether patients with DH and CD (mean age for both 49 years) have circulating autoantibodies against BP180, the major BP autoantigen. ELISA tests showed that only a few DH (3/46) and CD (2/43) patients had BP180-NC16A IgG autoantibodies. Immunoblotting found that more than half of the DH samples contained IgG autoantibodies against full-length BP180. Epitope mapping with 13 fusion proteins covering the BP180 polypeptide revealed that in DH and CD patients, IgG autoantibodies did not target the NC16A or other epitopes typical of BP but recognized other intracellular and mid-extracellular regions of BP180. None of the analyzed DH and CD patients with either ELISA or immunoblotting positivity had IgG or IgA reactivity against the cutaneous basement membrane in indirect immunofluorescence analysis or skin symptoms characteristic of BP. Although only a minority of middle-aged DH patients had IgG autoantibodies against the immunodominant epitopes of BP180, our results do not exclude the possibility that intermolecular epitope spreading could explain the switch from DH to BP in elderly patients.
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Affiliation(s)
- Antti Nätynki
- PEDEGO Research Unit, Department of Dermatology, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Jussi Tuusa
- PEDEGO Research Unit, Department of Dermatology, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Kaisa Hervonen
- Department of Dermatology, Tampere University Hospital, Tampere, Finland
- Celiac Disease Research Center, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Katri Kaukinen
- Celiac Disease Research Center, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Department of Internal Medicine, Tampere University Hospital, Tampere, Finland
| | - Outi Lindgren
- PEDEGO Research Unit, Department of Dermatology, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
- Department of Pathology, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Laura Huilaja
- PEDEGO Research Unit, Department of Dermatology, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Nina Kokkonen
- PEDEGO Research Unit, Department of Dermatology, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Teea Salmi
- Department of Dermatology, Tampere University Hospital, Tampere, Finland
- Celiac Disease Research Center, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Kaisa Tasanen
- PEDEGO Research Unit, Department of Dermatology, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
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Abstract
Pemphigoid diseases are a group of autoimmune blistering skin diseases defined by an immune response against certain components of the dermal-epidermal adhesion complex. They are prototypical, autoantibody-driven, organ-specific diseases with the emergence of inflammatory skin lesions dependent on the recruitment of immune cells, particularly granulocytes, into the skin. During an acute flare of disease, inflammatory skin lesions typically progressing from erythema through urticarial plaques to subepidermal blisters erosions erupt and, finally, completely resolve, thus illustrating that resolution of inflammation is continuously executed in pemphigoid disease patients and can be directly monitored on the skin. Despite these superb conditions for examining resolution in pemphigoid diseases as paradigm diseases for antibody-induced tissue inflammation, the mechanisms of resolution in pemphigoid are underinvestigated and still largely elusive. In the last decade, mouse models for pemphigoid diseases were developed, which have been instrumental to identify several key pathways for the initiation of inflammation in these diseases. More recently, also protective pathways, specifically IL-10 and C5aR2 signalling on the molecular level and Tregs on the cellular level, counteracting skin inflammation have been highlighted and may contribute to the continuous execution of resolution in pemphigoid diseases. The upstream orchestrators of this process are currently under investigation. Pemphigoid disease patients, particularly bullous pemphigoid patients, who are predominantly above 75 years of age, often succumb to the side effects of the immunosuppressive therapeutics nowadays still required to suppress the disease. Pemphigoid disease patients may therefore represent a group of patients benefiting most substantially from the introduction of non-immunosuppressive, proresolving therapeutics into the treatment regimens for their disease.
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Affiliation(s)
- Christian D Sadik
- Department of Dermatology, Allergy, and Venerology, University of Lübeck, Lübeck, Germany
| | - Enno Schmidt
- Department of Dermatology, Allergy, and Venerology, University of Lübeck, Lübeck, Germany. .,Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany.
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Wang M, Lehman JS, Camilleri MJ, Drage LA, Wieland CN. Circulating bullous pemphigoid autoantibodies in the setting of negative direct immunofluorescence findings for bullous pemphigoid: A single-center retrospective review. J Am Acad Dermatol 2019; 81:472-479. [PMID: 30928465 DOI: 10.1016/j.jaad.2019.03.062] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 03/11/2019] [Accepted: 03/24/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND Bullous pemphigoid (BP) autoantibody levels are generally elevated in patients with BP but can be present nonspecifically in patients without BP. OBJECTIVE To analyze the clinical findings of patients with elevated BP180 or BP230 autoantibody levels and negative direct immunofluorescence (DIF) study findings. METHODS We retrospectively reviewed records of patients seen at our institution during January 1, 2005-December 31, 2015, who were positive for BP180 or BP230 autoantibodies and had a negative DIF study finding. These patients' demographic characteristics and BP180 and BP230 levels were compared with those of a BP control group who were positive for BP180 or BP230 autoantibodies and had positive DIF study findings. RESULTS We identified 208 patients with BP autoantibodies but without positive DIF study findings. These patients' mean age and enzyme-linked immunosorbent assay values were significantly lower than those of the control group. Dermatitis was the most common final clinical diagnosis. Of the 208 patients, 41 (19.7%) had at least 2 years' follow-up. Four patients had positive DIF results upon repeating the test and ultimately received pemphigoid diagnoses. LIMITATIONS Retrospective design with limited follow-up. CONCLUSION Patients might harbor serum BP autoantibodies in the context of a wide range of dermatoses. Low positive BP180 and BP230 autoantibody levels should not be overinterpreted as evidence for BP in the setting of a negative DIF.
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Affiliation(s)
- Michael Wang
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota
| | - Julia S Lehman
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota; Division of Anatomic Pathology, Mayo Clinic, Rochester, Minnesota
| | - Michael J Camilleri
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota; Division of Anatomic Pathology, Mayo Clinic, Rochester, Minnesota
| | - Lisa A Drage
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota
| | - Carilyn N Wieland
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota; Division of Anatomic Pathology, Mayo Clinic, Rochester, Minnesota.
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10
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Znamenskaya LF, Chikin VV, Nefedova MA. Linear IgA bullous dermatosis. VESTNIK DERMATOLOGII I VENEROLOGII 2018. [DOI: 10.25208/0042-4609-2018-94-6-42-51] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Aim: to present a clinical case of linear IgA bullous dermatosis.Materials and methods. A 44 years old patient complaining of skin rashes on the trunk and extremities, accompanied by severe itching was examined. We carried out a morphological investigation of biopsy samples derived from the lesion and apparently unaffected skin areas using the method of indirect immunofluorescence.Results. The patient having rashes in the form of multiple vesicles and small bubbles with a tight cover, which had been grouped into figures resembling pearl necklaces, demonstrated the presence of focal subepidermal cracks (subepidermal bubble in one location), as well as a linear deposition of IgA along the epidermal basement membrane. According to the clinical picture and following the histological and immunofluorescent investigation of skin biopsies, the patient was diagnosed with linear IgA bullous dermatosis. Lesion regression was achieved as a result of systemic therapy with prednisolone at a dose of 50 mg per day.Conclusion. The diagnosis of linear IgA bullous dermatosis should be made on the basis of skin biopsy investigation by the method of indirect immunofluorescence. Systemic glucocorticosteroids are seen as an effective approach to the treatment of such patients.
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11
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Witte M, Zillikens D, Schmidt E. Diagnosis of Autoimmune Blistering Diseases. Front Med (Lausanne) 2018; 5:296. [PMID: 30450358 PMCID: PMC6224342 DOI: 10.3389/fmed.2018.00296] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 10/05/2018] [Indexed: 12/11/2022] Open
Abstract
Autoimmune skin blistering diseases (AIBD) are characterized by autoantibodies that are directed against structural proteins in the skin and adjacent mucous membranes. Some clinical signs are typical for a specific AIBD, however, correct diagnosis requires the detection of tissue-bound or circulating autoantibodies. The gold standard for diagnosis of AIBD is the detection of autoantibodies or complement component 3 by direct immunofluorescence (DIF) microscopy of a perilesional biopsy. Circulating antibodies can be detected via indirect immunofluorescence (IIF) microscopy of different tissue substrates including human skin, monkey esophagus, and more recently, recombinant forms of the different target antigens. Latter are also employed in various commercial ELISA systems and by immunoblotting in in-house assays available in specialized laboratories. ELISA systems are also particularly valuable for monitoring of the disease activity during the disease course which can be helpful for treatment decisions. Exact diagnosis is essential for both treatment and prognosis, since some AIBD are associated with malign tumors such as paraneoplastic pemphigus and anti-laminin 332 mucous membrane pemphigoid. This review presents clinical and immunopathological features of AIBD for the state-of the art diagnosis of these disorders.
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Affiliation(s)
- Mareike Witte
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Detlef Zillikens
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Enno Schmidt
- Department of Dermatology, University of Lübeck, Lübeck, Germany
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12
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Antigen recognition in the pathogenesis of immunoglobulin A-related autoimmune bullous diseases. Postepy Dermatol Alergol 2018; 35:338-343. [PMID: 30206444 PMCID: PMC6130143 DOI: 10.5114/ada.2018.77663] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 06/27/2017] [Indexed: 11/25/2022] Open
Abstract
Immunoglobulin A (IgA) is the most common subtype of antibodies in mucosal surfaces. In most of autoimmune bullous diseases, however, immunoglobulin G (IgG) is the main pathogenic antibody that plays a role through complementation. The IgA antibody for epidermal connection protein can be found in the sera of some patients with blistering skin disease. Of these patients, some have the IgA antibody in their sera, while others have IgG and IgA antibodies. IgA-related autoimmune bullous diseases are less common in clinical practice. In the past, these diseases were not fully understood and their classifications were confusing. Recently, some progress has been made in the study of these diseases.
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13
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Liu Y, Li L, Xia Y. BP180 Is Critical in the Autoimmunity of Bullous Pemphigoid. Front Immunol 2017; 8:1752. [PMID: 29276517 PMCID: PMC5727044 DOI: 10.3389/fimmu.2017.01752] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 11/24/2017] [Indexed: 12/20/2022] Open
Abstract
Bullous pemphigoid (BP) is by far the most common autoimmune blistering dermatosis that mainly occurs in the elderly. The BP180 is a transmembrane glycoprotein, which is highly immunodominant in BP. The structure and location of BP180 indicate that it is a significant autoantigen and plays a key role in blister formation. Autoantibodies from BP patients react with BP180, which leads to its degradation and this has been regarded as the central event in BP pathogenesis. The consequent blister formation involves the activation of complement-dependent or -independent signals, as well as inflammatory pathways induced by BP180/anti-BP180 autoantibody interaction. As a multi-epitope molecule, BP180 can cause dermal-epidermal separation via combining each epitope with specific immunoglobulin, which also facilitates blister formation. In addition, some inflammatory factors can directly deplete BP180, thereby leading to fragility of the dermal-epidermal junction and blister formation. This review summarizes recent investigations on the role of BP180 in BP pathogenesis to determine the potential targets for the treatment of patients with BP.
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Affiliation(s)
- Yale Liu
- Department of Dermatology, The Second Affiliated Hospital, School of Medicine, Xi'an Jiaotong University, Xi'an, China
| | - Liang Li
- National-Local Joint Engineering Research Center of Biodiagnostics and Biotherapy, The Second Affiliated Hospital, School of Medicine, Xi'an Jiaotong University, Xi'an, China
| | - Yumin Xia
- Department of Dermatology, The Second Affiliated Hospital, School of Medicine, Xi'an Jiaotong University, Xi'an, China
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14
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Gottlieb J, Ingen-Housz-Oro S, Alexandre M, Grootenboer-Mignot S, Aucouturier F, Sbidian E, Tancrede E, Schneider P, Regnier E, Picard-Dahan C, Begon E, Pauwels C, Cury K, Hüe S, Bernardeschi C, Ortonne N, Caux F, Wolkenstein P, Chosidow O, Prost-Squarcioni C. Idiopathic linear IgA bullous dermatosis: prognostic factors based on a case series of 72 adults. Br J Dermatol 2017; 177:212-222. [PMID: 27995619 DOI: 10.1111/bjd.15244] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND Linear IgA bullous dermatosis (LABD) is a clinically and immunologically heterogeneous, subepidermal, autoimmune bullous disease (AIBD), for which the long-term evolution is poorly described. OBJECTIVES To investigate the clinical and immunological characteristics, follow-up and prognostic factors of adult idiopathic LABD. METHODS This retrospective study, conducted in our AIBD referral centre, included adults, diagnosed between 1995 and 2012, with idiopathic LABD, defined as pure or predominant IgA deposits by direct immunofluorescence. Clinical, histological and immunological findings were collected from charts. Standard histology was systematically reviewed, and indirect immunofluorescence (IIF) on salt-split skin (SSS) and immunoblots (IBs) on amniotic membrane extracts using anti-IgA secondary antibodies were performed, when biopsies and sera obtained at diagnosis were available. Prognostic factors for complete remission (CR) were identified using univariate and multivariate analyses. RESULTS Of the 72 patients included (median age 54 years), 60% had mucous membrane (MM) involvement. IgA IIF on SSS was positive for 21 of 35 patients tested; 15 had epidermal and dermal labellings. Immunoelectron microscopy performed on the biopsies of 31 patients labelled lamina lucida (LL) (26%), lamina densa (23%), anchoring-fibril zone (AFz) (19%) and LL+AFz (23%). Of the 34 IgA IBs, 22 were positive, mostly for LAD-1/LABD97 (44%) and full-length BP180 (33%). The median follow-up was 39 months. Overall, 24 patients (36%) achieved sustained CR, 19 (29%) relapsed and 35% had chronic disease. CR was significantly associated with age > 70 years or no MM involvement. No prognostic immunological factor was identified. CONCLUSIONS Patients with LABD who are < 70 years old and have MM involvement are at risk for chronic evolution.
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Affiliation(s)
- J Gottlieb
- Dermatology Department, APHP, Henri-Mondor Hospital, Créteil, France.,Referral Center for Autoimmune Blistering Diseases, Île-de-France, France
| | - S Ingen-Housz-Oro
- Dermatology Department, APHP, Henri-Mondor Hospital, Créteil, France.,Referral Center for Autoimmune Blistering Diseases, Île-de-France, France.,Université Paris-Est Créteil Val de Marne, UPEC, DHU VIC, IRM, EA 7379 EpiDermE, Créteil, France
| | - M Alexandre
- Referral Center for Autoimmune Blistering Diseases, Île-de-France, France.,Dermatology Department, APHP, Avicenne Hospital, Bobigny, France
| | - S Grootenboer-Mignot
- Referral Center for Autoimmune Blistering Diseases, Île-de-France, France.,Department of Autoimmunity and Hypersensitivity, APHP, Bichat Hospital, Paris, France
| | - F Aucouturier
- Referral Center for Autoimmune Blistering Diseases, Île-de-France, France.,Immunology Department, APHP, Saint-Louis Hospital, Paris, France
| | - E Sbidian
- Dermatology Department, APHP, Henri-Mondor Hospital, Créteil, France.,Université Paris-Est Créteil Val de Marne, UPEC, DHU VIC, IRM, EA 7379 EpiDermE, Créteil, France.,Inserm, Centre d'Investigation Clinique 1430, Créteil, France
| | - E Tancrede
- Referral Center for Autoimmune Blistering Diseases, Île-de-France, France.,Dermatology Department, APHP, Saint-Louis Hospital, Paris, France
| | - P Schneider
- Referral Center for Autoimmune Blistering Diseases, Île-de-France, France.,Dermatology Department, APHP, Saint-Louis Hospital, Paris, France.,Pathology Department, APHP, Saint-Louis Hospital, Paris, France
| | - E Regnier
- Referral Center for Autoimmune Blistering Diseases, Île-de-France, France.,Dermatology Department, APHP, Tarnier Hospital, Paris, France
| | - C Picard-Dahan
- Referral Center for Autoimmune Blistering Diseases, Île-de-France, France.,Dermatology Department, APHP, Bichat Hospital, Paris, France
| | - E Begon
- Dermatology Department, René-Dubos Hospital, Pontoise, France
| | - C Pauwels
- Dermatology Department, Saint-Germain Hospital, Saint-Germain, France
| | - K Cury
- Referral Center for Autoimmune Blistering Diseases, Île-de-France, France.,Dermatology Department, APHP, Tenon Hospital, Paris, France
| | - S Hüe
- Referral Center for Autoimmune Blistering Diseases, Île-de-France, France.,Université Paris-Est Créteil Val de Marne, UPEC, DHU VIC, IRM, EA 7379 EpiDermE, Créteil, France.,Immunology Department, APHP, Henri-Mondor Hospital, Créteil, France
| | - C Bernardeschi
- Referral Center for Autoimmune Blistering Diseases, Île-de-France, France.,Pathology Department, APHP, Saint-Louis Hospital, Paris, France
| | - N Ortonne
- Referral Center for Autoimmune Blistering Diseases, Île-de-France, France.,Université Paris-Est Créteil Val de Marne, UPEC, DHU VIC, IRM, EA 7379 EpiDermE, Créteil, France.,Pathology Department, APHP, Henri-Mondor Hospital, Créteil, France
| | - F Caux
- Referral Center for Autoimmune Blistering Diseases, Île-de-France, France.,Dermatology Department, APHP, Avicenne Hospital, Bobigny, France.,Université Paris 13, Bobigny, France
| | - P Wolkenstein
- Dermatology Department, APHP, Henri-Mondor Hospital, Créteil, France.,Referral Center for Autoimmune Blistering Diseases, Île-de-France, France.,Université Paris-Est Créteil Val de Marne, UPEC, DHU VIC, IRM, EA 7379 EpiDermE, Créteil, France
| | - O Chosidow
- Dermatology Department, APHP, Henri-Mondor Hospital, Créteil, France.,Referral Center for Autoimmune Blistering Diseases, Île-de-France, France.,Université Paris-Est Créteil Val de Marne, UPEC, DHU VIC, IRM, EA 7379 EpiDermE, Créteil, France.,Inserm, Centre d'Investigation Clinique 1430, Créteil, France
| | - C Prost-Squarcioni
- Referral Center for Autoimmune Blistering Diseases, Île-de-France, France.,Dermatology Department, APHP, Avicenne Hospital, Bobigny, France.,Université Paris 13, Bobigny, France.,Pathology Department, APHP, Avicenne Hospital, Bobigny, France
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15
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Mersmann M, Dworschak J, Ebermann K, Komorowski L, Schlumberger W, Stöcker W, Zillikens D, Probst C, Schmidt E. Immunoadsorber for specific apheresis of autoantibodies in the treatment of bullous pemphigoid. Arch Dermatol Res 2016; 308:31-8. [PMID: 26498290 DOI: 10.1007/s00403-015-1606-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 09/29/2015] [Accepted: 10/14/2015] [Indexed: 01/28/2023]
Abstract
Bullous pemphigoid (BP) is an autoimmune blistering skin disease associated with autoantibodies against two hemidesmosomal proteins, BP180 (type XVII collagen) and BP230. As the pathogenic relevance of antibodies against the immunodominant NC16A domain of BP180 has been clearly demonstrated, specific removal of these antibodies should be a rational therapeutic approach. Here, we evaluated three recombinant forms of bacterially produced BP180 NC16A, a monomer, trimer, and tetramer, together with different matrices for their efficacy to specifically adsorb autoantibodies from BP plasma samples. An adsorber consisting of NC16A-trimer coupled to NHS-activated Sepharose 4 Fast Flow revealed satisfying adsorption rates and a high specificity. The NC16A-trimer adsorber was regenerable and autoclavable. It has the potential to be used for specific immunoadsorption to treat severe and refractory BP and other pemphigoid diseases associated with BP180 NC16A reactivity.
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Affiliation(s)
- Michael Mersmann
- Institute of Experimental Immunology, Euroimmun AG, Seekamp 31, 23560, Lübeck, Germany.
| | - Jenny Dworschak
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Kristin Ebermann
- Institute of Experimental Immunology, Euroimmun AG, Seekamp 31, 23560, Lübeck, Germany
| | - Lars Komorowski
- Institute of Experimental Immunology, Euroimmun AG, Seekamp 31, 23560, Lübeck, Germany
| | - Wolfgang Schlumberger
- Institute of Experimental Immunology, Euroimmun AG, Seekamp 31, 23560, Lübeck, Germany
| | - Winfried Stöcker
- Institute of Experimental Immunology, Euroimmun AG, Seekamp 31, 23560, Lübeck, Germany
| | - Detlef Zillikens
- Department of Dermatology, University of Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Christian Probst
- Institute of Experimental Immunology, Euroimmun AG, Seekamp 31, 23560, Lübeck, Germany
| | - Enno Schmidt
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
- Department of Dermatology, University of Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
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16
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Schmidt T, Sitaru C, Amber K, Hertl M. BP180- and BP230-specific IgG autoantibodies in pruritic disorders of the elderly: a preclinical stage of bullous pemphigoid? Br J Dermatol 2014; 171:212-9. [PMID: 24601973 DOI: 10.1111/bjd.12936] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2014] [Indexed: 12/22/2022]
Abstract
Pruritus increasingly occurs in the elderly population and is associated with a variety of dermatoses of mixed aetiology. Clinical and experimental evidence suggests that senile pruritus may be linked to autoimmune events initiated by loss of self-tolerance against cutaneous autoantigens, which is facilitated by immune ageing processes. T-cell immunity, which underpins the production of pathogenic autoantibodies in autoimmune diseases, is deregulated by immune senescence thereby leading to autoimmune disorders such as bullous pemphigoid (BP). High mortality rates of BP combined with steadily increasing incidence emphasize the need for an effective diagnostic strategy at an early stage. We summarize here the current understanding of immunological alterations during the ageing process, thereby focusing on aberrant T-cell responses against the basement membrane antigens BP180 and BP230, which may eventually lead to the clinical outcome of BP.
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Affiliation(s)
- T Schmidt
- Department of Dermatology and Allergology, Philipps University, Baldinger Str., D-35043, Marburg, Germany
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17
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Recke A, Trog LM, Pas HH, Vorobyev A, Abadpour A, Jonkman MF, van Zandbergen G, Kauderer C, Zillikens D, Vidarsson G, Ludwig RJ. Recombinant Human IgA1 and IgA2 Autoantibodies to Type VII Collagen Induce Subepidermal Blistering Ex Vivo. THE JOURNAL OF IMMUNOLOGY 2014; 193:1600-8. [DOI: 10.4049/jimmunol.1400160] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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18
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Takayama N, Nakazono S, Kumagai J, Kawamura T, Suzuki F, Ishii N, Hashimoto T, Namiki T. Case of subepidermal bullous disease with diffuse esophageal involvement presenting with immunoglobulin G autoantibodies to both the BP180 NC16a and C-terminal domains, and immunoglobulin A autoantibodies to the BP180 NC16a domain. J Dermatol 2014; 41:665-7. [PMID: 24930476 DOI: 10.1111/1346-8138.12522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Naoko Takayama
- Department of Dermatology, Yokohama City Minato Red Cross Hospital, Naka-ku, Yokohama, Japan
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19
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Abstract
Pemphigoid diseases are a group of well defined autoimmune disorders that are characterised by autoantibodies against structural proteins of the dermal-epidermal junction and, clinically, by tense blisters and erosions on skin or mucous membranes close to the skin surface. The most common of these diseases is bullous pemphigoid, which mainly affects older people and the reported incidence of which in Europe has more than doubled in the past decade. Prognosis and treatments vary substantially between the different disorders and, since clinical criteria are usually not sufficient, direct immunofluorescence microscopy of a perilesional biopsy specimen or serological tests are needed for exact diagnosis. In eight pemphigoid diseases the target antigens have been identified molecularly, which has allowed the development of standard diagnostic assays for detection of serum autoantibodies-some of which are commercially available. In this Seminar we discuss the clinical range, diagnostic criteria, diagnostic assay systems, and treatment options for this group of diseases.
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Affiliation(s)
- Enno Schmidt
- Department of Dermatology, University of Lübeck, Lübeck, Germany.
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20
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Agheli A, Becker M, Becker G, Chaudhry MR, Wang JC. Response of hemorrhagic bullous skin lesions of the breast secondary to primary systemic amyloidosis to a five-drug combination chemotherapy: a case report and review of the literature. Exp Hematol Oncol 2012; 1:19. [PMID: 23210921 PMCID: PMC3514100 DOI: 10.1186/2162-3619-1-19] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2012] [Accepted: 05/30/2012] [Indexed: 11/10/2022] Open
Abstract
Two major types of amyloidosis are primary amyloidosis or amyloid light chain amyloidosis and secondary amyloidosis. Although amyloidosis involves a variety of organ systems including skin, the occurrence of bullous skin lesions is rare. Little is known about the mechanism of blister formation. These blisters are often hemorrhagic and typically occur in the oral mucosa. Only a few case reports have described skin involvement in systemic amyloidosis. The manifestation of bullous lesions on the breast in association with primary amyloidosis has not been previously reported. Therefore, we report a case of cutaneous hemorrhagic bullous of the breast secondary to primary systemic amyloidosis, which may be important for medical oncologists to be aware of this uncommon presentation of plasma cell dysrasias. Furthermore, this case only partially responded to the commonly used multiple myeloma-type regimen, the skin lesions responded completely to a five-drug combination chemotherapy regimen, utilizing immunomodulators, liposomal doxorubicin, cyclophosphamide, bortezomib, and dexamethasone, suggesting that a more aggressive modality of chemotherapy may be necessary to treat such cases.
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Affiliation(s)
- Aref Agheli
- Division of Hematology/Oncology, Brookdale University Hospital & Medical Center, Brooklyn, NY, 11212, USA.
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21
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van Beek N, Rentzsch K, Probst C, Komorowski L, Kasperkiewicz M, Fechner K, Bloecker IM, Zillikens D, Stöcker W, Schmidt E. Serological diagnosis of autoimmune bullous skin diseases: prospective comparison of the BIOCHIP mosaic-based indirect immunofluorescence technique with the conventional multi-step single test strategy. Orphanet J Rare Dis 2012; 7:49. [PMID: 22876746 PMCID: PMC3533694 DOI: 10.1186/1750-1172-7-49] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2012] [Accepted: 08/02/2012] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Various antigen-specific immunoassays are available for the serological diagnosis of autoimmune bullous diseases. However, a spectrum of different tissue-based and monovalent antigen-specific assays is required to establish the diagnosis. BIOCHIP mosaics consisting of different antigen substrates allow polyvalent immunofluorescence (IF) tests and provide antibody profiles in a single incubation. METHODS Slides for indirect IF were prepared, containing BIOCHIPS with the following test substrates in each reaction field: monkey esophagus, primate salt-split skin, antigen dots of tetrameric BP180-NC16A as well as desmoglein 1-, desmoglein 3-, and BP230gC-expressing human HEK293 cells. This BIOCHIP mosaic was probed using a large panel of sera from patients with pemphigus vulgaris (PV, n=65), pemphigus foliaceus (PF, n=50), bullous pemphigoid (BP, n=42), and non-inflammatory skin diseases (n=97) as well as from healthy blood donors (n=100). Furthermore, to evaluate the usability in routine diagnostics, 454 consecutive sera from patients with suspected immunobullous disorders were prospectively analyzed in parallel using a) the IF BIOCHIP mosaic and b) a panel of single antibody assays as commonly used by specialized centers. RESULTS Using the BIOCHIP mosaic, sensitivities of the desmoglein 1-, desmoglein 3-, and NC16A-specific substrates were 90%, 98.5% and 100%, respectively. BP230 was recognized by 54% of the BP sera. Specificities ranged from 98.2% to 100% for all substrates. In the prospective study, a high agreement was found between the results obtained by the BIOCHIP mosaic and the single test panel for the diagnosis of BP, PV, PF, and sera without serum autoantibodies (Cohen's κ between 0.88 and 0.97). CONCLUSIONS The BIOCHIP mosaic contains sensitive and specific substrates for the indirect IF diagnosis of BP, PF, and PV. Its diagnostic accuracy is comparable with the conventional multi-step approach. The highly standardized and practical BIOCHIP mosaic will facilitate the serological diagnosis of autoimmune blistering diseases.
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Affiliation(s)
- Nina van Beek
- Department of Dermatology, University of Luebeck, Luebeck, Germany
| | - Kristin Rentzsch
- Institute of Experimental Immunology, EUROIMMUN AG, Luebeck, Germany
| | - Christian Probst
- Institute of Experimental Immunology, EUROIMMUN AG, Luebeck, Germany
| | - Lars Komorowski
- Institute of Experimental Immunology, EUROIMMUN AG, Luebeck, Germany
| | | | - Kai Fechner
- Institute of Experimental Immunology, EUROIMMUN AG, Luebeck, Germany
| | - Inga M Bloecker
- Institute of Experimental Immunology, EUROIMMUN AG, Luebeck, Germany
| | - Detlef Zillikens
- Department of Dermatology, University of Luebeck, Luebeck, Germany
| | - Winfried Stöcker
- Institute of Experimental Immunology, EUROIMMUN AG, Luebeck, Germany
| | - Enno Schmidt
- Department of Dermatology, University of Luebeck, Luebeck, Germany
- Comprehensive Center for Inflammation Medicine (CCIM), University of Luebeck, Luebeck, Germany
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22
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Pirkhammer D, Zillikens D, Födinger D, Zimmermann P, Rappersberger K. [Chronic bullous disease of childhood. Long-term therapy over 8 years with 4,4'-diaminodiphenylsulfone]. Hautarzt 2012; 63:644-7. [PMID: 22648456 DOI: 10.1007/s00105-011-2313-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
A 3-year-old boy presented with a generalized bullous disease, clinically strongly indicative of chronic bullous disease of childhood (CBDC). The diagnosis was confirmed by histopathology and further verified by several immunological and biochemical examinations. Direct immunofluorescence (IF) of perilesional skin revealed in vivo bound IgA-autoantibodies (aabs) in a linear pattern along the basement membrane zone; indirect IF revealed circulating IgA-aabs bound to the roof of "split skin" preparations of healthy human skin; immunoblotting of epidermal protein extracts showed that the aabs bound to a 97KD/120KD protein. Therapy with 4,4'-diaminodiphenylsulfone (DADPS, 2 mg/kg /daily), combined with prednisolone for the first month, was initiated, and promptly led to complete remission. Two attempts to stop DADPS treatment after 3 and 5 years of continuous therapy were followed by prompt recurrences. The boy is now 8 years old; with continuous DADPS therapy (1 mg/kg body weight/d), he displays regular physical and intellectual development.
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Affiliation(s)
- D Pirkhammer
- Abteilung für Dermatologie , Krankenanstalt Rudolfstiftung, Juchgasse 25, 1030 Wien, Österreich.
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23
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Schmidt E, della Torre R, Borradori L. Clinical features and practical diagnosis of bullous pemphigoid. Immunol Allergy Clin North Am 2012; 32:217-32, v. [PMID: 22560135 DOI: 10.1016/j.iac.2012.04.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Bullous pemphigoid (BP) represents the most common autoimmune subepidermal blistering disease. BP typically affects the elderly and is associated with significant morbidity. It has usually a chronic course with spontaneous exacerbations. The cutaneous manifestations of BP can be extremely protean. While diagnosis of BP in the bullous stage is straightforward, in the non-bullous stage or in atypical variants of BP signs and symptoms are frequently non-specific with eg, only itchy excoriated, eczematous, papular and/or urticarial lesions that may persist for several weeks or months. Diagnosis of BP critically relies on immunopathologic examinations including direct immunofluorescence microscopy and detection of serum autoantibodies by indirect immunofluorescence microscopy or BP180-ELISA.
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Affiliation(s)
- Enno Schmidt
- Department of Dermatology, University of Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany.
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24
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Kanayama Y, Tsuruta D, Tateishi C, Hasegawa Y, Amo K, Fukai K, Kobayashi H, Ishii M. Two cases of infantile linear immunoglobulin A/immunoglobulin G bullous dermatosis. J Dermatol 2012; 39:176-8. [PMID: 21767293 DOI: 10.1111/j.1346-8138.2011.01239.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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25
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Kasperkiewicz M, Zillikens D, Schmidt E. Pemphigoid diseases: Pathogenesis, diagnosis, and treatment. Autoimmunity 2011; 45:55-70. [DOI: 10.3109/08916934.2011.606447] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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26
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Jukić IL, Marinović B. Significance of immunofluorescence in the diagnosis of autoimmune bullous dermatoses. Clin Dermatol 2011; 29:389-97. [DOI: 10.1016/j.clindermatol.2011.01.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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27
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28
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Schmidt E, Zillikens D. The diagnosis and treatment of autoimmune blistering skin diseases. DEUTSCHES ARZTEBLATT INTERNATIONAL 2011; 108:399-405, I-III. [PMID: 21712975 DOI: 10.3238/arztebl.2011.0399] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2009] [Accepted: 07/23/2010] [Indexed: 12/24/2022]
Abstract
BACKGROUND Autoimmune blistering skin diseases are a heterogeneous group of disorders associated with autoantibodies that are directed against desmosomal structural proteins (in pemphigus diseases) or hemidesmosomal ones (in pemphigoid diseases and epidermolysis bullosa acquisita), or else against epidermal/ tissue transglutaminases (in dermatitis herpetiformis). Knowledge of the clinical presentation of these disorders and of the relevant diagnostic procedures is important not just for dermatologists, but also for general practitioners, ophthalmologists, ENT specialists, dentists, gynecologists, and pediatricians. METHODS The literature on the subject was selectively reviewed. There are no existing guidelines available in Germany. RESULTS The recently developed sensitive and specific assays for circulating autoantibodies in these diseases now enable a serological diagnosis in about 90% of cases. The incidence of autoimmune blistering skin diseases in Germany has doubled in the last 10 years, to a current figure of about 25 new cases per million persons per year, because of improved diagnostic techniques as well as the aging of the population. Accurate and specific diagnosis is the prerequisite for reliable prognostication and appropriate treatment. For severe and intractable cases, more effective treatments have recently become available, including immunoadsorption, high-dose intravenous immunoglobulin, the anti-CD20 antibody rituximab, and combinations of the above. CONCLUSION The diagnostic assessment of autoimmune blistering skin diseases can be expected to improve in the near future as new serological testing systems are developed that employ recombinant forms of the target antigens. The treatments currently in use still need to be validated by prospective, controlled trials.
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Affiliation(s)
- Enno Schmidt
- Exzellenzzentrum für Entzündungsmedizin, Klinik für Dermatologie, Allergologie und Venerologie, Universität zu Lübeck.
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29
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Csorba K, Schmidt S, Florea F, Ishii N, Hashimoto T, Hertl M, Kárpáti S, Bruckner-Tuderman L, Nishie W, Sitaru C. Development of an ELISA for sensitive and specific detection of IgA autoantibodies against BP180 in pemphigoid diseases. Orphanet J Rare Dis 2011; 6:31. [PMID: 21619684 PMCID: PMC3126693 DOI: 10.1186/1750-1172-6-31] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2010] [Accepted: 05/28/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pemphigoids are rare diseases associated with IgG, IgE and IgA autoantibodies against collagen XVII/BP180. An entity of the pemphigoid group is the lamina lucida-type of linear IgA disease (IgA pemphigoid) characterized by IgA autoantibodies against BP180. While for the detection of IgG and IgE autoantibodies specific to collagen XVII several ELISA systems have been established, no quantitative immunoassay has been yet developed for IgA autoantibodies. Therefore, the aim of the present study was to develop an ELISA to detect IgA autoantibodies against collagen XVII in the sera of patients with pemphigoids. METHODS We expressed a soluble recombinant form of the collagen XVII ectodomain in mammalian cells. Reactivity of IgA autoantibodies from patients with IgA pemphigoid was assessed by immunofluorescence microscopy and immunoblot analysis. ELISA test conditions were determined by chessboard titration experiments. The sensitivity, specificity and the cut-off were determined by receiver-operating characteristics analysis. RESULTS The optimized assay was carried out using sera from patients with IgA pemphigoid (n = 30) and healthy donors (n=105). By receiver operating characteristics (ROC) analysis, an area under the curve of 0.993 was calculated, indicating an excellent discriminatory capacity. Thus, a sensitivity and specificity of 83.3% and 100%, respectively, was determined for a cut-off point of 0.48. As additional control groups, sera from patients with bullous pemphigoid (n=31) and dermatitis herpetiformis (n = 50), a disease associated with IgA autoantibodies against epidermal transglutaminase, were tested. In 26% of bullous pemphigoid patients, IgA autoantibodies recognized the ectodomain of collagen XVII. One of 50 (2%) of dermatitis herpetiformis patients sera slightly topped the cut-off value. CONCLUSIONS We developed the first ELISA for the specific and sensitive detection of serum IgA autoantibodies specific to collagen XVII in patients with pemphigoids. This immunoassay should prove a useful tool for clinical and translational research and should essentially improve the diagnosis and disease monitoring of patients with IgA pemphigoid. Moreover, our findings strongly suggest that IgA pemphigoid and IgG bullous pemphigoid represent two ends of the clinical spectrum of an immunological loss of tolerance against components of hemidesmosomes, which is mediated by both IgG and IgA autoantibodies.
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Affiliation(s)
- Kinga Csorba
- Department of Dermatology, University of Freiburg, Hauptstrasse 7, 79104, Freiburg, Germany
- Faculty of Biology, University of Freiburg, Schaenzlestrasse 1, 79104, Freiburg, Germany
| | - Sabine Schmidt
- Department of Dermatology, University of Freiburg, Hauptstrasse 7, 79104, Freiburg, Germany
| | - Florina Florea
- Department of Dermatology, University of Freiburg, Hauptstrasse 7, 79104, Freiburg, Germany
| | - Norito Ishii
- Department of Dermatology, Kurume University, 67 Asahimachi, Kurume, Fukuoka 830-0011, Japan
| | - Takashi Hashimoto
- Department of Dermatology, Kurume University, 67 Asahimachi, Kurume, Fukuoka 830-0011, Japan
| | - Michael Hertl
- Department of Dermatology and Allergology, University of Marburg, Deutschhausstrasse 9, 35037, Marburg, Germany
| | - Sarolta Kárpáti
- Department of Dermatology, Venerology and Dermatooncology, Faculty of Medicine, Semmelweis University, Maria street 41, 1085, Budapest, Hungary
| | | | - Wataru Nishie
- Department of Dermatology, University of Freiburg, Hauptstrasse 7, 79104, Freiburg, Germany
| | - Cassian Sitaru
- Department of Dermatology, University of Freiburg, Hauptstrasse 7, 79104, Freiburg, Germany
- BIOSS Center for Biological Signaling Studies, University of Freiburg, Hebelstrasse 25, 79104, Freiburg, Germany
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Schmidt E, Zillikens D. Modern diagnosis of autoimmune blistering skin diseases. Autoimmun Rev 2010; 10:84-9. [DOI: 10.1016/j.autrev.2010.08.007] [Citation(s) in RCA: 114] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2010] [Accepted: 08/08/2010] [Indexed: 01/07/2023]
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Rose C, Schmidt E, Kerstan A, Thoma-Uszynski S, Wesselmann U, Käsbohrer U, Zillikens D, Shimanovich I. Histopathology of anti-laminin 5 mucous membrane pemphigoid. J Am Acad Dermatol 2009; 61:433-40. [PMID: 19700013 DOI: 10.1016/j.jaad.2009.02.012] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2008] [Revised: 02/02/2009] [Accepted: 02/05/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND Anti-laminin 5 mucous membrane pemphigoid (MMP) is an autoimmune blistering disease characterized by autoantibodies against the major basement membrane component laminin 5 (laminin 332, epiligrin). OBJECTIVE AND METHODS We reviewed 17 biopsy specimens from 9 patients with anti-laminin 5 MMP in an attempt to define typical histopathologic features of the disease. RESULTS Fifteen specimens showed subepidermal blister formation, while two biopsy specimens revealed an epithelial ulcer. In 11 biopsies a sparse to moderate inflammatory infiltrate composed of lymphocytes and neutrophils with some eosinophils was observed. Four biopsies showed a dense infiltrate dominated by neutrophils in two cases and by eosinophils in one case. The remaining biopsy revealed a dense lymphoplasmacellular infiltrate without granulocytes. Scarring of the upper dermis was present only in 5 specimens. Immunohistochemical analysis localized type IV collagen to the dermal side of the blister, suggesting that split formation occurred within the lamina lucida of the cutaneous basement membrane. LIMITATIONS The number of patients studied was relatively small. CONCLUSIONS Histopathology of anti-laminin 5 MMP is characterized by subepidermal blistering and a sparse to moderate superficial lymphohistiocytic infiltrate with neutrophils and/or eosinophils. Both infiltrate density and composition may vary, making anti-laminin 5 MMP indistinguishable from other autoimmune subepidermal blistering diseases by histopathology alone. Scarring is present only in a minority of cases and is not a sensitive clue to the diagnosis of anti-laminin 5 MMP.
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Affiliation(s)
- Christian Rose
- Department of Dermatology, University of Lübeck, Lübeck, Germany
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Schmidt E, Zillikens D. Research in practice: diagnosis of subepidermal autoimmune bullous disorders. J Dtsch Dermatol Ges 2009; 7:296-300. [DOI: 10.1111/j.1610-0387.2008.06974.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Schmidt E, Zillikens D. Diagnosis and clinical severity markers of bullous pemphigoid. F1000 MEDICINE REPORTS 2009; 1. [PMID: 20948767 PMCID: PMC2920699 DOI: 10.3410/m1-15] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
The use of a broad spectrum of novel detection systems for autoantibodies to the basement membrane proteins BP180 and BP230 has greatly facilitated the diagnosis of bullous pemphigoid, which most likely explains its increasing incidence in central Europe. Because the pathogenic relevance of antibodies to human BP180 has been convincingly shown both in vitro and in vivo, repeated testing for these antibodies appears to be helpful in guiding treatment decisions during the course of the disease.
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Affiliation(s)
- Enno Schmidt
- Department of Dermatology, University of Lübeck Ratzeburger Allee 160, D-23538 Lübeck Germany
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Bertram F, Bröcker EB, Zillikens D, Schmidt E. Prospective analysis of the incidence of autoimmune bullous disorders in Lower Franconia, Germany. J Dtsch Dermatol Ges 2009; 7:434-40. [PMID: 19170813 DOI: 10.1111/j.1610-0387.2008.06976.x] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Only limited epidemiologic data are available on autoimmune bullous diseases. Improved diagnostic tools should have led to an increased incidence. To test this hypothesis, all patients with autoimmune bullous disorders who were treated in the Department of Dermatology at the University of Würzburg, Germany, between January 2001 and June 2002 were analysed prospectively. PATIENTS AND METHODS Epidemiologic data of patients diagnosed with an autoimmune bullous disease during this time period were registered and statistically evaluated. Diagnosis was based on the clinical picture and specific immunopathological findings. Only patients from Lower Franconia, a well-defined administrative region of Southern Germany, were included into this study. RESULTS During the study period, 41 patients with an autoimmune bullous disease were diagnosed, including 27 with bullous pemphigoid, 4 with pemphigoid gestationis and mucous membrane pemphigoid, 2 with dermatitis herpetiformis and linear IgA disease, and 1 with epidermolysis bullosa acquisita and pemphigus vulgaris, respectively. The highest incidence was calculated for bullous pemphigoid (13.4 per 1 million inhabitants per year) followed by pemphigoid gestationis (2.0) and mucous membrane pemphigoid (2.0). Patients with mucous membrane pemphigoid were found to have the highest mean age at disease onset (76 years) followed by patients with bullous pemphigoid (74 years). CONCLUSIONS This is the first prospective study on the incidence of autoimmune bullous disorders. Subepidermal blistering autoimmune diseases were shown to be more frequent than previously reported for Central Europe. This is most likely due to improved diagnostic tools for and increased awareness of these diseases.
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Marcus KA, Halbertsma FJJ, van Steensel MAM. A case of juvenile bullous pemphigoid--successful treatment with diaminodiphenylsulfone and prednisone. Pediatr Dermatol 2009; 26:55-8. [PMID: 19250407 DOI: 10.1111/j.1525-1470.2008.00822.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Blistering skin diseases can be difficult to diagnose, particularly in children. Because of the wide variety of bullous disorders and the considerable clinical overlap between them, it is difficult to differentiate one from the other on clinical features alone. Appropriate additional investigations are required to confirm the diagnosis. These include routine histologic examination of the skin, in addition to immunohistochemical staining and immune serology. Here, we present a rare case of juvenile bullous pemphigoid, which we will use to illustrate the difficulties encountered in the diagnostic process and to show how acquired blistering disorders of childhood should be approached.
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Affiliation(s)
- Karen A Marcus
- Department of Paediatrics, Máxima Medical Centre Veldhoven, The Netherlands.
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36
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Viglizzo G, Cozzani E, Nozza P, Occella C, Parodi A. A case of linear IgA disease in a child with IgA and IgG circulating antibodies directed to BPAg2. Int J Dermatol 2007; 46:1302-4. [PMID: 18173529 DOI: 10.1111/j.1365-4632.2007.03317.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
A 7-year-old Caucasian girl had multiple bullae on the trunk, upper and lower limbs (Fig. 1a,b) for 10 days. The lesions were large, tense, and asymptomatic, and mucosae were not involved. Laboratory findings were all normal. Histopathology revealed a subepidermal blister containing numerous neutrophils, eosinophils, and fibrin. Direct immunofluorescence of perilesional skin disclosed linear deposition of IgA and slight linear deposits of IgM at the basement membrane zone (Fig. 2). Indirect immunofluorescence on monkey esophagus and on human salt-split skin was negative. Immunoblot assay (IB), performed with an epidermal extract, revealed IgA and IgG antibodies directed to BPAg2 antigen (Fig. 3), while it was negative when performed on dermal extract. Enzyme-linked immunosorbent serologic assay using a commercial kit (MBL, Naka-Ku Nagoya, Japan) with the noncollagenous domain (NC16A) of the BPAg2 antigen was negative for both IgA and IgG. A diagnosis of linear IgA disease (LAD) was made and a treatment with dapsone (50 mg/day) and prednisolone (30 mg/day) was initiated. One month later, lesions had cleared.
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Affiliation(s)
- Gianmaria Viglizzo
- Section of Dermatology, Dipartimento di Scienze Endocrinologiche e Metaboliche (DiSEM), University of Genoa, Viale Benedetto XV 7, 16132, Genoa, Italy
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37
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Buijsrogge JJA, Hagel C, Duske U, Kromminga A, Vissink A, Kloosterhuis AJ, van der Wal JE, Jonkman MF, Pas HH. IgG antibodies to BP180 in a subset of oral lichen planus patients. J Dermatol Sci 2007; 47:256-8. [PMID: 17604609 DOI: 10.1016/j.jdermsci.2007.05.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2007] [Revised: 05/01/2007] [Accepted: 05/22/2007] [Indexed: 11/23/2022]
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38
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Sitaru C, Dähnrich C, Probst C, Komorowski L, Blöcker I, Schmidt E, Schlumberger W, Rose C, Stöcker W, Zillikens D. Enzyme-linked immunosorbent assay using multimers of the 16th non-collagenous domain of the BP180 antigen for sensitive and specific detection of pemphigoid autoantibodies. Exp Dermatol 2007; 16:770-7. [PMID: 17697150 DOI: 10.1111/j.1600-0625.2007.00592.x] [Citation(s) in RCA: 95] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Bullous pemphigoid (BP) and pemphigoid gestationis (PG) are acquired autoimmune subepidermal blistering diseases characterized by autoantibodies against the hemidesmosomal proteins BP180/type XVII collagen and BP230. In the vast majority of BP and PG patients, these autoantibodies bind to epitopes clustered within the 16th non-collagenous domain of BP180. An ELISA system for the detection of these autoantibodies was developed and evaluated using 16th non-collagenous domain (NC16A) tetramers instead of monomers. In contrast to antigens fused to large proteins used in the past for the detection of autoantibodies against type XVII collagen, tetrameric antigen fragments bearing a small hexahistidine tag allow for high expression levels without the need to cleave off the fusion partner. Using tetrameric BP180 NC16A, positive reactions were found in 106 (89.8%) of 118 randomly selected BP sera and in all of 20 (100%) randomly selected PG sera, whereas only 2.2% of a large cohort of control subjects were positive in this assay, including patients with rheumatoid arthritis (two of 107), progressive systemic sclerosis (two of 50), systemic lupus erythematosus (one of 72), and healthy blood donors (10 of 494). Thus, the sensitivity and specificity of the new anti-tetrameric NC16A ELISA were 89.9% and 97.8% respectively. Levels of circulating autoantibodies against BP180 paralleled disease activity in the pemphigoid patients. In conclusion, the use of tetrameric NC16A in ELISA results in a sensitive and specific tool for diagnosis and monitoring of BP and PG.
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Affiliation(s)
- Cassian Sitaru
- Department of Dermatology, University of Lübeck, Ratzeburger Allee 160, Lübeck, Germany.
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39
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Schmidt E, Wehr B, Wolf K, Sitaru C, Bröcker EB, Zillikens D. Localisation of bullous pemphigoid antigen 180 (BP180) in cultured human keratinocytes: functionally relevant modification by calcium. Arch Dermatol Res 2006; 298:283-90. [PMID: 16906396 DOI: 10.1007/s00403-006-0690-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2005] [Revised: 04/26/2006] [Accepted: 07/19/2006] [Indexed: 10/24/2022]
Abstract
The expression of BP180 has previously been demonstrated to be influenced by both calcium (Ca(2+)) concentration and binding of anti-BP180-antibodies in cultured keratinocytes of the skin squamous cell carcinoma line DJM-1. Here, BP180 expression was studied in cultured normal human epidermal keratinocytes by confocal laser scanning microscopy. We exploited an experimental system, in which BP180 was previously shown to mediate, upon incubation with anti-BP180 antibodies, a specific signal-transducing event that leads to the release of inflammatory mediators, such as IL-8 from cultured normal human epidermal keratinocytes (NHEK). We found that without addition of BP180-specific IgG, BP180 is predominantly expressed on the cell surface irrespective of the Ca(2+) concentration. In contrast, cell surface BP180 was greatly reduced in NHEK kept in high Ca(2+) medium after incubation with BP180-specific IgG for 12 h compared to low Ca(2+) medium. This effect was seen with antibodies to both N- and C-terminal fragments of the BP180 ectodomain, respectively. In addition, a slightly higher BP180 expression was found in NHEK cultured in low compared to high Ca(2+) medium by Western blotting. Interestingly, in contrast to NHEK kept under low Ca(2+ )conditions, in NHEK grown in high Ca(2+) medium, no elevated levels of IL-8 were released after treatment of cells with anti-BP180 IgG compared to normal IgG. Our data indicate that the Ca(2+)-modulated expression of BP180 is functionally relevant. This finding sheds further light on the complex pathomechanism in blister formation of BP180-related autoimmune blistering skin diseases.
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Affiliation(s)
- Enno Schmidt
- Department of Dermatology, University of Würzburg, Josef-Schneider-Str. 2, 97080 Würzburg, Germany.
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40
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Mulyowa GK, Jaeger G, Kabakyenga J, Bröcker EB, Zillikens D, Schmidt E. Autoimmune subepidermal blistering diseases in Uganda: correlation of autoantibody class with age of patients. Int J Dermatol 2006; 45:1047-52. [PMID: 16961507 DOI: 10.1111/j.1365-4632.2006.02750.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND No data are available on the incidence and immunoreactivity of autoimmune subepidermal blistering skin diseases in East Africa. METHODS All patients with frank blisters/erosions on the skin and/or mucous membranes that attended the Department of Dermatology at Mbarara University, Uganda, from May 2000 to June 2002, were investigated. The diagnosis was based on the clinical presentation and on the presence of circulating autoantibodies detected by indirect immunofluorescence microscopy on 1 m NaCl-split human skin and by Western blotting of recombinant and cell-derived forms of BP180, BP230, and type VII collagen. RESULTS Twenty-two patients with autoimmune subepidermal blistering skin disorders were identified, including nine with bullous pemphigoid (41%), four with linear immunoglobulin A (IgA) disease (18%), three with mucous membrane pemphigoid (14%), two with linear IgG/IgA bullous dermatosis (9%), and one each with cicatricial pemphigoid and epidermolysis bullosa acquisita (5%). In addition, two patients with immunoreactivity to both the epidermal and dermal side of salt-split skin by indirect immunofluorescence microscopy, who were unreactive to type VII collagen, were provisionally diagnosed as "mixed pemphigoid" (9%). In patients with subepidermal blistering diseases, IgG reactivity correlated significantly with old age, whereas younger patients preferentially developed IgA autoantibodies (P = 0.024). CONCLUSIONS The age of patients with autoimmune subepidermal blistering diseases appears to influence the immunoglobulin class of autoantibodies. The high frequency of IgA autoantibodies in Ugandan patients may be explained by the age distribution of the Ugandan population.
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Affiliation(s)
- Grace K Mulyowa
- Department of Dermatology, University of Würzburg, Würzburg, Germany
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41
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Staubach P, Onnen K, Vonend A, Metz M, Siebenhaar F, Tschentscher I, Opper B, Magerl M, Lüdtke R, Kromminga A, Maurer M. Autologous whole blood injections to patients with chronic urticaria and a positive autologous serum skin test: a placebo-controlled trial. Dermatology 2006; 212:150-9. [PMID: 16484822 DOI: 10.1159/000090656] [Citation(s) in RCA: 96] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2005] [Accepted: 08/14/2005] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Patients with chronic urticaria (CU) frequently exhibit positive skin test reactions to autologous serum (ASST). Therapies aimed at inducing tolerance to circulating histamine-releasing factors in ASST+ CU patients, e.g. by treatment with autologous whole blood (AWB), have not yet been tested. OBJECTIVE To test whether ASST+ CU patients can benefit from repeated low-dose intramuscular injections of AWB. METHODS We characterized CU severity and duration, anti-Fc(epsilon)RI and anti-IgE expression, use of antihistamines, and quality of life in 56 CU patients (ASST+: 35, ASST-: 21) and assessed the therapeutic effects of 8 weekly AWB injections in a randomized, placebo-controlled, single-blind, parallel-group trial. RESULTS Numbers, size, intensity, and/or duration of CU symptoms, quality of life, as well as expression of anti-Fc(epsilon)RI or anti-IgE were similar in ASST+ and ASST- CU patients. However, CU in ASST+ patients was of longer duration and required markedly more antihistaminic medication. Interestingly, ASST+ patients, but not ASST- patients, showed significantly (1) reduced CU activity, (2) decreased use of antihistamines, and (3) improved quality of life after AWB treatment. Placebo treatment was ineffective in both groups, but differences of AWB and placebo treatment responses did not achieve statistical significance in either group, most likely due to the limited number of patients treated. CONCLUSION Our findings suggest that ASST+ CU is clinically different from other CU subforms and that ASST+ CU patients can benefit from AWB therapy.
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Affiliation(s)
- P Staubach
- Department of Dermatology, University of Mainz, Mainz, Germany
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42
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Shimanovich I, Rose C, Sitaru C, Bröcker EB, Zillikens D. Localized linear IgA disease induced by ampicillin/sulbactam. J Am Acad Dermatol 2004; 51:95-8. [PMID: 15243532 DOI: 10.1016/j.jaad.2004.03.027] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We describe a patient who developed an exclusively perianal-intergluteal vesicular eruption after receiving a course of ampicillin/sulbactam. Direct immunofluorescence microscopy of perilesional skin demonstrated linear deposits of IgA along the dermal-epidermal junction. Circulating IgA autoantibodies against the 120-kd soluble ectodomain of bullous pemphigoid antigen 180 (LAD-1 autoantigen) were detected by immunoblotting. Discontinuation of the antibiotics resulted in a rapid resolution of the skin lesions. This is a most unusual case of localized drug-induced linear IgA disease.
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Metz BJ, Ruggeri SY, Hsu S, Reed JA, Ghohestani AS, Uitto J, Ghohestani RF. Linear IgA dermatosis with IgA and IgG autoantibodies to the 180 kDa bullous pemphigoid antigen (BP180): evidence for a distinct subtype. Int J Dermatol 2004; 43:443-6. [PMID: 15186228 DOI: 10.1111/j.1365-4632.2004.02016.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Autoantibodies in linear immunoglobulin A (IgA) disease (LAD) are reported to be of IgA class and directed against a 97-120 kDa epidermal antigen. METHODS We report a 39-year-old woman with clinical features of LAD and with circulating IgA and IgG autoantibodies to the 180 kDa bullous pemphigoid antigen (BP180). RESULTS Histopathology of lesional skin revealed a subepidermal blister with mixed inflammatory cell infiltrate. Direct immunofluorescence of perilesional skin showed linear deposits of IgA along the dermal-epidermal junction. The antigen specificity of the patient's circulating antibodies was determined by Western blotting and enzyme-linked immunoabsorbent assay (ELISA) using various antigen sources, including cultured human keratinocytes, dermal protein lysates, and purified laminin-5, as well as proteins corresponding to BP180, the 230 kDa bullous pemphigoid antigen (BP230), laminin-5 subunits, and collagen IV alpha1-alpha6 chains. IgA and IgG antibodies in the patient's serum were directed against BP180, and no IgA or IgG reactivity was found against the other skin antigens. CONCLUSIONS These data provide evidence for the presence of a subtype of LAD with dual IgA and IgG autoimmune response to BP180.
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Affiliation(s)
- Brandie J Metz
- Department of Dermatology, Baylor College of Medicine, One Baylor Plaza FB800, Houston, TX 77030, USA
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Kromminga A, Sitaru C, Hagel C, Herzog S, Zillikens D. Development of an ELISA for the detection of autoantibodies to BP230. Clin Immunol 2004; 111:146-52. [PMID: 15093564 DOI: 10.1016/j.clim.2003.12.007] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2003] [Accepted: 12/24/2003] [Indexed: 11/17/2022]
Abstract
Bullous pemphigoid (BP) is an autoimmune subepidermal blistering disease associated with autoantibodies against the transmembrane hemidesmosomal protein BP180/collagen type XVII and the intracellular plaque protein BP230. The aim of the present study was to develop an ELISA system for the detection of circulating autoantibodies to BP230. We generated five overlapping cDNA constructs covering the entire length of BP230 and expressed them in baculovirus-infected Sf21 insect cells. ELISA reactivity against BP230 was found in 63% of 56 BP patients' sera; the specificity of the ELISA was 93%. Epitope mapping studies showed that the fragment representing the C-terminal portion of BP230 was by far the most frequent target within the molecule. This ELISA provides a useful tool for the detection of autoantibodies to BP230 in BP and other diseases associated with an autoimmune response to this protein.
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Affiliation(s)
- Arno Kromminga
- Institute for Immunology, Clinical Pathology, and Molecular Medicine (IPM), Hamburg, Germany
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45
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Shimanovich I, Hirako Y, Sitaru C, Hashimoto T, Bröcker EB, Butt E, Zillikens D. The Autoantigen of Anti-p200 Pemphigoid Is an Acidic Noncollagenous N-Linked Glycoprotein of the Cutaneous Basement Membrane. J Invest Dermatol 2003; 121:1402-8. [PMID: 14675190 DOI: 10.1111/j.1523-1747.2003.12609.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Anti-p200 pemphigoid is an autoimmune subepidermal blistering disease characterized by autoantibodies to a 200-kDa protein (p200) of the dermal-epidermal junction (DEJ). p200 has been demonstrated to be distinct from all major DEJ autoantigens and is thought to be important for cell-matrix adhesion. This study provides the first biochemical characterization of p200. Differential extraction experiments demonstrated that efficient recovery of p200 from the dermis was strongly dependent on the presence of reducing agents, suggesting that it forms highly insoluble oligomers and/or is extensively cross-linked to other extracellular matrix components by disulfide bonding. p200 was resistant to digestion with bacterial collagenase, whereas this treatment did degrade major collagenous proteins of the dermis, including type I, VI, and VII collagen. This finding firmly established the noncollagenous nature of p200. N-Glycosidase F reduced the molecular size of the p200 autoantigen from 200 to 190 kDa without decreasing its immunoreactivity. In contrast, digestion of p200 with neuraminidase, O-glycosidase, chondroitinase ABC, and heparitinase I had no effect on its electrophoretic mobility. These data suggest that the p200 molecule contains N-glycans but lacks O-linked oligosaccharides and chondroitin/heparan sulfate side chains. Two-dimensional gel electrophoresis demonstrated that p200 is an acidic protein with an isoelectric point of 5.4 to 5.6. Six different p200-specific sera recognized an identical protein spot of two-dimensionally separated dermal extracts, confirming that patients with this novel autoimmune disease indeed form a single pathobiochemical entity.
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Affiliation(s)
- Iakov Shimanovich
- Department of Dermatology, University of Würzburg, Würzburg, Germany
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46
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Allen J, Wojnarowska F. Linear IgA disease: the IgA and IgG response to the epidermal antigens demonstrates that intermolecular epitope spreading is associated with IgA rather than IgG antibodies, and is more common in adults. Br J Dermatol 2003; 149:977-85. [PMID: 14632802 DOI: 10.1111/j.1365-2133.2003.05648.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Linear IgA disease (LAD; adult and childhood) is a dapsone-responsive, acquired immunobullous disorder mediated by IgA antibodies directed at target antigens within the epithelial basement membrane. These antigens have not been completely characterized. OBJECTIVES To identify the target antigens in LAD, and to correlate these with the antibody isotype. METHODS We used 101 LAD sera without IgG antibodies detected by indirect immunofluorescence. The sera were analysed by immunoblotting for IgA (65 adults and 36 children) and IgG (61 adults and 34 children) autoantibodies, on salt-split, urea-extracted epidermal tissue extracts. RESULTS Antigens were targeted in LAD by IgA antibodies (54 adults and 23 children), IgG antibodies (34 adults and 19 children), and both isotypes (30 adults and 16 children). Three major antigens were recognized by IgA antibodies: LAD285 (22 adults and three children), BP230 (30 adults and eight children) and BP180 (collagen XVII), including the 97-kDa ectodomain (52 adults and 20 children). Seven 'minor' antigens were occasionally detected (18 adults and 13 children). IgA antibodies bound multiple antigens (33 adults and nine children) more frequently than single antigens (21 adults and 14 children), but the binding to multiple antigens was more restricted in children than in adults. IgG antibodies mainly bound a single antigen (29 adults and 16 children), predominantly BP180. CONCLUSIONS There was variation in the autoantibody response within the disease and the patient, with regard to target molecules and autoantibody class. The finding that IgG as well as IgA autoantibodies predominantly target BP180 supports a pivotal role for collagen XVII in adult and childhood LAD. The IgG response was very restricted compared with IgA autoantibodies (P < 0.01). Autoantibodies from children had a more restricted antigen repertoire than from adults (P < 0.05). Epitope spreading is common in LAD and is affected by the class of autoantibody and age of the patient.
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Affiliation(s)
- J Allen
- Department of Dermatology, The Oxford Radcliffe Hospital, Oxford OX3 7LJ, UK
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Goebeler M, Seitz C, Rose C, Sitaru C, Jeschke R, Marx A, Bröcker EB, Zillikens D. Successful treatment of linear IgA disease with salazosulphapyridine and intravenous immunoglobulins. Br J Dermatol 2003; 149:912-4. [PMID: 14616404 DOI: 10.1046/j.1365-2133.2003.05537.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Nashan D, Schwarz T. Cytokines and chemokines in human autoimmune skin disorders. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2003; 520:221-36. [PMID: 12613581 DOI: 10.1007/978-1-4615-0171-8_13] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Affiliation(s)
- Dorothée Nashan
- Ludwig Boltzmann Institute for Cell Biology and Inmmunobiology of the Skin, Department of Dematology, University of Munster, Germany
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Schmidt E, Kromminga A, Kürschner M, Zimmermann H, Katsen AD, Bröcker EB, Zillikens D, Zimmermann U, Sukhorukov VL. Trehalose conserves expression of bullous pemphigoid antigen 180 during desiccation and freezing. J Immunol Methods 2003; 275:179-90. [PMID: 12667682 DOI: 10.1016/s0022-1759(03)00020-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Bullous pemphigoid antigen 180 (BP180) is targeted by autoantibodies in a variety of subepidermal blistering skin diseases. We have recently developed a simple, highly specific and sensitive immunofluorescence (IF) assay for the detection of circulating antibodies against BP180. This novel assay involves the expression of full-length (FL) BP180 in Sf21 insect cells that are then examined under IF microscopy after staining with anti-BP180 antibodies. Application of this assay as a routine diagnostic tool requires long-term storage of FL-BP180, which can result in substantial loss of expression. Here, we show that the disaccharide trehalose, a natural cryo- and lyoprotectant, is capable of preserving the FL-BP180 antigen expressed in Sf21 insect cells under various (dry) storage conditions including 40 degrees C, room temperature (RT), 4-8, -20, and -80 degrees C. The protective effect was dose-dependent reaching a maximum at about 200 mM trehalose. Trehalose was superior to other sugars or conventional cryoprotective agents (e.g. sucrose, myo-inositol, DMSO) in preventing greatly reduced antigen expression. Trehalose conserved the expression of both extra- and intracellular epitopes of FL-BP180. Interestingly, protection of the intracellular domain was only observed when trehalose was introduced into the cytosol. Trehalose significantly prolonged the storage time of FL-BP180 expressed in Sf21 insect cells, thus permitting the routine use of the IF assay in clinics for the detection of serum antibodies. The method described here has potential applications for the preservation of other transmembrane proteins.
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Affiliation(s)
- Enno Schmidt
- Department of Biotechnology, Biocenter, University of Würzburg, Am Hubland, 97074, Würzburg, Germany
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Hofmann S, Thoma-Uszynski S, Hunziker T, Bernard P, Koebnick C, Stauber A, Schuler G, Borradori L, Hertl M. Severity and phenotype of bullous pemphigoid relate to autoantibody profile against the NH2- and COOH-terminal regions of the BP180 ectodomain. J Invest Dermatol 2002; 119:1065-73. [PMID: 12445194 DOI: 10.1046/j.1523-1747.2002.19529.x] [Citation(s) in RCA: 138] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Bullous pemphigoid, the most common autoimmune subepidermal bullous disorder, is associated with autoantibodies targeting antigenic sites clustered within the extracellular domain of BP180. To investigate epitope and subclass specificity of autoantibodies in bullous pemphigoid, we developed an enzyme-linked immunosorbent assay utilizing baculovirus-expressed recombinant forms of the NH2- and COOH-terminal regions of the extracellular domain of BP180 and examined sera obtained from patients with active bullous pemphigoid (n=116) and controls (n=100). Ninety-three (80%) and 54 (47%) of the 116 bullous pemphigoid sera recognized the NH2- and COOH-terminal regions, respectively, of the extracellular domain of BP180. Detailed analysis demonstrates that (i) this novel enzyme-linked immunosorbent assay is highly specific (98%) and sensitive (93%) as 108 of 116 bullous pemphigoid sera reacted with at least one of the baculovirus-derived recombinants, (ii) in active bullous pemphigoid, autoantibodies against the NH2-terminus of the extracellular domain of BP180 were predominantly of the IgG1 class, whereas a dual IgG1 and IgG4 response to this region was related to a more severe skin involvement, (iii) autoreactivity against both the NH2- and COOH-terminal regions was more frequently detected in patients with mucosal lesions, and (iv) levels of IgG (and IgG1) against the NH2-terminal, but not against the COOH-terminal portion of the extracellular domain of BP180, reflected disease severity indicating that autoantibodies against the NH2-terminus are critical in the pathogenesis of bullous pemphigoid. In conclusion, this novel enzyme-linked immunosorbent assay represents a highly sensitive and specific assay for rapid diagnosis of bullous pemphigoid and related disorders and may provide predictive parameters for the management of bullous pemphigoid patients.
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Affiliation(s)
- SilkeC Hofmann
- Department of Dermatology, Friedrich-Alexander-University Erlangen-Nürnberg, Germany
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