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Ghaedi F, Etesami I, Aryanian Z, Kalantari Y, Goodarzi A, Teymourpour A, Tavakolpour S, Mahmoudi H, Daneshpazhooh M. Drug-induced pemphigus: A systematic review of 170 patients. Int Immunopharmacol 2021; 92:107299. [PMID: 33418246 DOI: 10.1016/j.intimp.2020.107299] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 12/10/2020] [Accepted: 12/11/2020] [Indexed: 02/07/2023]
Abstract
Pemphigus encompasses a rare heterogeneous group of autoimmune blistering diseases characterized by cutaneous and/or mucosal blistering. Multiple factors, such as some specific types of drugs, have been found to be involved in the induction of pemphigus. Here, we have designed a systematic review by searching PubMed/Medline and Embase databases to find the drugs, involved in pemphigus induction and exacerbation (updated on 19 August 2019). From 1856 initially found articles, 134 studies (198 patients; 170 patients in the drug-induced patients and 28 in exacerbation group) have been included. Regarding drug-induced cases, the mean age was 57.19 ± 16.9-year-old (ranged 8-105), and patients had developed pemphigus within a mean of 154.27 days. Pemphigus vulgaris (38.9%), pemphigus foliaceus (33.5%), and paraneoplastic pemphigus (3.6%) were the most common subtypes. Furthermore, penicillamine (33.1%), captopril (7.7%), and bucillamine (6.5%) were the most reported drugs related to pemphigus induction; penicillamine was associated with the most persistent disease. Regardless of disease subtype, cutaneous, mucocutaneous, and mucosal involvements were reported in 68.6%, 30.1%, and 1.3% of patients, respectively. In total, the IgG deposition in the pathological studies, being positive for autoreactive antibodies in the serum against desmoglein 3 (Dsg3), and desmoglein 1 (Dsg1), were reported in 93%, 34.9%, and 72.7% of reported patients, respectively. Regarding the management of such patients, in 75% of healed cases, treatment (mainly transient systemic and topical corticosteroids and/or azathioprine) was needed besides stopping the probable pemphigus-inducing culprit drug, while drug cessation was enough to control the disease in 25%. As the outcomes, the lesions in 129 of 147 (87.8%) patients had been healed, while in 18 (12.2%), no healing was reported; fifteen out of 18 had died. In conclusion, some specific groups of treatments can induce pemphigus, including penicillamine, captopril, and bucillamine; despite the similar clinical and pathological manifestations to classical pemphigus, most of the cases are less severe and have a better prognosis.
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Affiliation(s)
- Forugh Ghaedi
- Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, 009821 Iran
| | - Ifa Etesami
- Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, 009821 Iran
| | - Zeinab Aryanian
- Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, 009821 Iran; Department of Dermatology, Babol University of Medical Sciences, Babol 0098111 Iran
| | - Yasamin Kalantari
- Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, 009821 Iran
| | - Azadeh Goodarzi
- Dermatology School of Medicine Iran University of Medical Sciences, Tehran 009821 Iran
| | - Amir Teymourpour
- Department of Epidemiology and biostaristics, school of public health, Tehran university of medical sciences, Tehran 009821 Iran
| | - Soheil Tavakolpour
- Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, 009821 Iran; Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA 02215, United States.
| | - HamidReza Mahmoudi
- Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, 009821 Iran
| | - Maryam Daneshpazhooh
- Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, 009821 Iran
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Devassy DE, Harshad SR, Devarbhai H. Pompholyx-Like Eruptions Induced by Penicillamine in a Patient with Wilson's Disease. Indian J Dermatol 2019; 64:321-323. [PMID: 31516144 PMCID: PMC6714198 DOI: 10.4103/ijd.ijd_328_18] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Wilson's disease is an inherited disorder of copper metabolism that results in excessive accumulation of copper in various organs, with liver being the primary site of involvement. D-penicillamine (DPA) as a chelating agent forms the mainstay of therapy; however, it can cause a myriad of adverse effects on long-term use. The major adverse effects reported with DPA include disorders of collagen synthesis, such as pseudoxanthoma elasticum-like lesions, autoimmune blistering diseases, and urticarial lesions. Here, we report a young girl who developed extensive pompholyx-like blisters within a few months of starting DPA which on histopathology showed a spongiotic reaction. The lesions improved on stopping DPA and initiation of oral steroids.
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Affiliation(s)
- Diana Elizabeth Devassy
- From the Department of Dermatology, St. Johns Medical College Hospital, Bengaluru, Karnataka, India
| | - Sujata Raj Harshad
- From the Department of Dermatology, St. Johns Medical College Hospital, Bengaluru, Karnataka, India
| | - Harshad Devarbhai
- Department of Gastroenterology, St. Johns Medical College Hospital, Bengaluru, Karnataka, India
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Abstract
A wide spectrum of drugs can sometimes give rise to numerous adverse orofacial manifestations, particularly dry mouth, taste disturbances, oral mucosal ulceration, and/or gingival swelling. There are few relevant randomized double-blind controlled studies in this field, and therefore this paper reviews the data from case reports, small series, and non-peer-reviewed reports of adverse drug reactions affecting the orofacial region (available from a MEDLINE search to April, 2003). The more common and significant adverse orofacial consequences of drug therapy are discussed.
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Affiliation(s)
- C Scully
- Eastman Dental Institute for Oral Health Care Sciences, University College, University of London, 256 Gray's Inn Road, London WC1X 8LD, UK.
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Pietkiewicz P, Gornowicz-Porowska J, Bowszyc-Dmochowska M, Dmochowski M. A retrospective study of antihypertensives in pemphigus: a still unchartered odyssey particularly between thiols, amides and phenols. Arch Med Sci 2015; 11:1021-7. [PMID: 26528346 PMCID: PMC4624747 DOI: 10.5114/aoms.2015.54857] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Revised: 05/29/2013] [Accepted: 09/22/2013] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Autoimmune pemphigus diseases comprise several entities with serious prognoses, including the pemphigus vulgaris (PV) group and pemphigus foliaceus (PF) group. Antihypertensives are suspected to be one of the factors triggering/sustaining pemphigus. Here, the data of pemphigus patients regarding arterial hypertension (AH) and taking potentially noxious drugs were statistically analyzed in a setting of a Polish university dermatology department. MATERIAL AND METHODS Medical histories of pemphigus patients (40 admissions of 24 female patients - 13 PV, 11 PF; and 102 admissions of 38 male patients - 24 PV, 14 PF), diagnosed at both immunopathological and biochemical-molecular levels, were studied. RESULTS Ten of 16 (62.50%) AH-positive PV patients received known PV triggers/sustainers 11 times (1-3 per patient). Fourteen of 15 (93.33%) AH-positive PF patients received known PF triggers/sustainers 21 times (1-3 per patient). No differences in numbers of patients taking potentially culprit drugs were shown between PV and PF (Fisher's exact test: p = 0.0829; Yates' χ(2) test: p = 0.1048). The most frequently used culprit drugs were ramipril in PV and enalapril in PF. On average, each PV/PF AH-positive patient received 3.161 different antihypertensives in his/her history of admissions (2.155 antihypertensives per admission). CONCLUSIONS Drug triggering should be suspected in every case of newly diagnosed or exacerbated pemphigus, as eliminating possible PV/PF triggers/sustainers may alleviate the clinical symptoms and enable the decrease of dose/range of immunosuppressants regardless of pemphigus form. Eliminating possible drug PV/PF triggers/sustainers may alleviate the clinical symptoms and enable the decrease of dose/range of immunosuppressants regardless of pemphigus form.
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Affiliation(s)
- Paweł Pietkiewicz
- Cutaneous Histopathology and Immunopathology Section, Department of Dermatology, Poznan University of Medical Sciences, Poznan, Poland
| | - Justyna Gornowicz-Porowska
- Cutaneous Histopathology and Immunopathology Section, Department of Dermatology, Poznan University of Medical Sciences, Poznan, Poland
| | - Monika Bowszyc-Dmochowska
- Cutaneous Histopathology and Immunopathology Section, Department of Dermatology, Poznan University of Medical Sciences, Poznan, Poland
| | - Marian Dmochowski
- Cutaneous Histopathology and Immunopathology Section, Department of Dermatology, Poznan University of Medical Sciences, Poznan, Poland
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Ishak R, Abbas O. Penicillamine revisited: historic overview and review of the clinical uses and cutaneous adverse effects. Am J Clin Dermatol 2013; 14:223-33. [PMID: 23605177 DOI: 10.1007/s40257-013-0022-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Penicillamine is a well-known heavy metal chelator, classically used in the treatment of Wilson disease, rheumatoid arthritis, and cystinuria. From a dermatologic standpoint, penicillamine was found to be useful in the treatment of systemic sclerosis. The successful therapeutic uses of penicillamine have been hindered by its numerous adverse effects, both cutaneous and extra-cutaneous. It is a unique drug since it provokes a diversity of dermatologic manifestations that include (1) acute hypersensitivity reactions, (2) dermopathies characterized by elastic fiber abnormalities including elastosis perforans serpiginosa and pseudo-pseudoxanthoma elasticum, (3) autoimmune disorders such as pemphigus and penicillamine-induced lupus erythematosus-like syndrome, and (4) miscellaneous dermatoses that result from undefined mechanisms. These cutaneous adverse effects may correlate with the dosage and duration of penicillamine therapy as well as the disease being treated.
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Affiliation(s)
- Rim Ishak
- Department of Dermatology, American University of Beirut Medical Center, Riad El Solh/Beirut, P.O. Box 11-0236, Beirut 1107 2020, Lebanon
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A prospective analysis of anti-desmoglein antibody profiles in patients with rheumatoid arthritis treated with thiol compounds. J Dermatol Sci 2010; 59:170-5. [DOI: 10.1016/j.jdermsci.2010.06.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2010] [Revised: 06/15/2010] [Accepted: 06/21/2010] [Indexed: 10/19/2022]
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HAMADA R, IWAGAKI M, NAKAJIMA K, IKEDA M, KODAMA H, WADA E, HASHIMOTO T. D-penicillamine-induced Pemphigus with Inconsistent Anti-desmoglein Antibodies. ACTA ACUST UNITED AC 2004. [DOI: 10.2336/nishinihonhifu.66.128] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Affiliation(s)
- S R Porter
- Department of Oral Medicine, Eastman Dental Institute for Oral Health Care Sciences, University College London, London, England, UK
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Affiliation(s)
- S Vassileva
- Department of Dermatology, Sofia Faculty of Medicine, Alexander's University Hospital, Bulgaria
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Abstract
The successful therapeutic use of D-penicillamine (DPA) has been hindered by its many adverse effects. Autoimmune bullous syndromes are among the less common adverse DPA reactions; they are not dose dependent and appear late in the treatment of diseases of altered immunity, most often rheumatoid arthritis. The majority of the DPA-induced bullous syndromes belong to the pemphigus spectrum, usually pemphigus foliaceus or erythematosus, have a lower prevalence of demonstrable tissue-fixed or circulating antibodies than spontaneously occurring pemphigus, display abnormal direct immunofluorescent patterns, and have a generally favorable prognosis. However, many cases do exhibit a full-blown chronic disease, unaffected by DPA withdrawal. DPA-induced cicatricial pemphigoid is a severe disease of both mucous and cutaneous involvement with a prognosis similar to the spontaneous disease. Cases of DPA-induced epidermolysis bullosa acquisita and DPA-induced bullous pemphigoid were not sufficiently substantiated by immunofluorescence or immunoprecipitation criteria.
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Affiliation(s)
- A Bialy-Golan
- Department of Dermatology, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Israel
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Smith EP, Taylor TB, Meyer LJ, Zone JJ. Antigen identification in drug-induced bullous pemphigoid. J Am Acad Dermatol 1993; 29:879-82. [PMID: 8408833 DOI: 10.1016/0190-9622(93)70262-r] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Immunobullous diseases usually develop spontaneously, but drug-induced bullous disease develops in a small subgroup of patients. We examined a patient in whom bullous pemphigoid developed after she received enalapril for treatment of hypertension. IgG antibody directed against a 230 kd antigen was identified. The eluted IgG autoantibody was shown to bind to the basement membrane zone on split skin. This study demonstrates that drug-induced bullous pemphigoid autoantibody in this patient was directed against the same antigen as the spontaneous bullous pemphigoid antigen.
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Affiliation(s)
- E P Smith
- Department of Internal Medicine, Veterans Affairs Medical Center, Salt Lake City, UT
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Affiliation(s)
- S Brenner
- Department of Dermatology, Tel-Aviv Sourasky Medical Center, Ichilov Hospital, Israel
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Jones E, Sobkowski WW, Murray SJ, Walsh NM. Concurrent pemphigus and myasthenia gravis as manifestations of penicillamine toxicity. J Am Acad Dermatol 1993; 28:655-6. [PMID: 8463474 DOI: 10.1016/s0190-9622(08)81790-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Affiliation(s)
- E Jones
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
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Pinto GM, Lamarão P, Vale T. Captopril-induced pemphigus vegetans with Charcot-Leyden crystals. J Am Acad Dermatol 1992; 27:281-4. [PMID: 1387657 DOI: 10.1016/0190-9622(92)70180-n] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
A 78-year-old woman developed intertriginous vegetating plaques, mouth ulcers, and a cerebriform tongue after 11 months of captopril therapy. Findings of clinical, histologic, and immunofluorescence testing were consistent with a diagnosis of pemphigus vegetans. In addition, Charcot-Leyden crystals were observed within some of the intraepidermal, eosinophilic abscess cavities, which were bordered by granular cells undergoing keratinization. The skin lesions cleared rapidly after discontinuation of captopril. To the best of our knowledge, this report describes the first case of pemphigus vegetans induced by captopril.
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Affiliation(s)
- G M Pinto
- Department of Dermatology, Curry Cabral Hospital, Lisboa, Portugal
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Abstract
Pemphigus erythematosus occurred in a patient with rheumatoid arthritis who was treated with D-penicillamine. The skin lesions appeared 4 months after the onset of D-penicillamine treatment and persisted 14 years after cessation of this drug. Topical betamethasone dipropionate applications resulted in complete regression of the cutaneous lesions.
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Affiliation(s)
- M J Willemsen
- Department of Dermatology, Akademisch Ziekenhuis Vrije Universiteit Brussels, Belgium
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Rasmussen HB, Jepsen LV, Brandrup F. Penicillamine-induced bullous pemphigoid with pemphigus-like antibodies. J Cutan Pathol 1989; 16:154-7. [PMID: 2671069 DOI: 10.1111/j.1600-0560.1989.tb00031.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
A rheumatoid arthritis case is described who developed bullous skin eruption with mucosal involvement after 3 years of treatment with penicillamine. Histologically, changes compatible with bullous pemphigoid were found. Direct immunofluorescence showed linear, as well as intercellular, deposits of IgG. By indirect immunofluorescence IgG antibodies reacting with the basal membrane zone, as well as the intercellular substance, were detected in the serum. We believe that the patient had bullous pemphigoid with pemphigus-like antibodies induced by penicillamine.
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Affiliation(s)
- H B Rasmussen
- Department of Dermatology, Odense University Hospital, Denmark
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Acquired forms. Clin Dermatol 1988. [DOI: 10.1016/0738-081x(88)90019-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Side-effects of penicillamine: some recent aspects. ACTA ACUST UNITED AC 1987. [DOI: 10.1007/978-94-010-9775-8_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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Abstract
Many of the adverse reactions produced by penicillamine and other compounds with an active sulfhydryl group form a distinctive pattern when viewed as a class. Alterations in taste perception, mucocutaneous lesions, proteinuria due to immune-complex membranous glomerulopathy, and pemphigus are adverse reactions that have been encountered with all of the compounds discussed herein. Hematologic reactions such as neutropenia and thrombocytopenia occur rarely and with variable frequency. The angiotension converting enzyme inhibitor captopril has an active sulfhydryl group. When it was first given in high doses to patients with severe hypertension, adverse effects similar in pattern to those just outlined were reported. With reduced doses and more careful patient selection, the more serious reactions are no longer found, but disturbances of taste perception, rash, and oral mucosal ulcers are still encountered.
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Affiliation(s)
- M Pisani
- Department of Dermatology, University of Naples First School of Medicine, Italy
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Velthuis PJ, Hendrikse JC, Nefkens JJ. Combined features of pemphigus and pemphigoid induced by penicillamine. Br J Dermatol 1985; 112:615-9. [PMID: 3890920 DOI: 10.1111/j.1365-2133.1985.tb15273.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
D-Penicillamine is able to induce a bullous eruption with the clinical, histological and immunological features of pemphigus. We present a case that had all the characteristics of pemphigus, but also in vivo bound IgG against the dermo-epidermal junction, i.e. the immunological features of bullous pemphigoid. Since no subepidermal blistering was observed, it is concluded that the penicillamine-induced auto-antibodies against the basement membrane zone were biologically inactive.
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Abstract
D-Penicillamine, a heavy metal chelator used in the treatment of Wilson's disease and other conditions, may be associated with both noncutaneous and cutaneous side effects. Some of the cutaneous lesions are due to a toxic-metabolic effect on connective tissue; some may be explained on the basis of autoimmunity; some are acute sensitivity reactions, and some are secondary to unknown mechanisms. The types of cutaneous manifestations may, in some instances, be correlated with the disease being treated and the dosage and duration of penicillamine therapy.
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Ruocco V, De Angelis E, De Luca M, Pisani M, Prota G. Specific incorporation of penicillamine into the epidermis of mice: an autoradiographic study. Br J Dermatol 1983; 108:441-4. [PMID: 6838767 DOI: 10.1111/j.1365-2133.1983.tb04596.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
[3H]-D-penicillamine was injected intra-peritoneally in mice. The highest concentration of the drug was found in the skin, particularly in the epidermis, and a well-defined kinetic sequence of appearance in the epidermis was shown. This finding is consistent with the hypothesis that penicillamine, by virtue of its chemical similarity to cysteine, can replace the latter during keratogenesis by a competition phenomenon, which could provoke acantholytic splitting both biochemically and immunologically.
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Jaffe IA. Induction of auto-immune syndromes by penicillamine therapy in rheumatoid arthritis and other diseases. SPRINGER SEMINARS IN IMMUNOPATHOLOGY 1981; 4:193-207. [PMID: 7034252 DOI: 10.1007/bf01857095] [Citation(s) in RCA: 35] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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