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Diercks GFH, Meijer JM, Bolling MC, Scholtens-Jaegers SMHJ, Bremer J, Horvath B. Absence of Epidermal Antibodies in Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis Patients but Beware of Single Positive Results. Dermatol Res Pract 2024; 2024:5504462. [PMID: 38803350 PMCID: PMC11129901 DOI: 10.1155/2024/5504462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 04/30/2024] [Accepted: 05/02/2024] [Indexed: 05/29/2024] Open
Abstract
Background Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare and potentially life-threatening mucocutaneous blistering diseases that clinically can resemble autoimmune bullous diseases. Moreover, it has been shown that autoantibodies against epidermal proteins are present in SJS/TEN. Objectives To establish the presence of antibodies against desmosomal and hemidesmosomal proteins in confirmed SJS/TEN patients. Methods Serum of SJS/TEN patients diagnosed based on clinical criteria, e.g., epidermal detachment with erosions and severe mucosal lesions, (suspicion of) a culprit drug, and matching histologic results was evaluated by various techniques, e.g., indirect immunofluorescence on monkey esophagus, salt split skin and rat bladder, immunoblotting (IB) and immunoprecipitation (IP), ELISAs against desmogleins and BP180, keratinocyte footprint assay, and keratinocyte binding assay. Results A total of 28 patients were included in this study, 15 men and 13 women with a mean age of 56 years. In most patients, none of the serological tests were positive. In two patients, an elevated DSG3 titer was found suspicious for pemphigus vulgaris. Three patients had elevated NC16a titers, suggesting bullous pemphigoid. However, in all these patients, no other tests were positive and in these patients, the biopsy for direct immunofluorescence showed no evidence for an autoimmune bullous disease. Three patients showed reactivity against rat bladder rat bladder; these were, however, completely negative for A2ML1, envoplakin, and periplakin in the IB as well as the IP. Conclusions Serological analysis for desmosomal and hemidesmosomal antibodies is reliable to rule an autoimmune bullous disease in patients with suspected SJS/TEN. However, one should not rely on one single test method since false positive results can occur. Moreover, this study also makes it less plausible that antibodies against desmosomal and/or hemidesmosomal components are involved in the pathogenesis of SJS/TEN.
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Affiliation(s)
- Gilles F. H. Diercks
- University of Groningen, University Medical Center Groningen, Department of Dermatology, Center of Blistering Diseases, European Reference Networks-Skin Member, Groningen, Netherlands
- European Reference Networks (ERN)—SKIN Center, Paris, France
| | - Joost M. Meijer
- University of Groningen, University Medical Center Groningen, Department of Dermatology, Center of Blistering Diseases, European Reference Networks-Skin Member, Groningen, Netherlands
- European Reference Networks (ERN)—SKIN Center, Paris, France
| | - Maria C. Bolling
- University of Groningen, University Medical Center Groningen, Department of Dermatology, Center of Blistering Diseases, European Reference Networks-Skin Member, Groningen, Netherlands
- European Reference Networks (ERN)—SKIN Center, Paris, France
| | | | - Jeroen Bremer
- University of Groningen, University Medical Center Groningen, Department of Dermatology, Center of Blistering Diseases, European Reference Networks-Skin Member, Groningen, Netherlands
- European Reference Networks (ERN)—SKIN Center, Paris, France
| | - Barbara Horvath
- University of Groningen, University Medical Center Groningen, Department of Dermatology, Center of Blistering Diseases, European Reference Networks-Skin Member, Groningen, Netherlands
- European Reference Networks (ERN)—SKIN Center, Paris, France
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Özhan AK, Demirhan A, Arikoglu T, Karahan F, Satıcı FEG, Tokmeci N, Gündoğan BD, Yalaki Aİ, Akbey V, Karabulut YY, Ünal S, Kuyucu S. Toxic Skin Reactions Should Be Differentiated from Allergic Reactions to Chemotherapeutic Drugs in Children: A Case Series and Review of the Literature. Dermatitis 2024; 35:275-287. [PMID: 38165639 DOI: 10.1089/derm.2023.0258] [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: 01/04/2024]
Abstract
Background: Chemotherapeutic drugs can lead to a wide spectrum of cutaneous findings, ranging from nonimmune toxic reactions to severe immune-mediated hypersensitivity reactions. The aim of this study was to evaluate the clinical, histopathological features, and prognosis of toxic skin reactions to chemotherapeutic drugs and to compare them with characteristics of immune-mediated reactions in children with malignancies. Methods: The medical records of all children with cancer who experienced skin reactions after chemotherapy administration and diagnosed as a toxic skin reaction between 2010 and 2022 were retrospectively analyzed. The diagnosis was re-evaluated and differentiated from other similar disorders by using clinical manifestations, photodocumentation, and histopathological findings. Results: A total of 17 children aged 2-17 years were involved: toxic erythema of chemotherapy (TEC) in 14 children, methotrexate-induced epidermal necrosis in 2 children, and toxic epidermal necrolysis (TEN)-like TEC in 1 child. The most commonly implicated drug was methotrexate. Most patients recovered rapidly after drug cessation and supportive measures. In 10 of the 17 patients, reintroduction of the culprit chemotherapeutic drug at reduced doses or increased dosage intervals was possible without any recurrence. Six patients could not receive further doses since they deceased due to sepsis and other complications. Conclusions: Cutaneous toxic eruptions to chemotherapeutic drugs may present with a severe phenotype resembling Stevens-Johnson syndrome/TEN. An accurate diagnosis prevents potentially harmful therapeutic interventions, withholding of chemotherapy, and erroneous assignment of drug allergies.
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Affiliation(s)
- Aylin Kont Özhan
- From the Department of Pediatric Allergy and Immunology, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Ali Demirhan
- Department of Pediatric Allergy and Immunology, Mersin City Training and Research Hospital, Mersin, Turkey
| | - Tuğba Arikoglu
- From the Department of Pediatric Allergy and Immunology, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Feryal Karahan
- Department of Pediatric Hematology and Oncology, Faculty of Medicine, Mersin University, Mersin, Turkey
| | | | - Nazan Tokmeci
- Department of Pediatric Allergy and Immunology, Adıyaman University Training and Research Hospital, Adıyaman, Turkey
| | - Begümhan Demir Gündoğan
- Department of Pediatric Hematology and Oncology, Dr. Behçet Uz Pediatric Diseases and Surgery Training and Research Hospital, İzmir, Turkey
| | - Aysu İlhan Yalaki
- From the Department of Pediatric Allergy and Immunology, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Veysi Akbey
- From the Department of Pediatric Allergy and Immunology, Faculty of Medicine, Mersin University, Mersin, Turkey
| | | | - Selma Ünal
- Department of Pediatric Hematology and Oncology, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Semanur Kuyucu
- From the Department of Pediatric Allergy and Immunology, Faculty of Medicine, Mersin University, Mersin, Turkey
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3
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Albrahim L, Alasmari AA, Aleissa M. Pemphigus vulgaris mimicking Steven-Johnson syndrome/toxic epidermal necrolysis: report of an unusual case. Dermatol Reports 2023; 15:9649. [PMID: 37822989 PMCID: PMC10563021 DOI: 10.4081/dr.2023.9649] [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: 12/20/2022] [Accepted: 01/10/2023] [Indexed: 10/13/2023] Open
Abstract
Pemphigus vulgaris (PV) is an autoimmune blistering disease affecting the skin and mucosa. It clinically presents as painful erosions, mainly in the oral cavity, and flaccid blisters and erosions on the skin. Steven-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) is a severe mucocutaneous drug hypersensitivity reaction characterized by painful, dusky, erythematous eruptions that often progress to blisters, erosions, and extensive epidermal detachment accompanied by systemic symptoms. Herein, we report the case of a 48-year-old man who presented with extensive skin and mucosal lesions following the ingestion of an unknown medication. The patient's symptoms clinically mimicked SJS, and accordingly, a preliminary diagnosis of SJS/TEN was made. However, clinical investigation of skin biopsy and direct immunofluorescence assay results indicated PV, and a final diagnosis of PV was established.
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Affiliation(s)
- Latifah Albrahim
- Division of Dermatology, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh
| | - Amal Aboud Alasmari
- Division of Dermatology, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh
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Grigore M, Costache M, Simionescu O. Paraneoplastic Pemphigus Mimicking Pemphigus Vulgaris Associated With Castleman Disease. Cureus 2023; 15:e36114. [PMID: 37065416 PMCID: PMC10098500 DOI: 10.7759/cureus.36114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/13/2023] [Indexed: 03/16/2023] Open
Abstract
Paraneoplastic pemphigus (PNP) is a rare bullous disease with a polymorphic presentation. Diagnosis can be difficult because it can mimic other bullous diseases, while the underlying neoplasm may be completely asymptomatic. We present the case of a 19-year-old female with a four-year history of exclusively oral bullous lesions, mimicking pemphigus vulgaris, before the diagnosis of a retroperitoneal Castleman disease. While PNP is a severe and sometimes deadly condition, our patient had a mild and long evolution on minimal treatment, with complete resolution after tumor excision. Practitioners should be aware of PNP in young patients presenting with bullous disease and should conduct prompt systemic investigations in refractory or long-evolving cases, even when PNP diagnostic criteria are not fully met.
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Salah E. TEN mimics: Classification and practical approach to toxic epidermal necrolysis-like dermatoses. Indian J Dermatol Venereol Leprol 2022; 89:337-346. [PMID: 36688885 DOI: 10.25259/ijdvl_244_2022] [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: 03/01/2022] [Accepted: 08/01/2022] [Indexed: 12/15/2022]
Abstract
Toxic epidermal necrolysis (TEN) is an acute life-threatening dermatologic emergency. However, many dermatoses can present with a TEN-like eruption. Those "TEN-mimics" are a true diagnostic challenge and an alarming differential diagnosis to such a serious condition. Herein, we will expose and classify the landscape of TEN-mimics. Also, the key differentiating clinical and/or laboratory points will be highlighted to help an accurate diagnosis of either a TEN or a TEN-like presentation.
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Affiliation(s)
- Eman Salah
- Department of Dermatology, Venereology & Andrology, Faculty of Medicine, Zagazig University, Egypt
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Hui HZ, Guo HX, Wang YJ, Shi BJ. Rare Case of Paraneoplastic Pemphigus Associated With Prostatic Cancer. Am J Dermatopathol 2022; 44:940-942. [PMID: 36197045 DOI: 10.1097/dad.0000000000002313] [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: 05/10/2022] [Accepted: 08/13/2022] [Indexed: 11/18/2022]
Abstract
ABSTRACT The combination of paraneoplastic pemphigus and prostate cancer is extremely unusual and has not been reported yet. Paraneoplastic pemphigus is caused by tumor-induced autoantibodies, which cause damage to the skin and mucosa. The essential treatment is active tumor control. Our patient received a robot-assisted radical prostatectomy and glucocorticoid therapy to improve his condition and relieve his skin lesions.
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Affiliation(s)
- Hai-Zhen Hui
- Department of Dermatology, Chongqing Hospital of Traditional Chinese Medicine (Chongqing Clinical Research Center for Dermatology, Chongqing Key Laboratory of Integrative Dermatology Research), District Yuzhong, Chongqing, PR China
- Guizhou University of Traditional Chinese Medicine, Guiyang, PR China; and
| | | | - Ying-Jun Wang
- Department of Dermatology, Chongqing Hospital of Traditional Chinese Medicine (Chongqing Clinical Research Center for Dermatology, Chongqing Key Laboratory of Integrative Dermatology Research), District Yuzhong, Chongqing, PR China
- Guizhou University of Traditional Chinese Medicine, Guiyang, PR China; and
| | - Bing-Jun Shi
- Department of Dermatology, Chongqing Hospital of Traditional Chinese Medicine (Chongqing Clinical Research Center for Dermatology, Chongqing Key Laboratory of Integrative Dermatology Research), District Yuzhong, Chongqing, PR China
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Kim M, Lee JY, Kim SC, Na JI. A Case of Paraneoplastic Pemphigus as a Preceding Manifestation of Underlying Follicular Lymphoma Treated with R-CHOP. Ann Dermatol 2021; 33:271-274. [PMID: 34079187 PMCID: PMC8137331 DOI: 10.5021/ad.2021.33.3.271] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 01/02/2020] [Accepted: 01/09/2020] [Indexed: 11/09/2022] Open
Abstract
Paraneoplastic pemphigus is a rare, life-threatening disorder associated with an underlying neoplasm, which presents with painful stomatitis and polymorphous skin lesions. Successful diagnosis of paraneoplastic pemphigus can lead to the diagnosis and treatment of the underlying malignancy. However, involvement of the respiratory system is typically unresponsive to treatment. Herein, we report the case of a 44-year-old female diagnosed with paraneoplastic pemphigus with underlying follicular lymphoma treated with a chemotherapy regimen including rituximab. Her skin lesions and underlying lymphoma responded to treatment, but bronchiolitis obliterans continued to progress and resulted in fatal respiratory failure.
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Affiliation(s)
- Minsu Kim
- Department of Dermatology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Ji Yun Lee
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Soo-Chan Kim
- Department of Dermatology and Cutaneous Biology Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Jung-Im Na
- Department of Dermatology, Seoul National University Bundang Hospital, Seongnam, Korea
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Onukogu I, Ramachandran P, Narh J, Sahni S, Joseph G. Paraneoplastic Pemphigus: An Indication for Treatment in Chronic Lymphocytic Leukemia. Cureus 2020; 12:e8316. [PMID: 32607299 PMCID: PMC7320649 DOI: 10.7759/cureus.8316] [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] [Indexed: 11/05/2022] Open
Abstract
Paraneoplastic disorders are rare multiorgan diseases associated with hematological malignancies such as chronic lymphocytic leukemia (CLL). Some of these paraneoplasms manifest as cutaneous lesions, appearing as a simple rash, ulcers or skin thickening. The pathogenesis for this process has been described as development of certain autoimmune reactions against cell wall antigens and proteins. An example is paraneoplastic pemphigus (PNP) which manifests as cutaneous bullae. Bullae may occur anytime during the course of the malignancy i.e. acute phase or remission. Diagnosis involves evaluation of clinical findings, serology and presence of characteristic histological findings. Its pathogenesis is described as development of auto-antibodies against cell junctional and basement membrane proteins. Presence of paraneoplasms has been associated with poorer prognosis and increased mortality in hematological malignancies including CLL. Currently, there are established indications for the treatment of CLL; however, presence of paraneoplasms as an indication for treatment is unclear. Patients with paraneoplasms who underwent expeditious treatment have exhibited better clinical outcomes. Herein we describe a case of a CLL patient in remission presenting with PNP and its response to treatment.
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Affiliation(s)
| | | | - Joshua Narh
- Internal Medicine, Brookdale University Hospital and Medical Center, New York, USA
| | - Sonu Sahni
- Internal Medicine, Brookdale University Hospital Medical Center, New York, USA.,Research Medicine, New York Institute of Technology College of Osteopathic Medicine, New York, USA.,Primary Care, Touro College of Osteopathic Medicine, New York, USA
| | - Gardith Joseph
- Oncology, Mount Sinai Medical Center, Brooklyn, USA.,Hematology and Oncology, Brookdale University Hospital and Medical Center, Brooklyn, USA
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Harrell J, Rubio XB, Nielson C, Hsu S, Motaparthi K. Advances in the diagnosis of autoimmune bullous dermatoses. Clin Dermatol 2019; 37:692-712. [PMID: 31864451 DOI: 10.1016/j.clindermatol.2019.09.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Autoimmune bullous dermatoses are defined by autoantibodies directed against adhesion proteins in the epidermis or basement membrane zone, resulting in blister formation on the skin and mucosa. Diagnosis depends on lesional biopsy for histopathology and perilesional biopsy for direct immunofluorescence. Additional diagnostic methods include indirect immunofluorescence, enzyme-linked immunosorbent assay, and immunoblot (Western blot), which may be selected in specific clinical scenarios due to improved sensitivity and/or specificity. This contribution reviews the available evidence supporting the use of each method to provide a practical reference for clinicians when diagnosing autoimmune bullous disorders. Techniques and cost are reviewed, and newer diagnostic techniques with potential for clinical application are.
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Affiliation(s)
- Jane Harrell
- University of Florida College of Medicine, Gainesville, Florida, USA
| | | | - Colton Nielson
- Department of Dermatology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Sylvia Hsu
- Department of Dermatology, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, USA
| | - Kiran Motaparthi
- Department of Dermatology, University of Florida College of Medicine, Gainesville, Florida, USA.
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10
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Deschaine MA, Lehman JS. The interface reaction pattern in the skin: an integrated review of clinical and pathological features. Hum Pathol 2019; 91:86-113. [DOI: 10.1016/j.humpath.2019.06.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 06/18/2019] [Accepted: 06/20/2019] [Indexed: 12/14/2022]
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11
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Ouedraogo E, Gottlieb J, de Masson A, Lepelletier C, Jachiet M, Salle de Chou C, Galicier L, Bagot M, Chevret S, Bouaziz JD. Risk factors for death and survival in paraneoplastic pemphigus associated with hematologic malignancies in adults. J Am Acad Dermatol 2019; 80:1544-1549. [DOI: 10.1016/j.jaad.2018.03.043] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 03/20/2018] [Accepted: 03/25/2018] [Indexed: 12/14/2022]
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