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Anderson HJ, Huang S, Lee JB. Paraneoplastic pemphigus/paraneoplastic autoimmune multiorgan syndrome: Part I. Clinical overview and pathophysiology. J Am Acad Dermatol 2024; 91:1-10. [PMID: 37597771 DOI: 10.1016/j.jaad.2023.08.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 07/24/2023] [Accepted: 08/07/2023] [Indexed: 08/21/2023]
Abstract
Paraneoplastic pemphigus/paraneoplastic autoimmune multiorgan syndrome (PNP/PAMS) is a highly fatal autoimmune blistering disease. The condition occurs in patients with underlying benign or malignant neoplasms, most commonly lymphoproliferative disorders. Both humoral and cell-mediated immunities contribute to the pathogenesis, and autoantibodies against plakin family proteins are characteristic. Patients typically present with severe stomatitis and polymorphous skin lesions, which are often resistant to treatment. Bronchiolitis obliterans (BO) is a frequent complication which contributes to the high mortality rate of PNP/PAMS. Given the rarity of this disorder and heterogeneity of clinical presentation, clinicians should maintain a high index of suspicion for PNP/PAMS to avoid delayed diagnosis. In this first part of a two-part continuing medical education (CME) series, risk factors, pathogenesis, and clinical features of PNP/PAMS are discussed.
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Affiliation(s)
- Hannah J Anderson
- Department of Dermatology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Simo Huang
- Department of Dermatology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Jason B Lee
- Department of Dermatology, Thomas Jefferson University, Philadelphia, Pennsylvania.
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Kurzeja M, Olszewska M, Grzybowski A, Rudnicka L. Ocular involvement in autoimmune bullous diseases. Clin Dermatol 2023; 41:481-490. [PMID: 37586570 DOI: 10.1016/j.clindermatol.2023.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
Autoimmune bullous diseases represent a heterogenous group of disorders caused by autoantibodies against adhesion molecules; the location of the target protein determines the level of cleft formation. The spectrum of ocular lesions in autoimmune bullous diseases can range from mild symptoms to severe involvement with sight impairment and even, in some cases, blindness. In pemphigus vulgaris, the prevalence of ocular involvement has been reported to be between 7% and 26%. The most common clinical sign of ocular pemphigus vulgaris is bilateral conjunctivitis with hyperemia. Ocular involvement also occurs in 41% to 70% of patients with paraneoplastic pemphigus. The main ocular manifestations are bilateral cicatrizing conjunctivitis with symblepharon formation, and shortening of the fornices. In mucous membrane pemphigoid, ocular involvement is seen in 61% to 70% of patients; the most frequent ocular finding is cicatricial conjunctivitis. Patients with autoimmune bullous diseases having common ocular involvement should be assessed by an ophthalmologist to avoid serious complications. Diagnostic procedures and treatment require multidisciplinary care based on the close cooperation between dermatologists and ophthalmologists.
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Affiliation(s)
- Marta Kurzeja
- Department of Dermatology, Medical University of Warsaw, Warsaw, Poland.
| | | | - Andrzej Grzybowski
- Department of Ophthalmology, University of Warmia and Mazury, Olsztyn, Poland; Institute for Research in Ophthalmology, Poznań, Poland
| | - Lidia Rudnicka
- Department of Dermatology, Medical University of Warsaw, Warsaw, Poland
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Irrera M, Bozzola E, Cardoni A, DeVito R, Diociaiuti A, Hachem ME, Girardi K, Marchesi A, Villani A. Paraneoplastic pemphigus and Castleman's disease: a case report and a revision of the literature. Ital J Pediatr 2023; 49:33. [PMID: 36941723 PMCID: PMC10029234 DOI: 10.1186/s13052-023-01442-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 03/08/2023] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND In literature, a few reports described an association between paraneoplastic pemphigus (PNP) and Castelman's disease (CD), but no consensus have been proposed for the diagnostic-therapeutical approach. Aim of this study is to present a case report and explore the relationship between PNP and CD in pediatric patients, focusing on clinical manifestations, histopathological findings, treatment and outcome to find elements for an early diagnosis. CASE PRESENTATION We present the clinical case of a 13 years old girl with a challenging diagnosis of PNP and CD who underwent therapy at first with Rituximab and then with Siltuximab, for the control of symptoms. CONCLUSIONS Reviewing literature, 20 clinical cases have been described in the pediatric age. Diagnosis may be challenging, requiring an average of 3 months (range from 3 weeks to 2 years). In all cases, the initial manifestations were mucocutaneous lesions, especially oral lesions with poor response to conventional treatment. Systemic symptoms may be present as well. Therapeutical approach is still discussed with no consensus. Almost all patients received corticosteroids with poor response. Other drugs including azathioprine, methotrexate, cyclosporine and monoclonal antibodies have been evaluated for the control of the disease. Further studies and experimental trials urge to define the diagnostic criteria and therapy protocol.
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Affiliation(s)
| | - Elena Bozzola
- Pediatric Unit, IRCCS Bambino Gesù Children's Hospital, Rome, Italy.
| | - Antonello Cardoni
- Unity of Pathology, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | - Rita DeVito
- Unity of Pathology, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | - Andrea Diociaiuti
- Dermatology Unit and Genodermatosis Unit, Genetics and Rare Diseases Research Division, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | - Maya El Hachem
- Dermatology Unit and Genodermatosis Unit, Genetics and Rare Diseases Research Division, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | - Katia Girardi
- Department of Pediatric Hematology/Oncology and Cell and Gene Therapy, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | | | - Alberto Villani
- Pediatric Unit, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
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Chen C, Xu Y, Yu J, Qian S, Xie Y. A first case of successful using of ibrutinib in treating paraneoplastic pemphigus related bronchiolitis obliterans concurrent with CLL. Front Med (Lausanne) 2023; 10:1132535. [PMID: 37007770 PMCID: PMC10056216 DOI: 10.3389/fmed.2023.1132535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 02/27/2023] [Indexed: 03/17/2023] Open
Abstract
Paraneoplastic pemphigus (PNP) is a rare life-threatening disease which always associated with an underlying neoplasm. Tumor-related PNP most commonly precedes the detection of a hematological malignancy, with some cases seen during disease remission following cytotoxic drug therapy or radiotherapy. The lung is the most frequently-involved site in PNP, second only to the eyes, and involvement is seen in 59.2% to 92.8% of PNP cases. Bronchiolitis obliterans (BO) is the end stage of respiratory involvement and is regarded as life-threatening. The key point in treatment of PNP is to control the associated underlying hematologic neoplasia. High-dose systemic corticosteroids combined with other immunosuppressants are considered the first line of treatment. Other therapies that have shown beneficial effects include plasmapheresis, intravenous immunogloblin (IVIG), and more recently, daclizumab, alemtuzumab, and rituximab. There is no effective treatment for BO with PNP, and suppression of the cellular immune response may be necessary. Patients with PNP-BO associated with lymphoma mostly die within approximately 1 year. Herein, we reported a patient who diagnosed with PNP-BO concurrent with chronic lymphocytic leukemia. He was successful treated with ibrutinib and had achieved the longest survival which suggested that ibrutinib may be the best treatment choice for such patient.
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Zaheri F, Pas HH, Bremer J, Meijer JM, Bolling MC, Horvath B, Diercks GFH. Paraneoplastic pemphigus: A detailed case series from the Netherlands revealing atypical cases. J Eur Acad Dermatol Venereol 2023; 37:147-153. [PMID: 35993495 PMCID: PMC10087213 DOI: 10.1111/jdv.18557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 07/27/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Paraneoplastic pemphigus (PNP) is an extremely rare life-threatening blistering autoimmune disease that is associated with an underlying neoplasm. There is a set diagnostic criterion for PNP, which is primarily based on a severe stomatitis and the detection of specific antibodies against envoplakin, periplakin and alpha-2-macroglobulin-like protein 1. However, it has become increasingly evident that there are patients with PNP that do not meet all the diagnostic criteria requirements. OBJECTIVES The aim of this study was to analyse our cohort of Dutch patients and to define the atypical cases that did not meet the diagnostic criteria. METHODS A retrospective case study of all known Dutch PNP patients of the past 25 years. Patients' clinical and immunological variables were thoroughly analysed and described. RESULTS Twenty-four patients were included in this study. The results revealed several atypical patient cases that did not completely meet the set diagnostic criteria. Of the 24 patients, two patients presented without stomatitis, in three patients an underlying neoplasm could not be detected, and in two patients the presence of specific autoantibodies could not be demonstrated, although all other criteria for PNP were met. Finally, three of the 24 patients survived the disease. CONCLUSION Although our findings showed similarities to previous studies and most of the patients met the criteria, there were a few atypical patient cases; highlighting the importance of not strictly adhering to the set criteria when making a diagnosis, as this can lead to a missed or late diagnosis. Thus, it is of crucial importance to combine clinical and elaborate laboratory results to confirm the diagnosis of PNP in suspected patients. Although PNP harbours an unfavourable prognosis in most cases, it might be resolved by timely treatment of the underlying cause.
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Affiliation(s)
- Farhat Zaheri
- Department of Dermatology, Expertise Center for Blistering Diseases, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Hendri H Pas
- Department of Dermatology, Expertise Center for Blistering Diseases, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Jeroen Bremer
- Department of Dermatology, Expertise Center for Blistering Diseases, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.,ERN-SKIN Expertise Center, Groningen, the Netherlands
| | - Joost M Meijer
- Department of Dermatology, Expertise Center for Blistering Diseases, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.,ERN-SKIN Expertise Center, Groningen, the Netherlands
| | - Marieke C Bolling
- Department of Dermatology, Expertise Center for Blistering Diseases, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.,ERN-SKIN Expertise Center, Groningen, the Netherlands
| | - Barbara Horvath
- Department of Dermatology, Expertise Center for Blistering Diseases, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.,ERN-SKIN Expertise Center, Groningen, the Netherlands
| | - Gilles F H Diercks
- Department of Dermatology, Expertise Center for Blistering Diseases, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.,ERN-SKIN Expertise Center, Groningen, the Netherlands.,Department of Pathology and Medical Biology, Division of Pathology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
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Liska J, Liskova V, Trcka O, Ondic O, Hauer L, Baxa J, Kacerovska D. Oral presentation of paraneoplastic pemphigus as the first sign of tonsillar HPV associated squamous cell carcinoma. A case report. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2022; 166:447-450. [PMID: 34188253 DOI: 10.5507/bp.2021.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 06/10/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Paraneoplastic pemphigus (PNP) in the oral cavity is a rare variant of blistering pemphigus disease closely associated with mostly malignant tumors. The diagnosis may even precede an underlying malignancy enabling early detection. Here, we describe a previously unreported case of PNP associated with HPV-related tonsillar squamous cell carcinoma. METHODS AND RESULTS A 50-year-old woman was referred to a dentist because of painful oral lesions resembling aphthae major and minor. Later, blisters appeared and an incisional biopsy was performed. Histological examination revealed an unusual coexistence of subepithelial and intraepithelial blisters raising suspicion of paraneoplastic pemphigus. The patient underwent 18F-FDG PET/MRI, showing a metabolically active process in the left palatal tonsil. Diagnostic biopsy revealed HPV type 16 associated tonsillar squamous cell carcinoma. A left tonsillectomy with elective left-sided neck dissection was performed. The postoperative period was complicated by bilateral fluidothorax. Two weeks after radical tumor removal, the mucosal and skin lesions of PNP disappeared. The patient currently shows no evidence of recurrence either of malignancy or PNP eight months after the surgery. CONCLUSION PNP is a rare autoimmune blistering disease characterized by polymorphous cutaneous and mucosal lesions associated with internal neoplasms including HPV associated squamous cell carcinoma of a tonsil. In order to identify an occult malignancy, a whole-body PET/CT or PET/MRI scan is recommended. Rarely, accurate patient management may depend on the dentist being familiar with this entity and on interdisciplinary cooperation involving dermatologist, radiologist, pathologist, and pneumologist. A strict patient follow-up is indicated.
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Affiliation(s)
- Jan Liska
- Department of Dentistry, University Hospital and Faculty of Medicine in Pilsen, Charles University, Alej Svobody 80, 304 60 Pilsen, Czech Republic
| | - Veronika Liskova
- Department of Dentistry, University Hospital and Faculty of Medicine in Pilsen, Charles University, Alej Svobody 80, 304 60 Pilsen, Czech Republic
| | - Ondrej Trcka
- Department of Otorhinolaryngology, University Hospital and Faculty of Medicine in Pilsen, Charles University, Alej Svobody 80, 304 60 Pilsen, Czech Republic
| | - Ondrej Ondic
- Sikl's Department of Pathology, Faculty of Medicine in Pilsen, Charles University, Ed. Benese 13, 305 99 Pilsen, Czech Republic.,Biopticka Laboratory, Mikulasske namesti 628, 326 00 Pilsen, Czech Republic
| | - Lukas Hauer
- Department of Dentistry, University Hospital and Faculty of Medicine in Pilsen, Charles University, Alej Svobody 80, 304 60 Pilsen, Czech Republic
| | - Jan Baxa
- Department of Imaging Methods, University Hospital and Faculty of Medicine in Pilsen, Charles University, Alej Svobody 80, 304 60 Pilsen, Czech Republic
| | - Denisa Kacerovska
- Sikl's Department of Pathology, Faculty of Medicine in Pilsen, Charles University, Ed. Benese 13, 305 99 Pilsen, Czech Republic.,Biopticka Laboratory, Mikulasske namesti 628, 326 00 Pilsen, Czech Republic
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[Factors associated with long-term survival in critically ill patients following surgery for solid tumors complicated with paraneoplastic pemphigus]. BEIJING DA XUE XUE BAO. YI XUE BAN = JOURNAL OF PEKING UNIVERSITY. HEALTH SCIENCES 2022; 54. [PMID: 36241242 PMCID: PMC9568377 DOI: 10.19723/j.issn.1671-167x.2022.05.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE Critically ill patients with solid tumors complicated with paraneoplastic pemphigus are usually treated in intensive care units (ICU) for perioperative management after surgical treatment. In this study, the clinical characteristics and predictors of long-term prognosis of these critically ill patients were analyzed. METHODS the clinical and laboratory data of 63 patients with solid tumors complicated with paraneoplastic pemphigus admitted to ICU from 2005 to 2020 were retrospectively analyzed, and the survival status of the patients were followed up. RESULTS Among the 63 patients, 79.4% had Castleman disease as the primary tumor, and 20.6% with other pathological types; 69.8% had severe-extensive skin lesions, and 30.2% had other skin lesions; the patients with bronchiolitis obliterans accounted for 44.4%, and 55.6% were not merged. Postoperative fungal infection occurred in 23.8% of the patients, and 76.2% without fungal infection. The median follow-up time was 95 months, and 25 patients died during the study period. The 1-year, 3-year and 5-year survival rates were 74.6% (95%CI 63.8%-85.4%), 67.4% (95%CI 55.6%-79.2%) and 55.1% (95%CI 47.9%-62.3%), respectively. The log-rank univariate analysis showed that the patients had age>40 years (P=0.042), preoperative weight loss>5 kg (P=0.002), preoperative albumin < 30 g/L (P < 0.001), paraneoplastic pemphigus complicated with bronchiolitis obliterans (P=0.002), and perioperative fungal infection (P < 0.001) had increased mortality. Cox univariate analysis showed that preoperative weight loss >5 kg (P=0.005), preoperative albumin < 30 g/L (P < 0.001), paraneoplastic pemphigus complicated with bronchiolitis obliterans (P=0.009), preoperative bacterial pulmonary infection (P=0.007), prolonged surgical time (P=0.048), postoperative oxygenation index (P=0.012) and low albumin (P=0.010) and hemoglobin concentration (P=0.035) in ICU, acute physiology and chronic health evaluation (APACHE Ⅱ) score (P=0.001); sequential organ failure assessment (SOFA) score (P=0.010), and postoperative fungal infection (P < 0.001) were risk factors for long-term survival. Cox regression model for multivariate analysis showed that preoperative weight loss > 5 kg (HR 4.44; 95%CI 1.47-13.38; P=0.008), and preoperative albumin < 30 g/L (HR 4.38; 95%CI 1.72-11.12; P=0.002), bronchiolitis obliterans (HR 2.69; 95%CI 1.12-6.50; P=0.027), and postoperative fungal infection (HR 4.85; 95%CI 2.01-11.72; P < 0.001) were independent risk factors for postoperative mortality. CONCLUSION The 5-year survival rate of critically ill patients undergoing surgery for paraneoplastic pemphigus combined with solid tumors is approximately 55.1%, with preoperative weight loss > 5 kg, albumin < 30 g/L, bronchiolitis obliterans and postoperative fungal infection were associated with an increased risk of near- and long-term postoperative mortality.
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Du X, Zhang M, Zhang S, Tian F, Wen T, Liu L. Myocardial Damage in a Highly Suspected Case With Paraneoplastic Pemphigus: A Case Report and Literature Review. Front Med (Lausanne) 2022; 9:917050. [PMID: 35770015 PMCID: PMC9234257 DOI: 10.3389/fmed.2022.917050] [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] [Received: 04/10/2022] [Accepted: 05/12/2022] [Indexed: 11/18/2022] Open
Abstract
Paraneoplastic pemphigus (PNP) is a rare mucocutaneous autoimmune disease. It has multiple clinical accompanied symptoms by affecting various types of epithelia, including the gastrointestinal and respiratory tract. However, an extensive review of the literature found no cases of PNP associated with myocardial damage. Here, we present a 56-year-old male patient with clinically and histopathologically typical paraneoplastic pemphigus (PNP), who had sustained myocardial injury due to non-cardiac disease involvement. Therefore, we suppose that, when persistent cardiac necrosis markers are elevated in patients with paraneoplastic pemphigus (PNP), the possibility of concomitant myocardial damage should get more attention from clinicians to obtain quick diagnosis and treatment.
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Affiliation(s)
- Xiao Du
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, China
- Research Institute of Blood Lipid and Atherosclerosis, Central South University, Changsha, China
- Modern Cardiovascular Disease Clinical Technology Research Center of Hunan Province, Changsha, China
- Cardiovascular Disease Research Center of Hunan Province, Changsha, China
| | - Miao Zhang
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, China
- Research Institute of Blood Lipid and Atherosclerosis, Central South University, Changsha, China
- Modern Cardiovascular Disease Clinical Technology Research Center of Hunan Province, Changsha, China
- Cardiovascular Disease Research Center of Hunan Province, Changsha, China
| | - Shilan Zhang
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, China
- Research Institute of Blood Lipid and Atherosclerosis, Central South University, Changsha, China
- Modern Cardiovascular Disease Clinical Technology Research Center of Hunan Province, Changsha, China
- Cardiovascular Disease Research Center of Hunan Province, Changsha, China
| | - Feng Tian
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, China
- Research Institute of Blood Lipid and Atherosclerosis, Central South University, Changsha, China
- Modern Cardiovascular Disease Clinical Technology Research Center of Hunan Province, Changsha, China
- Cardiovascular Disease Research Center of Hunan Province, Changsha, China
| | - Tie Wen
- Department of Emergency Medicine, Second Xiangya Hospital, Central South University, Changsha, China
- Emergency Medicine and Difficult Diseases Institute, Second Xiangya Hospital, Central South University, Changsha, China
- Tie Wen
| | - Ling Liu
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, China
- Research Institute of Blood Lipid and Atherosclerosis, Central South University, Changsha, China
- Modern Cardiovascular Disease Clinical Technology Research Center of Hunan Province, Changsha, China
- Cardiovascular Disease Research Center of Hunan Province, Changsha, China
- *Correspondence: Ling Liu
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Tagliati C, Rizzetto G, Lanni G, Marcucci M, Argalia G, Lucidi Pressanti G, Simonetti O, Offidani A. Thoracoabdominal computed tomography neoplasia detection in patients with paraneoplastic pemphigus: the importance of collaboration between specialists. ACTA DERMATOVENEROLOGICA ALPINA PANNONICA ET ADRIATICA 2022. [DOI: 10.15570/actaapa.2022.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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10
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Rivas-Calderon M, Yamazaki-Nakashimada MA, Orozco-Covarrubias L, Durán-McKinster C, Pacheco-Tovar D, Ávalos-Díaz E, Sáez-de-Ocariz M. Bronchiolitis Obliterans With Anti-Epiplakin Antibodies in a Boy With Paraneoplastic Pemphigus. Pediatrics 2022; 149:184740. [PMID: 35118492 DOI: 10.1542/peds.2021-052132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/12/2021] [Indexed: 11/24/2022] Open
Abstract
Paraneoplastic pemphigus is a rare and severe autoimmune blistering disease characterized by a recalcitrant and severe mucositis, and polymorphic cutaneous lesions, associated with benign and malignant neoplasms. Paraneoplastic pemphigus is caused by production of autoantibodies against various epidermal proteins involved in cell adhesion. Bronchiolitis obliterans (BO) is one of the leading causes of mortality in these patients. Recent advances have associated the presence of anti-epiplakin antibodies with the development of BO in adult patients. Here we describe the first pediatric patient in whom the association of anti-epiplakin antibodies and BO have been reported so far.
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Affiliation(s)
| | | | | | | | - Deyanira Pacheco-Tovar
- Department of Immunology, Unidad Académica de Ciencias Biológicas, Universidad Autónoma de Zacatecas, Mexico
| | - Esperanza Ávalos-Díaz
- Department of Immunology, Unidad Académica de Ciencias Biológicas, Universidad Autónoma de Zacatecas, Mexico
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Marinović B, Miše J, Jukić IL, Bukvić Mokos Z. Pemphigus-The Crux of Clinics, Research, and Treatment during the COVID-19 Pandemic. Biomedicines 2021; 9:1555. [PMID: 34829784 PMCID: PMC8615103 DOI: 10.3390/biomedicines9111555] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 10/22/2021] [Accepted: 10/25/2021] [Indexed: 12/17/2022] Open
Abstract
Pemphigus is a rare autoimmune disease characterised by the production of pathogenic autoantibodies in response to different desmosome proteins. The pathophysiological process leads to the development of blisters and erosions on mucosal and/or skin surfaces. The classical clinical variants of pemphigus are pemphigus vulgaris and pemphigus foliaceus. A diagnostic delay is very common in pemphigus, especially among patients with mucosal involvement. However, in recent years we have witnessed considerably fewer patients with extensive mucocutaneous manifestations, since patients with oral lesions are referred to dermatologists to start the treatment much sooner than they had been previously. Among non-classical variants of pemphigus, unusual cases with discrepancies between autoantibody profiles and clinics challenge the "desmoglein compensation theory". The identification of several other autoantigens that perform a role in the pathogenesis of different variants of pemphigus will progress immunodermatology towards an approach that will determine personalized pemphigus subtypes for each patient. Comorbidities among patients are primarily associated with the prolonged use of corticosteroids and other immunosuppressive agents. The SARS-CoV-2 pandemic raised concerns regarding the immunosuppressive effects of treatment and the risk of a more complicated COVID-19 infection, as well as on the ability to develop an adequate vaccine response.
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Affiliation(s)
- Branka Marinović
- Department of Dermatology and Venereology, University Hospital Centre Zagreb, School of Medicine University of Zagreb, Šalata 4, 10000 Zagreb, Croatia; (B.M.); (I.L.J.)
| | - Joško Miše
- Department of Dermatology and Venereology, University Hospital Centre Zagreb, European Reference Network (ERN)-Skin Reference Centre, Kišpatićeva 12, 10000 Zagreb, Croatia;
| | - Ines Lakoš Jukić
- Department of Dermatology and Venereology, University Hospital Centre Zagreb, School of Medicine University of Zagreb, Šalata 4, 10000 Zagreb, Croatia; (B.M.); (I.L.J.)
| | - Zrinka Bukvić Mokos
- Department of Dermatology and Venereology, University Hospital Centre Zagreb, School of Medicine University of Zagreb, Šalata 4, 10000 Zagreb, Croatia; (B.M.); (I.L.J.)
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Yee MD, Seline A, Young K, Wanat KA. Paraneoplastic pemphigus secondary to neuroendocrine carcinoma. JAAD Case Rep 2021; 15:22-25. [PMID: 34386565 PMCID: PMC8342845 DOI: 10.1016/j.jdcr.2021.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Megan D Yee
- Department of Dermatology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Alison Seline
- Department of Dermatology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Kara Young
- Department of Dermatology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Karolyn A Wanat
- Department of Dermatology, Medical College of Wisconsin, Milwaukee, Wisconsin
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Kishi T, Nakata J, Yamada T, Nakatsuka S, Matsuura A, Shibano M. Fatal progression of bronchiolitis obliterans in spite of complete remission of follicular lymphoma and paraneoplastic pemphigus. Ann Hematol 2021; 101:453-455. [PMID: 33754167 DOI: 10.1007/s00277-021-04499-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 03/17/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Tomohiro Kishi
- Department of Hematology, Sakai City Medical Center, Sakai City, Osaka, Japan
| | - Jun Nakata
- Department of Hematology, Sakai City Medical Center, Sakai City, Osaka, Japan. .,Department of Clinical Laboratory and Biomedical Sciences, Osaka University Graduate School of Medicine, Suita City, Osaka, Japan.
| | - Toshimasa Yamada
- Department of Diagnostic Pathology, Osaka University Graduate School of Medicine, Suita City, Osaka, Japan
| | - Shinichi Nakatsuka
- Department of Pathology, Sakai City Medical Center, Sakai City, Osaka, Japan
| | - Ai Matsuura
- Department of Hematology, Sakai City Medical Center, Sakai City, Osaka, Japan
| | - Masaru Shibano
- Department of Hematology, Sakai City Medical Center, Sakai City, Osaka, Japan
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Wang D, Chen Z. Paraneoplastic pemphigus associated with small lymphocytic lymphoma: A case report. Medicine (Baltimore) 2021; 100:e24039. [PMID: 33466152 PMCID: PMC7808545 DOI: 10.1097/md.0000000000024039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 10/28/2020] [Accepted: 12/04/2020] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION Paraneoplastic pemphigus (PNP) is a life-threatening autoimmune blistering disease associated with underlying neoplasms. Currently, this disease is very difficult to treat. PATIENT CONCERNS We reported a rare case of paraneoplastic pemphigus associated with small lymphocytic lymphoma responsive to desmoglein 3 (Dsg3) and bullous pemphigoid (BP) antigen 180. DIAGNOSES The initial diagnosis was hypothesized to be Stevens-Johnson syndrome based on the severe mucosal erosion and polymorphous skin lesions. However, the histopathological examination of the skin biopsy and immunology revealed PNP. INTERVENTIONS Anti-tumor therapy, immunosuppression and anti-infective therapy were administered. OUTCOMES After a series of treatments, the skin lesions had been alleviated remarkably. Enzyme-linked immunoassays indices for Dsg3 and bullous pemphigoid antigen 180 decreased (Dsg3, 32; bullous pemphigoid antigen 180, 70.44). Unfortunately, 2 months later, the patient suffered respiratory failure due to the lung impairment of small lymphocytic lymphoma and infection. Eventually, the patient chose to be discharged from the hospital and lost the opportunity for follow-up treatment as he could not afford the expensive treatment costs. LESSONS It is highly susceptible to misdiagnosis due to polymorphous skin lesions. In this case, it was also initially misdiagnosed as Stevens-Johnson syndrome. Therefore, we should pay great attention to differential diagnosis. When refractory stomatitis and mucosal erosions occur, the possibility of PNP should be considered first. At the same time, pathology, immunology and other related tests as well as the examination of primary tumors should be carried out as soon as possible.
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Affiliation(s)
- Dafen Wang
- The second Clinical Medical College of Zhejiang Chinese Medical University, Hangzhou, China
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Sirikham T, Tawanwongsri W, Rutnin S, Chanprapaph K, Vachiramon V. Exfoliative Erythroderma: An Unusual Presentation of Paraneoplastic Pemphigus Associated with Castleman's Disease. Case Rep Dermatol 2020; 12:76-81. [PMID: 32355489 PMCID: PMC7184796 DOI: 10.1159/000507357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 03/19/2020] [Indexed: 12/02/2022] Open
Abstract
We report a 23-year-old woman who presented with generalized scaly erythematous rash predominately on the upper trunk and hemorrhagic stomatitis. The histopathologic and immunopathologic findings were consistent with the diagnosis of paraneoplastic pemphigus. Castleman's tumor was diagnosed with computed tomography and exploratory laparotomy. A partial clinical improvement was observed after complete tumor removal and intravenous immunoglobulin administration. However, the patient died as a result of septicemia.
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Affiliation(s)
- Thirawut Sirikham
- Division of Dermatology, Department of Medicine, Suratthani Hospital, Suratthani, Thailand.,Division of Dermatology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Weeratian Tawanwongsri
- Division of Dermatology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Suthinee Rutnin
- Division of Dermatology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Kumutnart Chanprapaph
- Division of Dermatology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Vasanop Vachiramon
- Division of Dermatology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Maruta CW, Miyamoto D, Aoki V, de Carvalho RGR, Cunha BM, Santi CG. Paraneoplastic pemphigus: a clinical, laboratorial, and therapeutic overview. An Bras Dermatol 2019; 94:388-398. [PMID: 31644609 PMCID: PMC7007015 DOI: 10.1590/abd1806-4841.20199165] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Accepted: 06/17/2019] [Indexed: 12/27/2022] Open
Abstract
Paraneoplastic pemphigus is a rare and severe autoimmune blistering disease characterized by mucocutaneous lesions associated with benign and malignant neoplasms. Diagnostic criteria include the presence of chronic mucositis and polymorphic cutaneous lesions with occult or confirmed neoplasia; histopathological analysis exhibiting intraepidermal acantholysis, necrotic keratinocytes, and vacuolar interface dermatitis; direct immunofluorescence with intercellular deposits (IgG and C3) and at the basement membrane zone (IgG); indirect immunofluorescence with intercellular deposition of IgG (substrates: monkey esophagus and simple, columnar, and transitional epithelium); and, autoreactivity to desmogleins 1 and 3, desmocollins 1, 2, and 3, desmoplakins I and II, envoplakin, periplakin, epiplakin, plectin, BP230, and α-2-macroglobulin-like protein 1. Neoplasias frequently related to paraneoplastic pemphigus include chronic lymphocytic leukemia, non-Hodgkin lymphoma, carcinomas, Castleman disease, thymoma, and others. Currently, there is no standardized treatment for paraneoplastic pemphigus. Systemic corticosteroids, azathioprine, mycophenolate mofetil, cyclosporine, rituximab, cyclophosphamide, plasmapheresis, and intravenous immunoglobulin have been used, with variable outcomes. Reported survival rates in 1, 2, and 5 years are 49%, 41%, and 38%, respectively.
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Affiliation(s)
- Celina Wakisaka Maruta
- Department of Dermatology, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Denise Miyamoto
- Department of Dermatology, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Valeria Aoki
- Department of Dermatology, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | | | - Breno Medeiros Cunha
- Department of Dermatology, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Claudia Giuli Santi
- Department of Dermatology, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
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Abstract
A variety of cutaneous abnormalities can be seen in patients with malignant diseases, some of which are infectious, with others representing direct involvement of the skin by the underlying disorder. Yet another group of lesions can be regarded as associated markers of the malignant process, and, as such, are termed "paraneoplastic." This review considers the latter collection of conditions, grouping them by the generic type of malignancy that is usually linked to the paraneoplasia. Some of the processes show a predominant association with alimentary tract malignancies (acanthosis nigricans, acrodermatitis paraneoplastica, florid cutaneous papillomatosis, necrolytic migratory erythema, palmoplantar keratoderma, pancreatic fat necrosis, and pityriasis rotunda). Others are usually linked to a hematolymphoid malignancy (acquired ichthyosis, exfoliative erythroderma, necrobiotic xanthogranuloma, pemphigus paraneoplastica, plane xanthoma, pyoderma gangrenosum, scleromyxedema, Sweet syndrome, and leukocytoclastic vasculitis). Finally, yet another collection of paraneoplastic skin disorders can associate themselves with anatomically-diverse malignancies (Leser-Trelat syndrome, Trousseau syndrome, dermatomyositis, erythema gyratum repens, hypertrichosis lanuginosa acquisita, papuloerythroderma of Ofuji, tripe palms, and multicentric reticulohistiocytosis). Recognition of these processes by the pathologist can be a valuable step in the characterization of underlying malignant diseases.
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Affiliation(s)
- Mark R Wick
- PRW Laboratories, Charlottesville, VA, United State.
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Konichi-Dias RL, Ramos AF, de Almeida Santos Yamashita ME, Cárcano CBM. Paraneoplastic pemphigus associated with chronic lymphocytic leukemia: a case report. J Med Case Rep 2018; 12:252. [PMID: 30165900 PMCID: PMC6117874 DOI: 10.1186/s13256-018-1742-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 06/08/2018] [Indexed: 11/30/2022] Open
Abstract
Background Paraneoplastic pemphigus is a rare multiorgan disease of autoimmune causes, usually triggered by neoplasias, mainly of lymphoproliferative origin, such as leukemia and lymphoma. This disorder is categorized by the presence of autoantibodies that react against proteins, such as desmoplakins, desmogleins, desmocollins, and others that exist in cellular junctions. Paraneoplastic pemphigus can manifest clinically in a variety of ways, ranging from mucositis to lesions involving the skin and pulmonary changes. The diagnosis depends on the correlation between the clinical and histopathologic evaluations. Currently, the treatment of this disease is still very difficult and ineffective. The prognosis is poor, and the mortality rate is very high. Case presentation We report a case of a Caucasian patient who had chronic lymphocytic leukemia and developed paraneoplastic pemphigus with severe impairment of skin and mucosa. The initial diagnostic hypothesis was Stevens-Johnson syndrome. The histopathological examination of the skin biopsy was compatible with paraneoplastic pemphigus, and the definitive diagnosis was made on the basis of clinical-pathological correlation. Conclusions With the presence of multiorgan lesions in patients with lymphoproliferative neoplasia, paraneoplastic pemphigus should always be considered among the possible diagnostic hypotheses, because diagnosis and early treatment may allow a better prognosis for the patient.
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Affiliation(s)
| | - Aline Fernanda Ramos
- School of Health Sciences Dr. Paulo Prata (FACISB), Barretos, Sao Paulo, Brazil.,Barretos Cancer Hospital, Barretos, Sao Paulo, Brazil
| | | | - Cristiane Botelho Miranda Cárcano
- School of Health Sciences Dr. Paulo Prata (FACISB), Barretos, Sao Paulo, Brazil.,Barretos Cancer Hospital, Barretos, Sao Paulo, Brazil
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