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Rai R, Anand JB, Shanmugasekar C, Arunprasath P, Chaitra V, Zillikens D, Schimdt E. Anti-P 200 pemphigoid - The most common floor binding subepidermal autoimmune bullous disease in a tertiary care center in south India. Indian J Dermatol Venereol Leprol 2021; 87:787-791. [PMID: 34160166 DOI: 10.25259/ijdvl_79_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Accepted: 01/01/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND The pemphigoid group of diseases may present clinically and immunologically in a very similar fashion. Indirect immunofluorescence microscopy with readily available salt-split human skin in a BIOCHIP™ helps to classify these conditions as those with either with roof binding or floor binding of immunoreactants. Epidermolysis bullosa acquisita, anti-laminin 332 pemphigoid and anti-p200 pemphigoid show floor binding, while in the most frequent type of pemphigoid disease, bullous pemphigoid, epidermal side staining pattern is seen on salt-split skin Aims: The aim of the study was to detect the target antigens in sub-epidermal bullous diseases. METHODS Forty patients with bullous pemphigoid diagnosed by lesional histopathology and direct immunofluorescence microscopy were re-evaluated by a BIOCHIP™ mosaic containing both tissue substrates and recombinant target antigens. Sera with floor pattern staining on salt-split skin were further evaluated by immunoblotting with dermal extract. RESULTS Five patients with floor staining had anti-p200 pemphigoid. LIMITATIONS We could not perform serration pattern analysis of direct immunofluorescence in our patients. CONCLUSION Histopathology and direct immunofluorescence microscopy cannot differentiate between various entities of pemphigoid diseases. A multivariant approach using a BIOCHIP™ mosaic including salt-split skin followed by immunoblotting with dermal extract helps to identify the target antigen.
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Affiliation(s)
- Reena Rai
- Department of Dermatology, PSG IMSR, Coimbatore, Tamil Nadu, India
| | - J Bede Anand
- Department of Dermatology, PSG IMSR, Coimbatore, Tamil Nadu, India
| | - C Shanmugasekar
- Department of Dermatology, PSG IMSR, Coimbatore, Tamil Nadu, India
| | - P Arunprasath
- Department of Dermatology, PSG IMSR, Coimbatore, Tamil Nadu, India
| | - V Chaitra
- Department of Pathology, PSG IMSR, Coimbatore, Tamil Nadu, India
| | - Detlef Zillikens
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Enno Schimdt
- Department of Dermatology, University of Lübeck, Lübeck, Germany
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Chiorean R, Danescu S, Virtic O, Mustafa MB, Baican A, Lischka A, Hashimoto T, Kariya Y, Koch M, Sitaru C. Molecular diagnosis of anti-laminin 332 (epiligrin) mucous membrane pemphigoid. Orphanet J Rare Dis 2018; 13:111. [PMID: 29980216 PMCID: PMC6035451 DOI: 10.1186/s13023-018-0855-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Accepted: 06/26/2018] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Mucous membrane pemphigoid is a group of chronic subepithelial autoimmune blistering diseases that mainly affect mucous membranes. Laminin 332-specific autoantibodies are present in approximately 1/3 of the patients, being associated with an increased risk of malignancy. Because of the severe complications, an early recognition of the disease allowing a timely therapy is essential. The gold standard methods for detection of laminin 332-specific autoantibodies, including the immunoprecipitation and immunoblotting are non-quantitative, laborious and restricted to a few specialized laboratories worldwide. In addition, the use of radioimmunoassays, although highly sensitive and specific, are laborious, expensive and tightly regulated. Therefore, there is a stringent need for a quantitative immunoassay for the routine detection of laminin 332-specific autoantibodies more broadly available to diagnostic laboratories. The aim of this study was to compare different antigenic substrates, including native, recombinant laminin 332 and laminin 332-rich keratinocyte extracellular matrix, for development of an ELISA to detect autoantibodies in mucous membrane pemphigoid. RESULTS Using a relatively large number of sera from MMP patients with well-characterized autoantibody reactivity we show the suitability of ELISA systems using laminin 332 preparations as adjunct diagnostic tools in MMP. While glycosylation of laminin 332 does not appear to influence its recognition by MMP autoantibodies, ELISA systems using both purified, native and recombinant laminin 332 demonstrated a high sensitivity and good correlation with the detection of autoantibodies by immunoblotting. ELISA systems using different laminin 332 preparations represent a feasible and more accessible alternative for a broad range of laboratories. CONCLUSIONS Our findings qualify the use of immunoassays with the laminin 332-rich preparations as an ancillary diagnostic tool in mucous membrane pemphigoid.
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Affiliation(s)
- Roxana Chiorean
- Department of Dermatology, University Medical Center Freiburg, Hauptstrasse 7, 79104 Freiburg, Germany
- Department of Dermatology, University of Medicine and Pharmacy “Iuliu Hatieganu”, Cluj-Napoca, Romania
| | - Sorina Danescu
- Department of Dermatology, University of Medicine and Pharmacy “Iuliu Hatieganu”, Cluj-Napoca, Romania
| | - Oana Virtic
- Department of Dermatology, University Medical Center Freiburg, Hauptstrasse 7, 79104 Freiburg, Germany
| | - Mayson B. Mustafa
- Department of Dermatology, University Medical Center Freiburg, Hauptstrasse 7, 79104 Freiburg, Germany
| | - Adrian Baican
- Department of Dermatology, University of Medicine and Pharmacy “Iuliu Hatieganu”, Cluj-Napoca, Romania
| | - Annette Lischka
- Department of Dermatology, University Medical Center Freiburg, Hauptstrasse 7, 79104 Freiburg, Germany
| | - Takashi Hashimoto
- Department of Dermatology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Yoshinobu Kariya
- Department of Biochemistry, Fukushima Medical University, Fukushima, Japan
| | - Manuel Koch
- Institute for Dental Research and Oral Musculoskeletal Biology and Center for Biochemistry, Medical Faculty, University of Cologne, Cologne, Germany
| | - Cassian Sitaru
- Department of Dermatology, University Medical Center Freiburg, Hauptstrasse 7, 79104 Freiburg, Germany
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Sato H, Toriyama K, Yagi S, Takanari K, Takama H, Sawada M, Hashimoto T, Kamei Y. Surgical correction of microstomia in a patient with antilaminin 332 mucous membrane pemphigoid. Ann Plast Surg 2014; 72:553-5. [PMID: 23486114 DOI: 10.1097/sap.0b013e318268a8b1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Microstomia is a term used to describe a small oral aperture. Most of the reported cases are caused by scar contracture after facial trauma, burn injury, and tumor excision. We experienced a rare case of microstomia in a patient with antilaminin 332 mucous membrane pemphigoid, which was an acquired autoimmune disease and showed blisters and erosive lesions mainly on the mucous membranes. The patient had recurrent aphthous stomatitis and presented microstomia caused by scar contracture of oral mucosa. We surgically corrected microstomia by 5-flap Z-plasty for commissuroplasty and 2 Z-plasty of both upper and lower lips for an enlargement of oral aperture. The patient could achieve an enough oral aperture and was satisfied with the result. There was no recurrence of microstomia for 2 years.
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Affiliation(s)
- Hideyoshi Sato
- From the Departments of *Plastic and Reconstructive Surgery, †Dermatology, Nagoya University Graduate School of Medicine, Nagoya; and ‡Department of Dermatology, Kurume University School of Medicine and Kurume University Institute of Cutaneous Cell Biology, Kurume, Japan
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SAKAI K, UKICHI K, TAKADA A, MORIMOTO M, TANAKA YI, YAMANE GY. A case of anti-laminin 332 mucous membrane pemphigoid localized in the oral cavity. ACTA ACUST UNITED AC 2011. [DOI: 10.5794/jjoms.57.365] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Hashimoto T, Dainichi T, Ohyama B, Hamada T, Ishii N, Sato N, Tanigawa O, Nakayama J, Amano S, Nishiyama T, Karashima T, Nakama T, Yasumoto S. A case of antilaminin 332 mucous membrane pemphigoid showing a blister on the bulbar conjunctiva and a unique epitope on the alpha3 subunit. Br J Dermatol 2010; 162:898-9. [PMID: 20199543 DOI: 10.1111/j.1365-2133.2010.09648.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Rose C, Schmidt E, Kerstan A, Thoma-Uszynski S, Wesselmann U, Käsbohrer U, Zillikens D, Shimanovich I. Histopathology of anti-laminin 5 mucous membrane pemphigoid. J Am Acad Dermatol 2009; 61:433-40. [PMID: 19700013 DOI: 10.1016/j.jaad.2009.02.012] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2008] [Revised: 02/02/2009] [Accepted: 02/05/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND Anti-laminin 5 mucous membrane pemphigoid (MMP) is an autoimmune blistering disease characterized by autoantibodies against the major basement membrane component laminin 5 (laminin 332, epiligrin). OBJECTIVE AND METHODS We reviewed 17 biopsy specimens from 9 patients with anti-laminin 5 MMP in an attempt to define typical histopathologic features of the disease. RESULTS Fifteen specimens showed subepidermal blister formation, while two biopsy specimens revealed an epithelial ulcer. In 11 biopsies a sparse to moderate inflammatory infiltrate composed of lymphocytes and neutrophils with some eosinophils was observed. Four biopsies showed a dense infiltrate dominated by neutrophils in two cases and by eosinophils in one case. The remaining biopsy revealed a dense lymphoplasmacellular infiltrate without granulocytes. Scarring of the upper dermis was present only in 5 specimens. Immunohistochemical analysis localized type IV collagen to the dermal side of the blister, suggesting that split formation occurred within the lamina lucida of the cutaneous basement membrane. LIMITATIONS The number of patients studied was relatively small. CONCLUSIONS Histopathology of anti-laminin 5 MMP is characterized by subepidermal blistering and a sparse to moderate superficial lymphohistiocytic infiltrate with neutrophils and/or eosinophils. Both infiltrate density and composition may vary, making anti-laminin 5 MMP indistinguishable from other autoimmune subepidermal blistering diseases by histopathology alone. Scarring is present only in a minority of cases and is not a sensitive clue to the diagnosis of anti-laminin 5 MMP.
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Affiliation(s)
- Christian Rose
- Department of Dermatology, University of Lübeck, Lübeck, Germany
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8
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Abstract
Ocular manifestations are a comorbidity of a group of chronic autoimmune blistering diseases that includes mucous membrane pemphigoid, linear immunoglobulin A disease, epidermolysis bullosa acquisita, and ocular pemphigus vulgaris. Various diagnostic measures differentiate between the diseases and allow for appropriate treatment including a specific selection of immunomodulatory medications. New treatment modalities offer alternatives that may minimize disease severity and residual tissue damage and may reduce treatment-related complications.
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Abstract
Mucous membrane pemphigoid (MMP) is a sub-epithelial vesiculobullous disorder. It is now quite evident that a number of sub-epithelial vesiculobullous disorders may produce similar clinical pictures, and also that a range of variants of MMP exist, with antibodies directed against various hemidesmosomal components or components of the epithelial basement membrane. The term immune-mediated sub-epithelial blistering diseases (IMSEBD) has therefore been used. Immunological differences may account for the significant differences in their clinical presentation and responses to therapy, but unfortunately data on this are few. The diagnosis and management of IMSEBD on clinical grounds alone is impossible and a full history, general, and oral examination, and biopsy with immunostaining are now invariably required, sometimes supplemented with other investigations. No single treatment regimen reliably controls all these disorders, and it is not known if the specific subsets of MMP will respond to different drugs. Currently, apart from improving oral hygiene, immunomodulatory-especially immunosuppressive-therapy is typically used to control oral lesions. The present paper reviews pemphigoid, describing the present understanding of this fascinating clinical phenotype, summarising the increasing number of subsets with sometimes-different natural histories and immunological features, and outlining current clinical practice.
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Affiliation(s)
- J Bagan
- University of Valencia, Spain
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Bekou V, Thoma-Uszynski S, Wendler O, Uter W, Schwietzke S, Hunziker T, Zouboulis CC, Schuler G, Sorokin L, Hertl M. Detection of laminin 5-specific auto-antibodies in mucous membrane and bullous pemphigoid sera by ELISA. J Invest Dermatol 2005; 124:732-40. [PMID: 15816831 DOI: 10.1111/j.0022-202x.2005.23646.x] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Mucous membrane pemphigoid (MMP) is an autoimmune bullous disease that primarily affects mucous membranes leading to a scarring phenotype. MMP patients produce auto-antibodies (auto-ab) that preferentially recognize two components of the dermoepidermal basement membrane zone (BMZ): bullous pemphigoid (BP)180 and laminin 5 (LN5). Since detection of disease-specific auto-ab may be critical for diagnosis of MMP, we developed an ELISA with affinity-purified native human LN5. A total of 24 MMP, 72 BP, and 51 control sera were analyzed for LN5-specific auto-ab: 18/24 (75.0%) MMP and 29/72 (40.3%) BP sera were LN5 reactive. Sensitivity and specificity of the LN5 ELISA for MMP were 75% and 84.3%, respectively, and 40.3% and 88.2% for BP, respectively. The LN5 ELISA was more sensitive than a dot blot assay with native LN5, which detected LN5-reactive IgG in 14/24 (58.3%) MMP and 16/72 (22.2%) BP sera. In MMP, but not BP, levels of LN5-reactive IgG correlated with disease severity. Furthermore, IgG reactivity to LN5 of the MMP and BP sera was not significantly associated with IgG reactivity against other autoantigens of the BMZ, such as BP180 or BP230. Thus, the established LN5 ELISA holds great promise as a novel diagnostic and prognostic parameter for MMP.
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Affiliation(s)
- Vassiliki Bekou
- Department of Dermatology, Friedrich Alexander University Erlangen-Nürnberg, Erlangen, Germany
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Uchino Y, Kanekura T, Takeda K, Shimada H, Inoue M, Hashimoto T, Kanzaki T. A case of antiepiligrin cicatricial pemphigoid with nephrotic syndrome. J Dermatol 2004; 31:228-31. [PMID: 15187343 DOI: 10.1111/j.1346-8138.2004.tb00660.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2003] [Accepted: 12/02/2003] [Indexed: 11/27/2022]
Abstract
We report a 71-year-old woman with antiepiligrin cicatricial pemphigoid associated with nephrotic syndrome. She presented with a six-month history of pruritic blisters over her trunk and legs. She also had episodes of recurrent painful oral erosions. A skin biopsy showed a subepidermal bulla, and a direct immunofluorescence (DIF) study revealed linear deposition of IgG and C3 at the basement membrane zone (BMZ). Indirect immunofluorescence (IIF) staining of 1 M NaCl-split skin demonstrated circulating IgG autoantibodies reactive with the dermal side. Immunoprecipitation studies of the patient's serum disclosed IgG autoantibodies directed against a set of polypeptides that corresponded to laminin 5 (beta 3 gamma 2). Based upon the long-standing edema of her legs and her hypoproteinemia, she was diagnosed with nephrotic syndrome. To our knowledge, the association of antiepiligrin cicatricial pemphigoid with nephrotic syndrome has not been reported previously.
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Affiliation(s)
- Yuri Uchino
- Department of Dermatology, Kagoshima University Faculty of Medicine, Kagoshima, Japan
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12
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Matsushima S, Horiguchi Y, Honda T, Fujii S, Okano T, Tanabe M, Wakayama T, Hashimoto T, Yancey KB. A case of anti-epiligrin cicatricial pemphigoid associated with lung carcinoma and severe laryngeal stenosis: review of Japanese cases and evaluation of risk for internal malignancy. J Dermatol 2004; 31:10-5. [PMID: 14739497 DOI: 10.1111/j.1346-8138.2004.tb00497.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2003] [Accepted: 08/24/2003] [Indexed: 11/29/2022]
Abstract
A 68-year-old Japanese male with a five-year-history of lung carcinoma showed recurrent blisters and erosions on the oral and genital mucosae and the skin. The patient complained of dyspnea due to severe laryngeal stenosis and underwent a tracheostomy. A skin biopsy specimen showed a subepidermal blister and linear deposits of IgG and C3 at the basement membrane zone of the epidermis. Indirect immunofluorescence examination demonstrated circulating IgG anti-basement membrane zone autoantibodies that reacted to epiligrin on immunoblotting. Based on a diagnosis of anti-epiligrin cicatricial pemphigoid, he was treated with prednisolone, minocycline hydrochloride and nicotinamide. Although no new skin lesions appeared, he died of lung carcinoma five months after the tracheostomy. A review of reported cases with anti-epiligrin cicatricial pemphigoid in Japan disclosed that 5 of 16 cases (31.2%) were complicated by internal malignancies.
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Affiliation(s)
- Satoko Matsushima
- Departments of Dermatology, Osaka Red Cross Hospital, Ten'noji-ku, Osaka, Japan
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Egan CA, Lazarova Z, Darling TN, Yee C, Yancey KB. Anti-epiligrin cicatricial pemphigoid: clinical findings, immunopathogenesis, and significant associations. Medicine (Baltimore) 2003; 82:177-86. [PMID: 12792304 DOI: 10.1097/01.md.0000076003.64510.00] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
We report the clinical and immunopathologic findings in a cohort of 35 patients with anti-epiligrin cicatricial pemphigoid (AECP). These patients have a mucosal predominant subepithelial blistering disease that is clinically indistinguishable from other forms of cicatricial pemphigoid. The mucosal surfaces of the mouth and eye are most commonly involved. The skin is also involved in most patients, but usually this is less severe than mucosal involvement. AECP is characterized by the binding of circulating IgG autoantibodies to the dermal side of 1M NaCl split human skin on indirect immunofluorescence microscopy. These IgG antibasement membrane autoantibodies target laminin 5, a heterotrimeric protein consisting of alpha3, beta3, and gamma2 subunits. IgG autoantibodies predominantly target the G domain within the alpha subunit. The presence of circulating IgG autoantibodies are specific for the diagnosis of AECP and are not seen in patients with other autoimmune blistering diseases or normal volunteers. Furthermore, we expand on data previously reported on the finding of an increased relative risk for solid cancer in patients with AECP, especially in the first year after blister onset. The majority of cancers documented in a cohort of 35 patients assembled over 12 years of study were adenocarcinomas that were at an advanced stage at their time of detection. This circumstance is thought to account for a high incidence of mortality among AECP patients who develop an associated cancer. AECP patients also demonstrate a significant risk for mortality as a consequence of treatment with systemic immunosuppressives. The current longitudinal study suggests that only a minority of AECP patients go into remission.
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Affiliation(s)
- Conleth A Egan
- Dermatology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA.
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Abstract
UNLABELLED Cicatricial pemphigoid (CP) is a heterogeneous group of rare, chronic, subepithelial blistering disorders of the mucous membranes and, occasionally, the skin, which can have serious and rarely fatal consequences. The most common clinical features are desquamative gingivitis, oral erosions, and conjunctival fibrosis. Skin lesions occur less frequently and may present as widespread vesicles and bullae, as in bullous pemphigoid (BP). In some patients, the scarring can be a source of significant morbidity because it can result in odynophagia, strictures of the upper aerodigestive tract, or corneal opacities leading to eventual blindness. This article is a comprehensive review and discusses clinical, pathologic, and pathophysiologic aspects of this group of disorders collectively known as CP. (J Am Acad Dermatol 2000;43:571-91.) LEARNING OBJECTIVE At the conclusion of this learning activity, participants should be familiar with the clinical spectrum of CP, the histopathologic and immunopathologic characteristics, the differential diagnosis, the treatment, and the natural history of the disease. Furthermore, this learning activity should facilitate early diagnosis of CP and should promote the idea that the involvement of other specialists, including ophthalmologists, otolaryngologists, gastroenterologists, and oral medicine specialists, as appropriate, will aid in providing these patients with the highest quality of care.
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Affiliation(s)
- T E Fleming
- Department of Dermatology, Case Western Reserve University, Cleveland, OH, USA
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Uchiyama K, Yamamoto Y, Taniuchi K, Matsui C, Fushida Y, Shirao Y. Remission of antiepiligrin (laminin-5) cicatricial pemphigoid after excision of gastric carcinoma. Cornea 2000; 19:564-6. [PMID: 10928780 DOI: 10.1097/00003226-200007000-00033] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE To describe a case of antiepiligrin cicatricial pemphigoid with unusual ocular manifestations and its remission after surgical removal of gastric carcinoma. METHODS We describe a 61-year-old Japanese man with antiepiligrin cicatricial pemphigoid. RESULTS He presented with conjunctival injection and discharge preceded by a 6-month period of erosive lesions in the oral mucosa and the truncal skin. An advanced gastric carcinoma was found and his serum immunoprecipitated laminin-5. Despite topical treatment with betamethasone, ofloxacin, and artificial tear solutions, serious symblepharon along the Meibomian line developed with little shortening of the inferior conjunctival sac. Following radical gastrectomy, the ocular and cutaneous lesions turned completely quiet. CONCLUSION The present case differed from past cases by lacking inferior conjunctival sac shortening and by showing erosive lesions solely at the mucocutaneous junctions. The ocular involvement in this case correlated very well with the severity of gastric carcinoma.
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Affiliation(s)
- K Uchiyama
- Department of Ophthalmology, Kanazawa University School of Medicine, Ishikawa, Japan
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16
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Kawahara Y, Zillikens D, Yancey KB, Marinkovich MP, Nie Z, Hashimoto T, Nishikawa T. Subepidermal blistering disease with autoantibodies against a novel dermal 200-kDa antigen. J Dermatol Sci 2000; 23:93-102. [PMID: 10808126 DOI: 10.1016/s0923-1811(99)00093-6] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
A number of autoimmune subepidermal blistering diseases are characterized by the distinct autoantigens of the cutaneous basement membrane zone. Recently, a few cases with autoantibodies against a novel 200-kDa dermal protein have been reported. We collected nine cases of subepidermal blistering disease with IgG antibodies against this 200-kDa antigen. In this report, we describe the clinical and immunological appearances in these cases. Five cases showed bullous pemphigoid-like features, one case resembled dermatitis herpetiformis, and another case showed mixed features of bullous pemphigoid and linear IgA bullous dermatosis. It was interesting to note that psoriasis coexisted in four cases. By indirect immunofluorescence on 1 M NaCl split skin, IgG antibodies from all sera reacted with the dermal side of the split. By immunoblot analysis, IgG antibodies recognized a 200-kDa protein of dermal extract. IgG affinity-purified antibodies on the 200-kDa immunoblot membrane stained the dermal side of 1 M NaCl split skin. Various examinations suggested that the 200-kDa antigen is not identical to any chains of laminins-1, -5 or -6. This autoimmune subepidermal blistering disease against the dermal 200-kDa protein may form a new distinct entity, which often associates with psoriasis.
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Affiliation(s)
- Y Kawahara
- Department of Dermatology, Keiyu Hospital, 3-7-3 Minatomirai, Nishi-ku, Yokohama, Japan
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17
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Abstract
Cicatricial pemphigoid is a chronic subepithelial autoimmune blistering disease of mucous membranes and skin. Recently, a subtype of cicatricial pemphigoid with autoantibodies to epiligrin was identified. We describe a Taiwanese patient who presented with ocular, oral, and cutaneous involvement. Direct immunofluorescence showed IgG and C3 deposition in epidermal basement membrane; indirect immunofluorescence showed circulating IgG autoantibodies reactive with the dermal side of 1 mol/L sodium chloride-split skin. Immunoblotting of laminin 5 isolated from the extracellular matrix of cultured human keratinocytes showed no specific reactivity. In contrast, with immunoprecipitation of the conditioned culture media from biosynthetically radiolabeled human keratinocytes, this patient's serum clearly reacted with a series of disulfide-linked polypeptides that correspond to laminin 5(alpha3beta3gamma2) and laminin 6(alpha3beta1gamma1). This is the first confirmed case of a patient of Chinese ancestry with this disease entity.
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Affiliation(s)
- R C Hsu
- Department of Dermatology, Kaohsiung Medical College,Taiwan
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18
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Scully C, Carrozzo M, Gandolfo S, Puiatti P, Monteil R. Update on mucous membrane pemphigoid: a heterogeneous immune-mediated subepithelial blistering entity. ORAL SURGERY, ORAL MEDICINE, ORAL PATHOLOGY, ORAL RADIOLOGY, AND ENDODONTICS 1999; 88:56-68. [PMID: 10442946 DOI: 10.1016/s1079-2104(99)70194-0] [Citation(s) in RCA: 67] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Most oral involvement in the skin diseases (dermatoses) is related to mucous membrane pemphigoid or lichen planus. Mucous membrane pemphigoid was the subject of a European Symposium held in Turin, Italy, in June 1997. This review is based on that symposium. Mucous membrane pemphigoid is a subepithelial vesiculobullous disorder mainly of late middle age; it has a slight predilection for women. Whereas mucous membrane pemphigoid was formerly considered a single entity, it is now quite evident that a number of subepithelial vesiculobullous disorders may produce similar clinical pictures and also that a range of variants of mucous membrane pemphigoid exists, with antibodies directed against various hemidesmosomal components or components of the epithelial basement membrane. The term immune-mediated subepithelial blistering diseases has therefore been used. Diagnosis and management of immune-mediated subepithelial blistering diseases on clinical grounds alone are impossible; a full history, general and oral examinations, and biopsy with immunostaining are now invariably required, sometimes supplemented with other investigations. Most patients with mucous membrane pemphigoid affecting the mouth manifest desquamative gingivitis, a fairly common complaint typically seen in women who are middle-aged or older. Oral vesicles and erosions may also occur, and there can be a positive Nikolsky sign. Some patients have lesions of other stratified squamous epithelia, presenting as conjunctival, nasal, oesophageal, laryngeal, vulval, penile, or anal involvement. Apart from improving oral hygiene, immunomodulatory-in particular, immunosuppressive-therapy is typically required to control oral lesions in mucous membrane pemphigoid. No single treatment regimen reliably controls all these disorders.
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Affiliation(s)
- C Scully
- Eastman Dental Institute for Oral Health Care Science and International Centre for Excellence in Dentistry, United Kingdom.
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Lazarova Z, Hsu R, Yee C, Yancey KB. Antiepiligrin cicatricial pemphigoid represents an autoimmune response to subunits present in laminin 5 (alpha3beta3gamma2). Br J Dermatol 1998; 139:791-7. [PMID: 9892943 DOI: 10.1046/j.1365-2133.1998.02502.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Sera from 20 patients with antiepiligrin cicatricial pemphigoid were studied to define the specific reactivity of their IgG autoantibodies. IgG from all patients bound exclusively to the dermal side of 1 mol/L NaCl split skin and immunoprecipitated laminin 5 (alpha3beta3gamma2) from extracts of human keratinocytes (HKs). Immunoblot studies on purified laminin 5 subunits demonstrated that patient IgG bound alpha3 alone in 16 patients. In two patients, IgG autoantibodies were directed predominantly to the gamma2 subunit, yet showed trace reactivity to alpha3 as well. Sera from two patients did not immunoblot any laminin 5 subunits, their IgG presumably immunoprecipitating laminin 5 via a conformational epitope. Sera from patients with alpha3 subunit-specific IgG immunoprecipitated all subunits of laminin 5 as well as polypeptides of 190 and 200 kDa from the conditioned media of HKs. Preclearance studies and experiments utilizing affinity-purified patient IgG demonstrated that the latter signified laminin 6 (alpha3beta1gamma1) that was bound by cross-reactive alpha3 subunit-specific patient IgG. Sera from patients with gamma2 subunit-specific IgG showed no reactivity to laminin 6, except for faint reactivity provided by low levels of their alpha3 subunit-specific IgG. Taken together, these findings indicate that antiepiligrin cicatricial pemphigoid signifies an autoimmune response to subunits present in laminin 5.
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Affiliation(s)
- Z Lazarova
- Dermatology Branch, National Cancer Institute, Building 10, Room 12N238, National Institutes of Health, 10 Center Drive MSC 1908, Bethesda, MD 20892-1908, USA
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Kawahara Y, Amagai M, Ohata Y, Ishii K, Hasegawa Y, Hsu R, Yee C, Yancey KB, Nishikawa T. A case of cicatricial pemphigoid with simultaneous IgG autoantibodies against the 180 kd bullous pemphigoid antigen and laminin 5. J Am Acad Dermatol 1998; 38:624-7. [PMID: 9555805 DOI: 10.1016/s0190-9622(98)70129-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Y Kawahara
- Department of Dermatology, Keio University School of Medicine, Tokyo, Japan
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21
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22
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Kobayashi T, Konohana A, Hattori S. A case of linear IgA disease: an immunofluorescent study using confocal laser scan microscopy. J Dermatol 1997; 24:306-9. [PMID: 9198319 DOI: 10.1111/j.1346-8138.1997.tb02795.x] [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: 02/04/2023]
Abstract
A 79-year-old Japanese woman presented with erythema and bullae on her trunk and limbs. Histological examination of the skin lesions showed subepidermal bullae and polymorphonuclear leukocyte infiltration into the papillary dermis. A direct immunofluorescent study showed the linear deposition of IgA, but not of IgG or IgM, in the basement membrane zone. Indirect immunofluorescence of the serum using confocal laser scan microscopy showed IgA, but not IgG, reactivity in the basement membrane zone. In double immunostaining experiments, IgA reactivity was also observed on the epidermal side; laminin 5 was detected on the dermal side.
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Affiliation(s)
- T Kobayashi
- Department of Dermatology, Saiseikai Yokohamashi Nanbu Hospital, Yokohama, Japan
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23
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AUTOIMMUNE SUBEPITHELIAL BLISTERING DISEASES WITH OCULAR INVOLVEMENT. Radiol Clin North Am 1997. [DOI: 10.1016/s0033-8389(22)00265-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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24
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Caux FA, Giudice GJ, Diaz LA, Fairley JA. AUTOIMMUNE SUBEPITHELIAL BLISTERING DISEASES WITH OCULAR INVOLVEMENT. Immunol Allergy Clin North Am 1997. [DOI: 10.1016/s0889-8561(05)70295-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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