Epidermolysis bullosa acquisita: a clinical disorder of varied etiologies. Two cases and a review of immunologic and other reported findings

About linear igA/igG bullous dermatosis

A case study of linear IgA/IgG bullous dermatosis has been described, and issues related to classification as well as clinical, histological and immunopathological signs of the disease have been discussed.

Paraneoplastic epidermolysis bullosa acquisita associated with multiple myeloma

Epidermolysis bullosa acquisita is a rare acquired autoimmune subepidermal blistering disease that clinically resembles other vesiculobullous lesions such as pemphigus vulgaris and cicatricial pemphigoid. Multiple myeloma is the most common plasma cell malignant disorder characterized by a single clonal expansion and increased level of a single immunoglobulin. Epidermolysis bullosa acquisita has been reported with other systemic diseases such as lymphoma. In this case report, we present a patient with paraneoplastic epidermolysis bullosa acquisita associated with multiple myeloma.

Differences in direct immunofluorescence staining patterns in epidermolysis bullosa acquisita and bullous pemphigoid

BACKGROUND

Both bullous pemphigoid (BP) and epidermolysis bullosa acquisita (EBA) are characterized by linear IgG deposits along the basement membrane zone (BMZ). Although these diseases can be distinguished by special tests, the staining pattern on direct immunofluorescence (DIF) is identical.

OBJECTIVE

The purpose of the present study was to reevaluate DIF as a diagnostic tool in differentiating EBA from BP.

METHODS

We performed DIF studies on biopsy specimens from eight consecutive patients with EBA and 18 consecutive patients with BP.

RESULTS

In five of eight cases of EBA, C3 deposition was essentially absent. IgG was the predominant class of immunoglobulins in the deposits and was present along the BMZ in all eight cases. C3 was present in 17 of 18 cases of BP. IgG was the predominant immunoglobulin present in 15 of these 18.

CONCLUSION

Patients with EBA are more likely to have linear IgG staining along the BMZ without concomitant C3 deposition than are patients with BP. This difference may be a function of the ability of the autoantibodies to fix complement.

In situ localization of IgG in epidermolysis bullosa acquisita by immunogold technique

BACKGROUND

Epidermolysis bullosa acquisita (EBA) is an immunologically mediated mechanobullous dermatosis. Recently, serum antibodies in patients with EBA have been reported to bind to the carboxyl terminus of type VII collagen, the disease antigen. However, the precise localization of immunoglobulins in diseased skin has not been demonstrated.

OBJECTIVE

In the present study skin samples taken from a 59-year-old man with EBA were processed for immunoelectron microscopy.

METHODS

A preembedding immunogold ultrastructural technique was applied.

RESULTS

Gold particles, indicative of IgG binding, were deposited within the anchoring plaques and within the lamina densa in some perilesional skin sections. In a similar distribution, IgG-containing amorphous aggregates were detected within the basement membrane zone of perilesional and lesional skin. In some places these immunoglobulin deposits covered the whole region of anchoring fibrils.

CONCLUSION

These results demonstrate the precise localization of IgG within the basement membrane zone of EBA skin that corresponds to the carboxyl terminus of collagen VII in normal skin.

Epidermolysis bullosa acquisita in identical twins

Identical twin sisters developed generalized erythema and bullae on skin and mucous membranes at 18 and 19 years of age. Atrophic scars and milia were formed later. Indirect immunofluorescence (IF) study of the separated skin by incubation in 1.0M NaCl showed antibasement membrane zone (BMZ) antibodies bound to the dermal side. The HLA-DR typing demonstrated DR2/DW11. Pulse therapy resulted in marked clinical improvement. This is the first report of epidermolysis bullosa acquisita (EBA) in identical twins and suggests the possibility that the disease may have a genetic component.

Epidermolysis bullosa acquisita: a disease of autoimmunity to type VII collagen

Epidermolysis bullosa acquisita (EBA) is one of a group of primary blistering diseases characterized by dermal/epidermal separation at the basement membrane (BM) of stratified squamous epithelium and IgG anti-BM autoantibodies (ABM). EBA ABMs can be distinguished from IgG ABMs in all other primary blistering diseases by their reactivity with the BM matrix protein, type VII collagen (C-VII). The clinical and histological features of EBA are highly variable and may be indistinguishable from those of other primary bullous diseases. The diagnosis can be confirmed by one of several methods that directly or indirectly demonstrate IgG ABMs to C-VII. IgG ABMs to C-VII are not specific for EBA. They have been described in SLE patients with and without a secondary blistering eruption, bullous eruption of SLE (BSLE). IgA ABMs to C-VII have been described in a subgroup of patients with linear IgA bullous dermatosis. Recent evidence suggests that autoimmunity to C-VII in EBA and BSLE is regulated by the same genes within the major histocompatibility complex (MHC) and contributes to the pathogenesis of acute inflammation and blisters in both disorders. The finding of ABMs to C-VII in SLE and BSLE, evidence that EBA and BSLE share an immunogenetic predisposition to C-VII autoimmunity, and an apparent association between susceptibility to SLE and EBA suggest a close relationship between SLE and autoimmunity to C-VII.

Epidermolysis bullosa acquisita antigen and the carboxy terminus of type VII collagen have a common immunolocalization to anchoring fibrils and lamina densa of basement membrane

In this study a variety of immunoelectron microscopic methods were used to define the precise ultrastructural binding site of epidermolysis bullosa acquisita antibodies (EBA-Ab). We used two EBA sera which immunoblotted with the same skin-extracted protein as that labelled by a monoclonal antibody (LH7.2) which is known to react with the carboxy terminus of type VII collagen. Gold-conjugated antibodies were used in two different immunoelectron microscopic procedures to compare the labelling characteristics of EBA-Ab and LH7.2 in normal human skin. Antibody incubations were performed using ultra-thin cryosections of unfixed skin and thin slices of fresh skin (en bloc technique) before conventional fixation and embedding in Epon. Both methods showed similar labelling features for both EBA-Ab and LH7.2. With ultra-thin cryosections there was labelling of the lamina densa and an undefined component of the sublamina densa region. With the en bloc technique, labelling of dermal ends of anchoring fibrils and of amorphous material recently defined as 'anchoring plaques' was evident. There was no labelling of the central banded portions of anchoring fibrils. We conclude that EBA-Ag is localized to the dermal ends of anchoring fibrils in addition to the lamina densa and possibly anchoring plaques, and thus has the same distribution as the carboxy terminus of type VII collagen.

Epidermolysis bullosa acquisita preceding the development of systemic lupus erythematosus

In most cases of epidermolysis bullosa acquisita that occur in patients with systemic lupus erythematosus, the diagnosis of systemic lupus erythematosus is made before the development of blistering. We observed three patients with well-documented epidermolysis bullosa acquisita that developed several years before the onset of systemic lupus erythematosus. One patient was producing anti-U1RNP autoantibodies at the time epidermolysis bullosa acquisita was diagnosed, and all five produced this antibody during the systemic lupus erythematosus phase of their illness. In addition, in all five cases of epidermolysis bullosa acquisita with systemic lupus erythematosus antibodies to double-stranded DNA ultimately developed, and severe systemic lupus erythematosus and lupus nephritis developed in four patients. Sera from 15 other patients with epidermolysis bullosa acquisita without overt systemic lupus erythematosus were analyzed for systemic lupus erythematosus-related autoantibodies. Four patients were found to have at least one such autoantibody. These findings further document an association between epidermolysis bullosa acquisita and systemic lupus erythematosus and suggest that patients with systemic lupus erythematosus who present with epidermolysis bullosa acquisita may represent a subset of lupus erythematosus that puts the patient at increased risk for the development of more severe systemic illness. Patients presenting with epidermolysis bullosa acquisita, especially those who are black or Hispanic, should be monitored for the development of potentially life-threatening systemic lupus erythematosus.

The presence of intra-lamina lucida blister formation in epidermolysis bullosa acquisita: possible role of leukocytes

In evaluating patients we have noted disparity between the locations of bound immunoreactants and the level of blistering in epidermolysis bullosa acquisita (EBA). We examined 10 consecutive EBA patients by routine histology, direct (DIF) and indirect (IIF; intact and NaCl-split skin) immunofluorescence, immunofluorescence mapping (IM), and/or direct immunoelectron microscopy (DIEM). DIF was positive in each. IIF was positive in 3/8 and 6/7 patients when intact and split skin were used as substrates. DIEM revealed immunoreactants within the lamina densa (LD) in 6/10, sub-LD in 1/10, and both LD and sub-LD in 3/10 patients. In contrast, by DIEM and IM, blister formation was noted within the lamina lucida (LL) in 7/9 and 8/10, sub-LD in 1/9 and 1/10, and within both LL and sub-LD in 1/9 and 1/10, respectively. In the presence of neutrophils within the upper dermis (n = 6), cleavage occurred within the LL in 5 specimens; in one additional specimen containing predominantly neutrophils, cleavage occurred within both LL and sub-LD. In the presence of mononuclear cells (n = 2), intra-LL cleavage occurred. In the presence of eosinophils, cleavage occurred within both LL and sub-LD. In the one specimen lacking any infiltrate, the cleavage plane was exclusively sub-LD. Intra-LL cleavage planes are more common than sub-LD ones in at least early cases of EBA. These findings likely represent the intra-LL-separating effect of leukocyte-derived proteolytic enzymes, when such cells are chemoattracted to the dermoepidermal junction by bound immuno-reactants.

Clearing of epidermolysis bullosa acquisita with cyclosporine

Epidermolysis bullosa acquisita is a chronic, severe, subepidermal, blistering disease of the skin, characterized by marked resistance to topical and systemic therapy. This report concerns a well-documented case of a woman who had had epidermolysis bullosa acquisita for 6 years and had remained hospitalized continuously for 7 months in 1987. Her case ultimately was controlled with cyclosporine after the failure of a variety of therapeutic modalities in the hospital, including prednisone, methotrexate, azathioprine, phenytoin, vitamin E, gold sodium thiomalate (Myochrysine), isotretinoin, and plasmapheresis. In contrast to patients with pemphigus and pemphigoid treated with cyclosporine, our patient's autoantibodies did not disappear on therapy. Although its mechanism of action in epidermolysis bullosa acquisita is unknown, we propose that cyclosporine may be a helpful drug for patients whose disease is refractory to more traditional forms of therapy.

Localization of bullous pemphigoid antibody--an indirect immunofluorescence study of 228 cases using a split-skin technique

We have re-examined the site of deposition of IgG anti-basement membrane zone antibodies in 228 sera from suspected cases of bullous pemphigoid (BP), using 1.0 M sodium chloride split-skin as substrate for indirect immunofluorescence. Nine sera (4%) produced fluorescence on the floor of the split suggesting sub-basal lamina antibody deposition compatible with a diagnosis of epidermolysis bullosa acquisita (EBA). This ultrastructural localization was confirmed in only three of these nine by immuno-electron microscopy. Clinical details were available on six of these nine cases, and none had clinical features suggesting EBA. We have found the split-skin immunofluorescence technique unhelpful in identifying 'missed' cases of EBA. The prevalence of EBA presenting as BP would appear to be very low indeed in the U.K.

Disseminated cicatricial pemphigoid in a child and in an adult. Ultrastructural diagnostic criteria and differential diagnosis with special reference to acquired epidermolysis bullosa

The first case of an infant affected with a rare, disseminated variant of benign cicatricial pemphigoid is described, showing the same ultrastructural features of initial blister formation as an adult patient. These consist in edematous changes within the superficial dermis caused by vesiculation or dissolution of cellular and noncellular connective tissue elements, coalescing into subepidermal blisters. Differential diagnosis excludes other nonhereditary bullous disorders because of the ultrastructure of the dermo-epidermal junction in nascent blisters and in perilesional skin. In spite of evident clinical, histological, and immunohistological similarities as well as controversial and confusing immunological studies, acquired epidermolysis bullosa can be clearly separated from our case by a diagnostic hallmark on the electron-microscopical level, i.e., band-like IgG depositions beneath the basal lamina. This is demonstrated in comparing the two cases of disseminated cicatricial pemphigoid with three patients suffering from acquired epidermolysis bullosa, thus providing evidence that disseminated cicatricial pemphigoid and acquired epidermolysis bullosa are two distinct nosologic entities.

Severe ocular involvement in a patient with epidermolysis bullosa acquisita

A patient with epidermolysis bullosa acquisita and prominent ocular involvement that resulted in blindness is described. Because the severe eye involvement dominated the clinical picture, she had been diagnosed as having cicatricial pemphigoid. Clinicians should be aware that epidermolysis bullosa acquisita may mimic cicatricial pemphigoid and bullous pemphigoid.

Bullous pemphigoid: associated diseases

Bullous pemphigoid is a fairly common chronic disease of elderly persons, many of whom have other medical conditions and problems. In the main, a search for commonly associated diseases is not warranted.

Epidermolysis bullosa acquisita in an 8-year-old girl

Epidermolysis bullosa acquisita is an autoimmune blistering disease with the distinct feature of having an autoantibody directed against an antigen located below the basement membrane of human skin and mucous membrane. We identified this disease in an 8-year-old girl, the youngest patient documented by immunoelectron microscopy.

Anatomical distribution and immunological characteristics of epidermolysis bullosa acquisita antigen and bullous pemphigoid antigen

A Japanese patient with epidermolysis bullosa acquisita (EBA) was autopsied, and direct immunofluorescence (DIF) testing was performed. Using this patient's serum (EBA serum) and three bullous pemphigoid (BP) sera, the anatomical distribution and immunological characteristics of EBA antigen and BP antigen were investigated by indirect immunofluorescence (IIF). EBA antigen showed the same anatomical distribution as BP antigen in DIF and IIF studies; both antigens were limited to the skin, tongue, oesophagus, trachea, cornea and bladder. EBA antigen was located on the dermal side of both NaCl and PBS-separated skin, whereas BP antigen was limited to the epidermal side. Ethanol fixation abrogated the antigenic stability of BP antigen, but not that of EBA antigen. No difference was found when acetone or formalin fixation was used. The separation methods and prefixation in ethanol could be useful techniques applicable to the classification of the bullous disorders which manifest circulating anti-BMZ antibodies.

Epidermolysis bullosa acquisita antigen is synthesized by both human keratinocytes and human dermal fibroblasts

In order to determine the source of epidermolysis bullosa acquisita (EBA) antigen, we studied its synthesis by human keratinocytes and fibroblasts in culture. To identify the antigen, we used the sera of 5 patients with EBA. These sera had antibodies directed against the epidermal basement membrane zone (BMZ) at titers of 5-80. The 5 sera were further characterized by immunoblotting on extracts of the epidermal BMZ. In concert with previous reports, 4 sera stained a 290 kD polypeptide, 3 sera weakly stained a 145 kD polypeptide, and 1 serum did not bind either polypeptide. To study the synthesis of the EBA antigen, cultured human keratinocytes and fibroblasts, derived from neonatal foreskins, were metabolically labeled with 14C-labeled amino acids. Radiolabeled newly synthesized proteins that were extracted from these cultures with nonionic detergent were used in an immunoprecipitation assay. The precipitated proteins were identified by sodium dodecyl sulfate-polyacrylamide gel electrophoresis and fluorography. All 5 EBA sera, but none of 3 bullous pemphigoid or 4 normal human sera, precipitated a 290 kD polypeptide from extracts of both keratinocytes and fibroblasts. Approximately equal amounts of this 290 kD polypeptide were precipitated from equivalent amounts of extracts from either cell type. The 290 kD polypeptide was also specifically precipitated by EBA sera from extracts of a human squamous cell carcinoma line, SCC-15. The 145 kD polypeptide was not detected in the newly synthesized proteins of any of these cell cultures. This finding suggests that the 145 kD polypeptide is not a precursor of the 290 kD polypeptide. Taken together these results demonstrate that the EBA antigen is synthesized by both human keratinocytes and fibroblasts, and is not a tissue (epidermal)-specific product.

Localized vulvar pemphigoid in a child

Bullous pemphigoid often affects the elderly but is not common in children. At least two localized variants, cicatricial pemphigoid and localized, chronic pemphigoid of Brunsting-Perry, have been described. A case of bullous pemphigoid in a 9-year-old girl was unusual because erosions were limited to the vulvar area. Other bullous dermatoses were considered in the differential diagnosis. Histopathologic examination and immunofluorescence microscopic studies, as well as immunoelectron microscopic studies, which yielded unique results, were performed to confirm the diagnosis.

Epidermolysis bullosa acquisita of the immunopathological type (dermolytic pemphigoid)

Epidermolysis bullosa acquisita (EBA) of the immunopathological type is a distinct disease entity which we propose to name dermolytic pemphigoid. Clinical features of this disease are heterogeneous. An inflammatory phase may mimic bullous pemphigoid or, less commonly, mucosal pemphigoid or dermatitis herpetiformis. The noninflammatory mechanobullous phase equates with classic EBA and features marked skin fragility, bullae and/or erosions at sites of trauma, which result in scarring and milia. The inflammatory or the noninflammatory phase may occur separately or in combination. Transition from inflammatory to noninflammatory phases has been seen. Linear basement membrane zone (BMZ) immune deposits of immunoglobulin G (IgG) are present in the lesional and uninvolved skin of affected patients by immunofluorescence and are essential for the diagnosis. Many patients also have circulating antibasement membrane zone IgG antibodies. Immunoelectron microscopy localizes the immune deposits in the lamina densa and sublamina densa zone and serves to distinguish this disease from diseases with lamina lucida antibodies, such as bullous pemphigoid and mucosal pemphigoid. The EBA antigen has recently been identified and partially characterized from human skin using circulating antibasement membrane zone antibodies from patients with EBA. The EBA antigen consists of 2 components of Mr 290,000 and 145,000, and were shown to be distinct from other known basement membrane components. Mouse monoclonal antibody, H3a, recognizes the same 290 kilodaltons (kd) and 145 kd proteins and localizes to the lamina densa and sublamina densa zone of human skin. The EBA antigen is a newly recognized basement membrane component that is restricted in its distribution to the BMZ of stratified squamous epithelium of both keratinizing and nonkeratinizing types.

Evidence that anti-basement membrane zone antibodies in bullous eruption of systemic lupus erythematosus recognize epidermolysis bullosa acquisita autoantigen

Circulating and tissue-deposited IgG antibodies to the cutaneous basement membrane zone (BMZ) were detected in 3 patients with the clinical, pathologic, and immunologic features of bullous eruption of systemic lupus erythematosus (SLE). The antibodies were present in sera and IgG fractions in all cases and in eluates of cutaneous immune deposits from one of the cases. The antibodies were easily detected in sera by indirect immunofluorescence on adult human thigh skin separated through the lamina lucida by incubation in 1.0 M NaCl but were less easily detected on intact neonatal foreskin. The antibodies had features of epidermolysis bullosa acquisita (EBA) anti-BMZ antibodies including binding to the dermal side of the BMZ in separated skin, binding to the cutaneous but not vascular or glomerular basement membranes, binding to and just below the lamina densa, and binding to 290 or 290 and 145 kD dermal proteins previously identified as components of the EBA autoantigen. The antibodies were relatively specific for SLE patients with features of bullous eruption of SLE since they were detected in 3 of 4 of those cases and in only 1 of 20 SLE patients without blisters. These results show anti-BMZ antibodies with features of EBA antibodies are present in patients with bullous eruption of SLE and suggest there may be a close relationship between that disease and EBA. The results also suggest that EBA antibodies may be part of the autoantibody spectrum of SLE and that separated skin is more sensitive than intact skin for their detection.

A mouse monoclonal antibody against a newly discovered basement membrane component, the epidermolysis bullosa acquisita antigen

A mouse monoclonal antibody, H3a, directed against the newly described epidermolysis bullosa acquisita (EBA) antigen was obtained using hybridoma techniques. The distribution of the monoclonal antibody is identical to that of the polyclonal serum antibody of patients with EBA. By immunofluorescence, a linear band is seen at the dermal-epidermal junction and, by immunoelectron microscopy, immune reaction products are present in the lamina densa and sublamina densa regions. Sodium dodecyl sulfate-polyacrylamide gel electrophoresis followed by Western immunoblot analysis shows that the monoclonal antibody recognizes 290 and 145 kilodalton proteins present in the immunizing junctional extract, identical with the newly discovered EBA antigen. This monoclonal antibody should be useful in the further isolation and characterization of the EBA antigen.

Epidermolysis bullosa acquisita--a pemphigoid-like disease

Epidermolysis bullosa acquisita (EBA) is an immunologically distinctive disease with characteristic clinical features. These include extreme skin fragility, trauma-induced blisters and erosions, and healing with scars and milia. These clinical features are currently the major means of routinely distinguishing EBA from bullous pemphigoid (BP) and cicatricial pemphigoid (CP). In this study we describe five patients with EBA who presented with or developed clinical as well as histologic and immunohistologic features indistinguishable from those characteristic of BP or CP. At different times during the course of their disease, it closely resembled classic BP or CP and cases of BP or CP with atypical features or evolving features of EBA. To determine how often EBA might present and be misdiagnosed as BP, we reviewed our experience with bullous diseases and screened eighty-five "BP" sera for EBA antibodies. The results of this study show EBA can mimic the clinical, histologic, and immunohistologic features of BP and CP, suggest that a BP-like clinical presentation occurs in as many as 50% of EBA patients, and suggest that 10% of patients referred to medical centers and diagnosed as BP have EBA.

Distribution of monkey esophagus antigens reactive with IgA-class antibodies in the sera of dermatitis herpetiformis patients

Antibodies of IgA class reactive to the lining of the smooth muscle bundles, i.e., endomysium (EmA), are present in the sera of patients with dermatitis herpetiformis and coeliac disease. These antibodies can be detected on monkey esophagus, a substrate of choice for pemphigus and pemphigoid antibodies. The amount of antigen reactive with IgA-EmA is greatest in the lower portion of the esophagus and decreases towards the uppermost part.

Identification of the skin basement-membrane autoantigen in epidermolysis bullosa acquisita

Epidermolysis bullosa acquisita is an acquired chronic blistering disease of the skin, in which separation of the skin occurs in the basement-membrane zone between the epidermis and the dermis. There is evidence that blistering is initiated by an immune process. Using serum samples from nine patients as a source of antibodies, we have identified a major protein of the basement membrane of human skin that serves as the antigen (or target) for autoantibodies in this disorder. This previously unrecognized protein, which consists of two components of 290,000 and 145,000 daltons, is distinct from other known components of the basement membrane. These studies provide evidence that epidermolysis bullosa acquisita is a specific disease that is different from other primary bullous diseases, such as bullous pemphigoid and pemphigus vulgaris, and suggest that the basement-membrane component that has been identified may have a role in normal epidermal-dermal adherence.

Dermatologic conditions reported in patients with rheumatoid arthritis

Dermatologists, while becoming increasingly involved in the diagnosis and management of patients with connective tissue diseases, have left rheumatoid arthritis relatively unexplored. An increased awareness of possible pathomechanisms of rheumatoid arthritis may allow for generalizations that lead to increased understanding of other connective tissue disorders. The types of cutaneous disorders that occur in association with rheumatoid arthritis include: vasoreactive dermatoses (e.g., various forms of vasculitis), which may occur secondary to the circulating immune complexes present in rheumatoid arthritis; autoimmune bullous disorders, which may occur in the setting of a suppressor T cell defect in rheumatoid arthritis; and various miscellaneous cutaneous associations. Hopefully, this review will lead to an increased understanding of both rheumatoid arthritis and the wide array of cutaneous associations of rheumatoid arthritis.

Subepidermal bullous disease and glomerulonephritis in a child

The infant described in this report had been generalized, subepidermal bullous eruption and concurrent glomerulonephritis. Immunofluorescence studies demonstrating deposition of immunoglobulin and complement in the skin and kidney suggest a common pathogenesis for the two disorders. The elevation of this infant's serum immunoglobulins and depression of serum complement support an immunologic process as the likely mechanism. It is important for clinicians caring for children with bullous skin diseases to search for evidence of renal disease and complement abnormalities.