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Huang S, Anderson HJ, Lee JB. Paraneoplastic pemphigus/paraneoplastic autoimmune multiorgan syndrome: Part II. Diagnosis and management. J Am Acad Dermatol 2024; 91:13-22. [PMID: 37714216 DOI: 10.1016/j.jaad.2023.08.084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 08/09/2023] [Accepted: 08/11/2023] [Indexed: 09/17/2023]
Abstract
In the second part of this Continuing Medical Education article on paraneoplastic pemphigus/paraneoplastic autoimmune multiorgan syndrome (PNP/PAMS), its diagnostic criteria, investigative work-up, and management are reviewed. PNP/PAMS is a rare autoimmune blistering disorder associated with high morbidity and mortality. Recognizing PNP/PAMS's key features and its diagnostic criteria is critical in initiating appropriate work-up. Evaluating PNP/PAMS requires knowledge of its findings on histopathology, direct immunofluorescence, indirect immunofluorescence, and enzyme-linked immunosorbent assay. Lastly, treatments for PNP/PAMS are reviewed with suggestions based on case reports and expert opinions in the literature.
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Affiliation(s)
- Simo Huang
- Department of Dermatology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Hannah J Anderson
- Department of Dermatology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Jason B Lee
- Department of Dermatology, Thomas Jefferson University, Philadelphia, Pennsylvania.
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Gambichler T, Susok L. Comments on the first European guideline for paraneoplastic autoimmune multiorgan syndrome. J Eur Acad Dermatol Venereol 2024; 38:e644-e645. [PMID: 38317436 DOI: 10.1111/jdv.19819] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 01/16/2024] [Indexed: 02/07/2024]
Affiliation(s)
- Thilo Gambichler
- Department of Dermatology, Dortmund Hospital gGmbH and Faculty of Health, Witten/Herdecke University, Dortmund, Germany
- Department of Dermatology, Christian Hospital Unna, Unna, Germany
- Department of Dermatology, Ruhr-University Bochum, Bochum, Germany
| | - Laura Susok
- Department of Dermatology, Christian Hospital Unna, Unna, Germany
- Department of Dermatology, Ruhr-University Bochum, Bochum, Germany
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Singhal A, Sharma A, Das KJ. Lymphoma With a Skin Rash. JAMA Oncol 2024:2819653. [PMID: 38842817 DOI: 10.1001/jamaoncol.2024.1558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024]
Abstract
A 62-year-old female had a generalized vesiculobullous rash on her face for 4 months. It started over the lips and gradually progressed to involve the oral mucosa and skin of the whole body. What is your diagnosis?
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Affiliation(s)
- Abhinav Singhal
- Department of Nuclear Medicine, National Cancer Institute, Jhajjar Campus, All India Institute of Medical Sciences, New Delhi, India
| | - Aparna Sharma
- Department of Medical Oncology, National Cancer Institute, Jhajjar Campus, All India Institute of Medical Sciences, New Delhi, India
| | - Kalpa Jyoti Das
- Department of Nuclear Medicine, National Cancer Institute, Jhajjar Campus, All India Institute of Medical Sciences, New Delhi, India
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Bansari A, Wallace JA, Yang L, Kapoor A. Paraneoplastic pemphigus presenting as a prodrome to aggressive T cell lymphoma. BMJ Case Rep 2024; 17:e258580. [PMID: 38839409 DOI: 10.1136/bcr-2023-258580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024] Open
Abstract
Paraneoplastic pemphigus (PNP) is a rare disease with an unclear mechanism of pathogenesis. We present a case of a male patient who presented with wound management after being diagnosed with Castleman disease-associated paraneoplastic pemphigus (PNP). The patient's condition was not improving; as a result, extensive workup was repeated, which confirmed the diagnosis of aggressive T cell lymphoblastic lymphoma. Our case signifies the importance of keeping a high index of suspicion for PNP-associated malignancies. This case report also adds emphasis to the diagnostic challenges faced by clinicians, making clinical correlation with multidisciplinary approach essential. Therefore, if clinically indicated, we need to revisit the diagnosis and seek alternative explanations to prevent delays in management.
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Affiliation(s)
- Asha Bansari
- Medicine, University of Florida, Gainesville, Florida, USA
| | | | - Lijun Yang
- University of Florida, Gainesville, Florida, USA
| | - Atul Kapoor
- University of Florida, Gainesville, Florida, USA
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5
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Antiga E, Bech R, Maglie R, Genovese G, Borradori L, Bockle B, Caproni M, Caux F, Chandran NS, Corrà A, D’Amore F, Daneshpazhooh M, De D, Didona D, Dmochowski M, Drenovska K, Ehrchen J, Feliciani C, Goebeler M, Groves R, Günther C, Handa S, Hofmann SC, Horvath B, Ioannidis D, Jedlickova H, Kowalewski C, Kridin K, Joly P, Lim YL, Marinovic B, Maverakis E, Meijer J, Patsatsi A, Pincelli C, Prost C, Setterfield J, Sprecher E, Skiljevic D, Tasanen K, Uzun S, Van Beek N, Vassileva S, Vorobyev A, Vujic I, Wang G, Wang M, Wozniak K, Yayli S, Zambruno G, Hashimoto T, Schmidt E, Mascarò JM, Marzano AV. S2k guidelines on the management of paraneoplastic pemphigus/paraneoplastic autoimmune multiorgan syndrome initiated by the European Academy of Dermatology and Venereology (EADV). J Eur Acad Dermatol Venereol 2023; 37:1118-1134. [PMID: 36965110 PMCID: PMC10806824 DOI: 10.1111/jdv.18931] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 01/16/2023] [Indexed: 03/27/2023]
Abstract
BACKGROUND Paraneoplastic pemphigus (PNP), also called paraneoplastic autoimmune multiorgan syndrome (PAMS), is a rare autoimmune disease with mucocutaneous and multi-organ involvement. PNP/PAMS is typically associated with lymphoproliferative or haematological malignancies, and less frequently with solid malignancies. The mortality rate of PNP/PAMS is elevated owing to the increased risk of severe infections and disease-associated complications, such as bronchiolitis obliterans. OBJECTIVES These guidelines summarize evidence-based and expert-based recommendations (S2k level) for the clinical characterization, diagnosis and management of PNP/PAMS. They have been initiated by the Task Force Autoimmune Blistering Diseases of the European Academy of Dermatology and Venereology with the contribution of physicians from all relevant disciplines. The degree of consent among all task force members was included. RESULTS Chronic severe mucositis and polymorphic skin lesions are clue clinical characteristics of PNP/PAMS. A complete assessment of the patient with suspected PNP/PAMS, requiring histopathological study and immunopathological investigations, including direct and indirect immunofluorescence, ELISA and, where available, immunoblotting/immunoprecipitation, is recommended to achieve a diagnosis of PNP/PAMS. Detection of anti-envoplakin antibodies and/or circulating antibodies binding to the rat bladder epithelium at indirect immunofluorescence is the most specific tool for the diagnosis of PNP/PAMS in a patient with compatible clinical and anamnestic features. Treatment of PNP/PAMS is highly challenging. Systemic steroids up to 1.5 mg/kg/day are recommended as first-line option. Rituximab is also recommended in patients with PNP/PAMS secondary to lymphoproliferative conditions but might also be considered in cases of PNP/PAMS associated with solid tumours. A multidisciplinary approach involving pneumologists, ophthalmologists and onco-haematologists is recommended for optimal management of the patients. CONCLUSIONS These are the first European guidelines for the diagnosis and management of PNP/PAMS. Diagnostic criteria and therapeutic recommendations will require further validation by prospective studies.
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Affiliation(s)
- Emiliano Antiga
- Department of Health Sciences, Section of Dermatology, University of Florence, Florence, Italy
| | - Rikke Bech
- Department of Dermatology and Venerology, Aarhus University Hospital, Aarhus, Denmark
| | - Roberto Maglie
- Department of Health Sciences, Section of Dermatology, University of Florence, Florence, Italy
| | - Giovanni Genovese
- Dermatology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Luca Borradori
- Department of Dermatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Barbara Bockle
- Department of Dermatology, Venereology and Allergology, Innsbruck Medical University, Innsbruck, Austria
| | - Marzia Caproni
- Department of Health Sciences, Section of Dermatology, University of Florence, Florence, Italy
- Rare Diseases Unit, Azienda USL Toscana Centro, European Reference Network Skin Member, Florence, Italy
| | - Frédéric Caux
- Department of Dermatology, Groupe Hospitalier Paris-Seine-Saint-Denis, AP-HP, Bobigny, France
| | - Nisha Suyien Chandran
- Division of Dermatology, Department of Medicine, National University Hospital, Singapore, Singapore
- Department of Medicine, NUS Yong Loo Lin School of Medicine, Singapore, Singapore
| | - Alberto Corrà
- Department of Health Sciences, Section of Dermatology, University of Florence, Florence, Italy
| | - Francesco D’Amore
- Department of Haematology, University Hospital of Aarhus, Aarhus, Denmark
| | - Maryam Daneshpazhooh
- Autoimmune Bullous diseases Research Center, Department of Dermatology, Razi Hospital, University of Medical Sciences, Tehran, Iran
| | - Dipankar De
- Department of Dermatology, PGIMER, Chandigarh, India
| | - Dario Didona
- Department of Dermatology and Allergology, Philipps University, Marburg, Germany
| | - Marian Dmochowski
- Autoimmune Blistering Dermatoses Section, Department of Dermatology, Poznan University of Medical Sciences, Poznań, Poland
| | - Kossara Drenovska
- Department of Dermatology and Venereology, Medical Faculty, Medical University, Sofia, Bulgaria
| | - Jan Ehrchen
- Department of Dermatology, University of Münster, Münster, Germany
| | - Claudio Feliciani
- Section of Dermatology, Department of Clinical and Experimental Medicine, University of Parma, Parma, Italy
| | - Matthias Goebeler
- Department of Dermatology, Venereology and Allergology, University Hospital Würzburg, Würzburg, Germany
| | - Richard Groves
- Clinical Immunodermatology, St. John’s Institute of Dermatology Guy’s Hospital, Great Maze Pond, London, United Kingdom
| | - Claudia Günther
- Department of Dermatology, University Hospital Carl Gustav Carus, Technical University Dresden, Dresden, Germany
| | - Sanjeev Handa
- Department of Dermatology, Venereology & Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Silke C. Hofmann
- Department of Dermatology, Allergy and Dermatosurgery, Helios University Hospital, University Witten/Herdecke, Wuppertal, Germany
| | - Barbara Horvath
- Department of Dermatology, Expertise Center for Blistering disease, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Dimitrios Ioannidis
- 1 Department of Dermatology-Venereology, Aristotle University School of Medicine, Thessaloniki, Greece
| | - Hana Jedlickova
- Department of Dermatovenereology, Masaryk University, St. Anna Hospital, Brno, Czech Republic
| | - Cezary Kowalewski
- Department Dermatology and Immunodermatology, Medical University of Warsaw, Poland
| | - Khalaf Kridin
- Unit of Dermatology and Skin Research Laboratory, Baruch Padeh Medical Center, Poriya, Israel
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - Pascal Joly
- Department of Dermatology, Rouen University Hospital and INSERM U1234, Centre de référence des maladies bulleuses autoimmunes, Normandie University, Rouen, France
| | - Yen Loo Lim
- National Skin Centre, Singapore
- Yong Loo Lin School of Medicine, Lee Kong Chian School of Medicine, Duke-NUS, Singapore
| | - Branka Marinovic
- University Hospital Center Zagreb, School of Medicine University of Zagreb, Zagreb, Croatia
| | - Emanual Maverakis
- Department of Dermatology, University of California Davis, Sacramento, California, USA
| | - Joost Meijer
- Department of Dermatology, Expertise Center for Blistering disease, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Aikaterini Patsatsi
- Autoimmune Bullous Diseases Unit, 2nd Dermatology Department, Aristotle University School of Medicine, Thessaloniki, Greece
| | - Carlo Pincelli
- DermoLab, Department of Surgical, Medical, Dental and Morphological Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Catherine Prost
- Department of Dermatology and Referral Center for Autoimmune Bullous Diseases (MALIBUL), Avicenne University Hospital, Hôpitaux Universitaires de Paris Seine-Saint-Denis (HUPSSD), Assistance Publique – Hôpitaux de Paris (AP-HP), Université Sorbonne Paris Nord (USPN), Bobigny, France
| | - Jane Setterfield
- Centre for Host-Microbiome Interactions, Faculty of Dentistry, Oral and Craniofacial Sciences, King’s College London, London, United Kingdom
| | - Eli Sprecher
- Division of Dermatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Dusan Skiljevic
- Department of Dermatovenereology, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- Clinic of Dermatovenereology, University Clinical Center of Serbia, Belgrade, Serbia
| | - Kaisa Tasanen
- PEDEGO Research Unit, Department of Dermatology, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Soner Uzun
- Department of Dermatology and Venereology, Akdeniz University Faculty of Medicine, Antalya, Turkey
| | - Nina Van Beek
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Snejina Vassileva
- Department of Dermatology and Venereology, Medical Faculty, Medical University, Sofia, Bulgaria
| | - Artem Vorobyev
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Igor Vujic
- Department of Dermatology, Klinik Landstraße, Vienna, Austria
- Faculty of Medicine and Dentistry, Danube Private University, Krems, Austria
| | - Gang Wang
- Department of Dermatology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Mingyue Wang
- Department of Dermatology, Peking University First Hospital, Beijing, China
- National Clinical Research Center for Skin and Immune Diseases, Beijing, China
| | - Katarzyna Wozniak
- Department of Dermatology, Immunodermatology and Venereology, Medical University of Warsaw, Warsaw, Poland
| | - Savas Yayli
- Department of Dermatology, Koç University School of Medicine, Istanbul, Turkey
| | - Giovanna Zambruno
- Genodermatosis Unit, Genetics and Rare Diseases Research Division, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Takashi Hashimoto
- Department of Dermatology, Osaka Metroplitan University Graduate School of Medicine, Osaka, Japan
| | - Enno Schmidt
- Department of Dermatology, University of Lübeck, Lübeck, Germany
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - José Manuel Mascarò
- Department of Dermatology, Hospital Clínic of Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Angelo Valerio Marzano
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
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Irrera M, Bozzola E, Cardoni A, DeVito R, Diociaiuti A, Hachem ME, Girardi K, Marchesi A, Villani A. Paraneoplastic pemphigus and Castleman's disease: a case report and a revision of the literature. Ital J Pediatr 2023; 49:33. [PMID: 36941723 PMCID: PMC10029234 DOI: 10.1186/s13052-023-01442-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 03/08/2023] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND In literature, a few reports described an association between paraneoplastic pemphigus (PNP) and Castelman's disease (CD), but no consensus have been proposed for the diagnostic-therapeutical approach. Aim of this study is to present a case report and explore the relationship between PNP and CD in pediatric patients, focusing on clinical manifestations, histopathological findings, treatment and outcome to find elements for an early diagnosis. CASE PRESENTATION We present the clinical case of a 13 years old girl with a challenging diagnosis of PNP and CD who underwent therapy at first with Rituximab and then with Siltuximab, for the control of symptoms. CONCLUSIONS Reviewing literature, 20 clinical cases have been described in the pediatric age. Diagnosis may be challenging, requiring an average of 3 months (range from 3 weeks to 2 years). In all cases, the initial manifestations were mucocutaneous lesions, especially oral lesions with poor response to conventional treatment. Systemic symptoms may be present as well. Therapeutical approach is still discussed with no consensus. Almost all patients received corticosteroids with poor response. Other drugs including azathioprine, methotrexate, cyclosporine and monoclonal antibodies have been evaluated for the control of the disease. Further studies and experimental trials urge to define the diagnostic criteria and therapy protocol.
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Affiliation(s)
| | - Elena Bozzola
- Pediatric Unit, IRCCS Bambino Gesù Children's Hospital, Rome, Italy.
| | - Antonello Cardoni
- Unity of Pathology, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | - Rita DeVito
- Unity of Pathology, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | - Andrea Diociaiuti
- Dermatology Unit and Genodermatosis Unit, Genetics and Rare Diseases Research Division, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | - Maya El Hachem
- Dermatology Unit and Genodermatosis Unit, Genetics and Rare Diseases Research Division, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | - Katia Girardi
- Department of Pediatric Hematology/Oncology and Cell and Gene Therapy, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | | | - Alberto Villani
- Pediatric Unit, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
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Barry KK, Plumptre I, Bazewicz CG, Green BP, Treat JR, Hughes M, Morel KD, Wiss K, Liang MG. Paraneoplastic pemphigus associated with Castleman disease: A multicenter case series. Pediatr Dermatol 2023; 40:90-95. [PMID: 36128651 DOI: 10.1111/pde.15138] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 08/31/2022] [Indexed: 01/25/2023]
Abstract
INTRODUCTION Paraneoplastic pemphigus (PNP) is a rare, often fatal, autoimmune blistering disease of the skin and mucous membranes. In children, PNP is frequently associated with Castleman disease (CD). This series describes five cases of PNP associated with CD. METHODS Data were collected retrospectively from the medical records of patients with a diagnosis of PNP and CD from January 2013 to June 2022. Patients ≤22 years old with clinical and immunopathologic evidence of PNP were included; CD was diagnosed histopathologically. RESULTS Two children, two adolescents, and one young adult (two males, three females) were included. The average age at disease presentation was 11.8 years (range: 7-22 years). Oral (n = 5) and anogenital (n = 3) mucositis were common. Four patients had "unicentric" CD (UCD); one patient had "multicentric" CD (MCD). Castleman tumors were in the retroperitoneum (n = 4) or axilla (n = 1). One patient had myasthenia gravis without thymoma. Three patients had bronchiolitis obliterans (BO). Three patients had complete resection of their CD; two had partial resection. Three patients remain alive with a median follow-up of 13 months (range: 12 months to 13 years); two are clinically stable with resolution of mucocutaneous lesions; one has persistent BO requiring ongoing ventilatory support. Patients who remain alive had UCD with complete resection; all deceased patients had partial resection and BO. CONCLUSION Most patients had UCD, and the retroperitoneum was the most common location. Patients with MCD, incomplete resection, and BO died; patients with UCD and complete resection remain alive, even in the setting of BO. Consideration of PNP is critical when pediatric patients present with mucositis as PNP may be clinically indistinguishable from more common causes of mucositis.
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Affiliation(s)
- Kelly K Barry
- Department of Dermatology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Isabella Plumptre
- Department of Dermatology, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Christopher G Bazewicz
- Department of Dermatology, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Brian P Green
- Department of Dermatology, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - James R Treat
- Division of Pediatric Dermatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Meagan Hughes
- Department of Dermatology, Children's Hospital of Los Angeles, Los Angeles, California, USA
| | - Kimberly D Morel
- Departments of Dermatology and Pediatrics, Columbia University Medical Center, New York, New York, USA
| | - Karen Wiss
- Department of Dermatology, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA.,Department of Pediatrics, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Marilyn G Liang
- Department of Dermatology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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8
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Kanj AN, Ryu JH. Severe Airflow Obstruction From Constrictive (Obliterative) Bronchiolitis in Paraneoplastic Autoimmune Multiorgan Syndrome. Chest 2022; 162:179-183. [DOI: 10.1016/j.chest.2022.02.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 02/07/2022] [Accepted: 02/28/2022] [Indexed: 10/18/2022] Open
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Sathishkumar D, Agrawal P, Baitule AM, Thomas M, Eapen A, Kumar S, George R. Paraneoplastic Autoimmune Multiorgan Syndrome: A Retrospective Study from a Tertiary Care Center in South India. Indian Dermatol Online J 2021; 12:572-576. [PMID: 34430462 PMCID: PMC8354390 DOI: 10.4103/idoj.idoj_640_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 10/09/2020] [Accepted: 12/20/2020] [Indexed: 11/23/2022] Open
Abstract
Background: Paraneoplastic autoimmune multiorgan syndrome (PAMS), first described as paraneoplastic pemphigus (PNP) is a heterogeneous autoimmune syndrome with a diverse spectrum of clinical and immunopathological features associated with an internal neoplasm. Materials and Methods: The details of the patients diagnosed with PAMS/PNP from an Indian tertiary center between January 2010 to December 2019 were retrieved from the hospital database. The clinical manifestations, histopathological features, immunofluorescence findings, and other relevant clinical details were obtained. Results: There were eight patients (4 males, 4 females) with PAMS, age ranging from 8 to 46 years (mean 31 years), of whom two were 8-year-old children. The mucocutaneous manifestations were polymorphic and all had recalcitrant oral mucosal involvement. The most common mucosal presentation was pemphigus-like (5/8), and the cutaneous presentation was lichen planus-like (5/8). Castleman's disease (5/8) was the commonest neoplasm followed by thymoma (2/8). Interface dermatitis was seen in all biopsies and three different patterns of direct immunofluorescence were seen, which were intercellular “fish-net” fluorescence in the epidermis (2/8), granular/linear deposition along the basement membrane (4/8) and a combination of both patterns (1/8). Indirect immunofluorescence done on rat bladder in 3 patients showed intercellular “fish-net” fluorescence. Desmoglein levels were not elevated in any of our patients. The follow-up period ranged from 1 to 112.5 months (mean, 23.6 months) with a mortality rate of 12.5%. Conclusion: In our study, Castleman's disease was the most common associated malignancy, and the mucocutaneous and histopathological findings were heterogeneous. Timely diagnosis and early intervention improved the outcome in our patients.
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Affiliation(s)
- Dharshini Sathishkumar
- Department of Dermatology, Venereology and Leprosy, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Poonam Agrawal
- Department of Dermatology, Venereology and Leprosy, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Amey Madhav Baitule
- Department of Pathology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Meera Thomas
- Department of Pathology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Anu Eapen
- Department of Radiology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Sathish Kumar
- Department of Paediatric Rheumatology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Renu George
- Department of Dermatology, Venereology and Leprosy, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
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Gwiti P, Melegh Z, Johnston S, Sutak J. Paraneoplastic pemphigus caused by pre-existing stroma-rich variant of Castleman disease: from a pathologist's point of view. BMJ Case Rep 2021; 14:e241374. [PMID: 33975839 PMCID: PMC8118026 DOI: 10.1136/bcr-2020-241374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2021] [Indexed: 11/04/2022] Open
Abstract
A young woman presented with mucocutaneous blisters and ulcerating lesions, and was diagnosed with erythrodermic pemphigus complicated by bronchiolitis obliterans. Her clinical condition did not improve on immunosuppressive therapy. She had a history of an asymptomatic retroperitoneal mass, presumed to be a dermoid cyst, followed up clinically. Due to the pre-existing nature of the retroperitoneal mass, the paraneoplastic nature of the pemphigus was initially not recognised, but after a multidisciplinary team meeting a biopsy was performed. Histology revealed a rare stroma-rich variant of Castleman disease with a prominent stroma demonstrating a myoid phenotype. Resection of the retroperitoneal tumour resulted in resolution of the cutaneous blisters. This emphasises the importance to consider paraneoplastic disease in treatment-resistant pemphigus as surgical removal of the tumour forms the mainstay of therapy. The differential diagnosis should include Castleman disease and careful evaluation of histology is essential with the awareness of this rare stroma-rich variant.
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Affiliation(s)
- Paida Gwiti
- Department of Cellular Pathology, Peterborough City Hospital, Peterborough, Cambridgeshire, UK
| | - Zsombor Melegh
- Centre for Medical Education, University of Bristol, Bristol, UK
- Department of Cellular Pathology, North Bristol NHS Trust, Westbury on Trym, UK
| | - Sarah Johnston
- Department of Immunology, North Bristol NHS Trust, Westbury on Trym, Bristol, UK
| | - Judit Sutak
- Department of Cellular Pathology, North Bristol NHS Trust, Westbury on Trym, UK
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Abstract
Haematological malignancies induce important alterations of the immune system, which account for the high frequency of autoimmune complications observed in patients. Cutaneous immune-mediated diseases associated with haematological malignancies encompass a heterogeneous group of dermatoses, including, among others, neutrophilic and eosinophilic dermatoses, autoantibody-mediated skin diseases, vasculitis and granulomatous dermatoses. Some of these diseases, such as paraneoplastic pemphigus, are associated with an increased risk of death; others, such as eosinophilic dermatoses of haematological malignancies, run a benign clinical course but portend a significant negative impairment on a patient’s quality of life. In rare cases, the skin eruption reflects immunological alterations associated with an unfavourable prognosis of the associated haematological disorder. Therapeutic management of immune-mediated skin diseases in patients with haematological malignancies is often challenging. Systemic corticosteroids and immunosuppressive drugs are considered frontline therapies but may considerably augment the risk of serious infections. Indeed, developing a specific targeted therapeutic approach is of crucial importance for this particularly fragile patient population. This review provides an up-to-date overview on the immune-mediated skin diseases most frequently encountered by patients with onco-haematological disorders, discussing new pathogenic advances and therapeutic options on the horizon.
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12
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Solimani F, Meier K, Zimmer CL, Hashimoto T. Immune serological diagnosis of pemphigus. Ital J Dermatol Venerol 2020; 156:151-160. [PMID: 33228340 DOI: 10.23736/s2784-8671.20.06788-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Pemphigus is a rare autoimmune blistering disease which manifests with painful erosions and blisters of the skin and mucosa. This disorder is caused by autoantibodies attacking desmosomal proteins, necessary for cell-cell contact stability and epidermal integrity. Desmoglein (Dsg) 1 and Dsg3 are the two major target antigens in pemphigus. Yet, many other target proteins, which have been described over the years, seem to be involved in the loss of epidermal integrity. Clinical examination, combined to serological advances and detection of targeted antigens, permitted to differentiate among several pemphigus subtypes, in which pemphigus vulgaris and pemphigus foliaceus are the most common. Nowadays, serological analysis in pemphigus is a fundamental step of the diagnostic algorithm. This is based on analysis of clinical symptoms, histopathological examination of lesional skin, detection of tissue bound and circulating antibodies by direct and indirect immunofluorescence, and determination of target antigens either by enzyme-linked immunosorbent essay (ELISA) or by western blot analysis. A correct and exhaustive diagnostic algorithm is fundamental to characterize pemphigus subtypes, which lastly permits to adopt a correct treatment approach. Moreover, quality and quantity of circulating antibodies in patient's sera deliver important information regarding clinical course, disease severity and treatment response; thus, relevantly affecting physician's decision. To facilitate this process, "easy-to-perform" diagnostic kits with high sensitivity and specificity are being commercialized. In this review, we focus on available methods and established assays to correctly detect circulating autoantibodies in pemphigus. Moreover, we discuss subtype specific serological peculiarities in the five most relevant subtypes (pemphigus vulgaris, pemphigus foliaceus, pemphigus vegetans, paraneoplastic pemphigus and intercellular IgA dermatosis (also called as IgA pemphigus).
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Affiliation(s)
- Farzan Solimani
- Department of Dermatology, Venereology and Allergology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany -
| | - Katharina Meier
- Department of Dermatology, Venereology and Allergology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Christine L Zimmer
- Department of Dermatology and Allergology, Philipps University, Marburg, Germany
| | - Takashi Hashimoto
- Department of Dermatology, Osaka City University Graduate School of Medicine, Osaka, Japan
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13
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Abstract
Originally described by Anhalt as paraneoplastic pemphigus in 1990, paraneoplastic autoimmune multiorgan syndrome (PAMS) is a potentially lethal blistering disease, characterized by polymorphous clinical features, including mucocutaneous erosions, blisters, lichenoid papules, and erythemas. Several autoantibodies have been detected in serum of PAMS patients, including antiplakins, anti-alpha-2-macroglobulin like 1, and antidesmogleins autoantibodies. The mortality rate of PAMS is up to 90%. This is due on the one hand to the poor response to treatments and on the other hand to the delay in the diagnosis and to the prognosis of the underlying neoplasia.
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Affiliation(s)
- Dario Didona
- Department of Dermatology and Allergology, Philipps University, Marburg, Germany -
| | | | - Pascal Joly
- Department of Dermatology, Rouen University Hospital and INSERM U905, Reference center for autoimmune bullous diseases, Normandie University, Rouen, France
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14
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Calabria E, Fortuna G, Aria M, Mignogna MD. Autoimmune mucocutaneous blistering diseases in the south of Italy: a 25-year retrospective study on 169 patients. J Oral Pathol Med 2020; 49:672-680. [PMID: 32531813 DOI: 10.1111/jop.13059] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 04/22/2020] [Accepted: 06/02/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Autoimmune mucocutaneous blistering diseases (AMBDs) represent a heterogeneous group of organ-specific and potentially life-threatening diseases. We sought to determine the relationship between clinical remission and therapeutic regimens with clinical type and phenotype of AMBDs, as well as clinical outcomes achieved based on different therapeutic regimens. METHODS A retrospective single-center study on 169 AMBDs patients, including pemphigus vulgaris (PV), mucous membrane pemphigoid (MMP), paraneoplastic autoimmune multiorgan syndrome (PAMS), and lichen planus pemphigoides (LPP), was performed from 1994 to 2019 in an oral medicine tertiary center, where we collected sociodemographic data, clinical type and phenotype, prescribed therapies, and related outcomes. RESULTS The mean age of AMBDs patients was 55.0 ± 16.4 years. They were followed for a mean of 8.4 ± 5.8 years. The majority of these patients (62.1%) were successfully managed with conventional immunosuppressive therapy (CIST) alone. However, 37.9% of patients required additional biological treatments, either because they were non-responders or developed severe side effects from CIST, or because of the rapid and severe progression of the disease. Overall, complete clinical remission was achieved in 92.3% of patients. A statistically significant difference was noted between the frequency distribution of AMBDs patients among different therapeutic regimens (P = .002), of different clinical phenotype and type of AMBDs patients and clinical remission (P = .012 and P = .005, respectively). No difference was reported regarding clinical outcomes and different therapeutic regimens. CONCLUSIONS AMBDs' management may be challenging, nonetheless CIST and biologic regimens introduced, when needed as reliable alternatives to CIST, result in a very high percentage of CCR.
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Affiliation(s)
- Elena Calabria
- Department of Neurosciences, Reproductive Sciences and Dentistry, Federico II University of Naples, Naples, Italy.,UCL Eastman Dental Institute, London, UK
| | - Giulio Fortuna
- Glasgow Dental School & Hospital, School of Medicine, Dentistry and Nursing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK.,D.eb.RA. Mexico Foundation, Nuevo Leon, Mexico.,Federico Navarro Institute-School of Orgonomy "Piero Borrelli", Naples, Italy
| | - Massimo Aria
- Department of Economics and Statistics, Federico II University of Naples, Naples, Italy
| | - Michele D Mignogna
- Department of Neurosciences, Reproductive Sciences and Dentistry, Federico II University of Naples, Naples, Italy
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15
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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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16
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Didona D, Fania L, Didona B, Eming R, Hertl M, Di Zenzo G. Paraneoplastic Dermatoses: A Brief General Review and an Extensive Analysis of Paraneoplastic Pemphigus and Paraneoplastic Dermatomyositis. Int J Mol Sci 2020; 21:ijms21062178. [PMID: 32245283 PMCID: PMC7139382 DOI: 10.3390/ijms21062178] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Revised: 02/16/2020] [Accepted: 02/18/2020] [Indexed: 02/06/2023] Open
Abstract
Skin manifestations of systemic disease and malignancy are extremely polymorphous. Clinicians should be familiarized with paraneoplastic dermatoses in order to perform an early diagnosis of the underlying neoplasm. Lack of familiarity with cutaneous clues of internal malignancy may delay diagnosis and treatment of cancer. In this review, we described several paraneoplastic dermatoses and discussed extensively two paradigmatic ones, namely paraneoplastic pemphigus and paraneoplastic dermatomyositis.
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Affiliation(s)
- Dario Didona
- Department of Dermatology and Allergology, Philipps University, 35043 Marburg, Germany; (R.E.); (M.H.)
- Correspondence: ; Tel.: +49-(6421)-58-64882; Fax: +49-(6421)-58-62902
| | - Luca Fania
- First Dermatology Division, IDI-IRCCS, 00167 Rome, Italy;
| | | | - Rüdiger Eming
- Department of Dermatology and Allergology, Philipps University, 35043 Marburg, Germany; (R.E.); (M.H.)
| | - Michael Hertl
- Department of Dermatology and Allergology, Philipps University, 35043 Marburg, Germany; (R.E.); (M.H.)
| | - Giovanni Di Zenzo
- Molecular and Cell Biology Laboratory, IDI-IRCCS, 00167 Rome, Italy;
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17
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Bogdanov I, Darlenski R, Hristakieva E, Manuelyan K. The rash that presents as a vesiculobullous eruption. Clin Dermatol 2020; 38:19-34. [DOI: 10.1016/j.clindermatol.2019.10.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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18
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Lepekhova AA, Teplyuk NP, Bolotova IM. Modern diagnostic methods of paraneoplastic pemphigus. VESTNIK DERMATOLOGII I VENEROLOGII 2019. [DOI: 10.25208/0042-4609-2019-95-5-7-16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Paraneoplastic pemphigus (PNP) is one of the least investigated and rare forms of bullous dermatoses, which comes from underlying neoplasm. The article presents a literature review of dermatologist`s longstanding international experience about etiology, pathogenesis, diagnostics and treatment of this disease. According to the research results of native and foreign authors systematization of modern diagnostic methods of PNP and detectable antigens was performed.Conflict of interest: the authors state that there is no potential conflict of interest requiring disclosure in this article.
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Affiliation(s)
- A. A. Lepekhova
- I. M. Sechenov First Moscow State Medical University, Ministry of Health of the Russian Federation
| | - N. P. Teplyuk
- I. M. Sechenov First Moscow State Medical University, Ministry of Health of the Russian Federation
| | - I. M. Bolotova
- Pirogov Russian National Research Medical University, Ministry of Health of the Russian Federation
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19
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Maruta CW, Miyamoto D, Aoki V, de Carvalho RGR, Cunha BM, Santi CG. Paraneoplastic pemphigus: a clinical, laboratorial, and therapeutic overview. An Bras Dermatol 2019; 94:388-398. [PMID: 31644609 PMCID: PMC7007015 DOI: 10.1590/abd1806-4841.20199165] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Accepted: 06/17/2019] [Indexed: 12/27/2022] Open
Abstract
Paraneoplastic pemphigus is a rare and severe autoimmune blistering disease characterized by mucocutaneous lesions associated with benign and malignant neoplasms. Diagnostic criteria include the presence of chronic mucositis and polymorphic cutaneous lesions with occult or confirmed neoplasia; histopathological analysis exhibiting intraepidermal acantholysis, necrotic keratinocytes, and vacuolar interface dermatitis; direct immunofluorescence with intercellular deposits (IgG and C3) and at the basement membrane zone (IgG); indirect immunofluorescence with intercellular deposition of IgG (substrates: monkey esophagus and simple, columnar, and transitional epithelium); and, autoreactivity to desmogleins 1 and 3, desmocollins 1, 2, and 3, desmoplakins I and II, envoplakin, periplakin, epiplakin, plectin, BP230, and α-2-macroglobulin-like protein 1. Neoplasias frequently related to paraneoplastic pemphigus include chronic lymphocytic leukemia, non-Hodgkin lymphoma, carcinomas, Castleman disease, thymoma, and others. Currently, there is no standardized treatment for paraneoplastic pemphigus. Systemic corticosteroids, azathioprine, mycophenolate mofetil, cyclosporine, rituximab, cyclophosphamide, plasmapheresis, and intravenous immunoglobulin have been used, with variable outcomes. Reported survival rates in 1, 2, and 5 years are 49%, 41%, and 38%, respectively.
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Affiliation(s)
- Celina Wakisaka Maruta
- Department of Dermatology, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Denise Miyamoto
- Department of Dermatology, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Valeria Aoki
- Department of Dermatology, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | | | - Breno Medeiros Cunha
- Department of Dermatology, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Claudia Giuli Santi
- Department of Dermatology, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
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20
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Follicular Dendritic Cell Sarcoma With Indolent T-Lymphoblastic Proliferation Is Associated With Paraneoplastic Autoimmune Multiorgan Syndrome. Am J Surg Pathol 2019; 42:1647-1652. [PMID: 30222603 DOI: 10.1097/pas.0000000000001158] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Nonclonal expansions of immature T cells outside of the thymus, termed indolent T-lymphoblastic proliferation (iT-LBP), have been identified in rare lymphoproliferative disorders. We report that iT-LBP is a frequent finding in cases of follicular dendritic cell sarcoma (FDCS), and shows an association with paraneoplastic autoimmune multiorgan syndrome (PAMS). We studied 31 cases of FDCS by paraffin immunohistochemistry using antibodies to CD21, CD23, CD35, clusterin, CXCL13, podoplanin, CD3, CD4, CD8, CD20, CD1a, and TdT. Chart review was performed to characterize the clinical behavior including evidence of autoimmune disease. FDCS occurred in a wide variety of nodal and extranodal sites. Fourteen of 31 (45%) cases contained immature TdT-positive T cells; in 5 cases these cells were numerous and present throughout the tumor. Four of these 5 patients with numerous immature T cells developed autoimmune disease, clinically categorized as PAMS and/or myasthenia gravis. PAMS persisted after tumor resection, causing severe morbidity and mortality. These findings suggest that the neoplastic follicular dendritic cells can recruit or foster the proliferation of immature T cells and that these cells may play a role in mediating PAMS. Recognition of iT-LBP in FDCS is important to avoid misdiagnosis as thymoma or T-lymphoblastic lymphoma, and may predict serious autoimmune complications in some patients.
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21
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Leuci S, Ruoppo E, Adamo D, Calabria E, Mignogna MD. Oral autoimmune vesicobullous diseases: Classification, clinical presentations, molecular mechanisms, diagnostic algorithms, and management. Periodontol 2000 2019; 80:77-88. [DOI: 10.1111/prd.12263] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Stefania Leuci
- Oral Medicine Unit, Department of Neurosciences, Reproductive and Odontostomatological SciencesFederico II University of Naples Naples Italy
| | - Elvira Ruoppo
- Oral Medicine Unit, Department of Neurosciences, Reproductive and Odontostomatological SciencesFederico II University of Naples Naples Italy
| | - Daniela Adamo
- Oral Medicine Unit, Department of Neurosciences, Reproductive and Odontostomatological SciencesFederico II University of Naples Naples Italy
| | - Elena Calabria
- Oral Medicine Unit, Department of Neurosciences, Reproductive and Odontostomatological SciencesFederico II University of Naples Naples Italy
| | - Michele Davide Mignogna
- Oral Medicine Unit, Department of Neurosciences, Reproductive and Odontostomatological SciencesFederico II University of Naples Naples Italy
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22
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Amber KT, Valdebran M, Grando SA. Paraneoplastic autoimmune multiorgan syndrome (PAMS): Beyond the single phenotype of paraneoplastic pemphigus. Autoimmun Rev 2018; 17:1002-1010. [DOI: 10.1016/j.autrev.2018.04.008] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 04/15/2018] [Indexed: 12/20/2022]
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23
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Decaux J, Ferreira I, Van Eeckhout P, Dachelet C, Magremanne M. Buccal paraneoplastic pemphigus multi-resistant: Case report and review of diagnostic and therapeutic strategies. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2018; 119:506-509. [PMID: 29885912 DOI: 10.1016/j.jormas.2018.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 05/11/2018] [Accepted: 06/01/2018] [Indexed: 10/14/2022]
Abstract
Paraneoplastic pemphigus is a rare autoimmune blistering disease generally associated with malignancy. The clinical presentation consists typically of painful and diffuse erosive stomatitis that may be accompanied by polymorphic skin lesions and systemic involvement. Diagnosis is based on clinical manifestations and confirmed by histology and immunological testing. The current first-line treatment is systemic corticosteroids and adjuvant therapies, including immunosuppressive agents. We report a case of buccal paraneoplastic pemphigus resistant to ibrutinib and rituximab successfully treated with azathioprine and polyclonal immunoglobulins.
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Affiliation(s)
- J Decaux
- Department of oral and maxillofacial surgery, cliniques universitaires Saint-Luc, université catholique de Louvain, avenue Hippocrate 10, 1200 Woluwe-Saint-Lambert, Belgium.
| | - I Ferreira
- Department of pathology, cliniques universitaires Saint-Luc, université catholique de Louvain, avenue Hippocrate 10, 1200 Woluwe-Saint-Lambert, Belgium
| | - P Van Eeckhout
- Department of pathology, cliniques universitaires Saint-Luc, université catholique de Louvain, avenue Hippocrate 10, 1200 Woluwe-Saint-Lambert, Belgium
| | - C Dachelet
- Department of pathology, cliniques universitaires Saint-Luc, université catholique de Louvain, avenue Hippocrate 10, 1200 Woluwe-Saint-Lambert, Belgium
| | - M Magremanne
- Department of oral and maxillofacial surgery, cliniques universitaires Saint-Luc, université catholique de Louvain, avenue Hippocrate 10, 1200 Woluwe-Saint-Lambert, Belgium
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24
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Allenova A, Lepekhova A, Olisova O, Teplyuk N, Kolkhir P. Paraneoplastic pemphigus in Russian patients: a single center case series. Int J Dermatol 2018; 57:e44-e46. [PMID: 29797440 DOI: 10.1111/ijd.14056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Revised: 03/06/2018] [Accepted: 04/24/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Anastasiia Allenova
- Division of Immune-mediated Skin Diseases, Department of Dermatology and Venereology, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Anfisa Lepekhova
- Division of Immune-mediated Skin Diseases, Department of Dermatology and Venereology, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Olga Olisova
- Division of Immune-mediated Skin Diseases, Department of Dermatology and Venereology, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Natalya Teplyuk
- Division of Immune-mediated Skin Diseases, Department of Dermatology and Venereology, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Pavel Kolkhir
- Division of Immune-mediated Skin Diseases, Department of Dermatology and Venereology, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
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25
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Paraneoplastic Pemphigus. A Life-Threatening Autoimmune Blistering Disease. ACTAS DERMO-SIFILIOGRAFICAS 2017; 108:902-910. [DOI: 10.1016/j.ad.2017.04.024] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2016] [Revised: 04/16/2017] [Accepted: 04/18/2017] [Indexed: 11/18/2022] Open
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26
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Tirado-Sánchez A, Bonifaz A. Paraneoplastic Pemphigus. A Life-Threatening Autoimmune Blistering Disease. ACTAS DERMO-SIFILIOGRAFICAS 2017. [DOI: 10.1016/j.adengl.2017.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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27
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Paraneoplastic Pemphigus: Insight into the Autoimmune Pathogenesis, Clinical Features and Therapy. Int J Mol Sci 2017; 18:ijms18122532. [PMID: 29186863 PMCID: PMC5751135 DOI: 10.3390/ijms18122532] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 11/09/2017] [Accepted: 11/24/2017] [Indexed: 11/17/2022] Open
Abstract
Paraneoplastic pemphigus is a rare autoimmune skin disease that is always associated with a neoplasm. Usually, oral, skin, and mucosal lesions are the earliest manifestations shown by paraneoplastic pemphigus patients. The pathogenesis of paraneoplastic pemphigus is not yet completely understood, although some immunological aspects have been recently clarified. Because of its rarity, several diagnostic criteria have been proposed. Besides, several diagnostic procedures have been used for the diagnosis, including indirect immunofluorescence, direct immunofluorescence, and ELISA. We reviewed the most recent literature, searching on PubMed "paraneoplastic pemphigus". We included also papers in French, German, and Spanish. We found 613 papers for "paraneoplastic pemphigus". Among them, 169 were review papers. Because of its varying clinical features, paraneoplastic pemphigus still represents a challenge for clinicians. Furthermore, diagnosis and management of paraneoplastic pemphigus requires close collaboration between physicians, including dermatologist, oncologist, and otorhinolaryngologist.
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28
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Kartan S, Shi VY, Clark AK, Chan LS. Paraneoplastic Pemphigus and Autoimmune Blistering Diseases Associated with Neoplasm: Characteristics, Diagnosis, Associated Neoplasms, Proposed Pathogenesis, Treatment. Am J Clin Dermatol 2017; 18:105-126. [PMID: 27878477 DOI: 10.1007/s40257-016-0235-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Autoimmune paraneoplastic and neoplasm-associated skin syndromes are characterized by autoimmune-mediated cutaneous lesions in the presence of a neoplasm. The identification of these syndromes provides information about the underlying tumor, systemic symptoms, and debilitating complications. The recognition of these syndromes is particularly helpful in cases of skin lesions presenting as the first sign of the malignancy, and the underlying malignancy can be treated in a timely manner. Autoimmune paraneoplastic and neoplasm-associated bullous skin syndromes are characterized by blister formation due to an autoimmune response to components of the epidermis or basement membrane in the context of a neoplasm. The clinical manifestations, histopathology and immunopathology findings, target antigens, associated neoplasm, current diagnostic criteria, current understanding of pathogenesis, and treatment options for a selection of four diseases are reviewed. Paraneoplastic pemphigus manifests with clinically distinct painful mucosal erosions and polymorphic cutaneous lesions, and is often associated with lymphoproliferative neoplasm. In contrast, bullous pemphigoid associated with neoplasm presents with large tense subepidermal bullae of the skin, and mild mucosal involvement, but without unique clinical features. Mucous membrane pemphigoid associated with neoplasm is a disorder of chronic subepithelial blisters that evolve into erosions and ulcerations that heal with scarring, and involves stratified squamous mucosal surfaces. Linear IgA dermatosis associated with neoplasm is characterized by annularly grouped pruritic papules, vesicles, and bullae along the extensor surfaces of elbows, knees, and buttocks. Physicians should be aware that these autoimmune paraneoplastic and neoplasm-associated syndromes can manifest distinct or similar clinical features as compared with the non-neoplastic counterparts.
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29
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Lee SY, Kim JH, Cho DH. High-dose-rate intraluminal brachytherapy for paraneoplastic autoimmune multiorgan syndrome. Exp Ther Med 2016; 12:1435-1439. [PMID: 27602070 PMCID: PMC4998192 DOI: 10.3892/etm.2016.3458] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Accepted: 05/26/2016] [Indexed: 12/22/2022] Open
Abstract
Paraneoplastic autoimmune multiorgan syndrome (PAMS), also known as paraneoplasic pemphigus, involves the skin, internal organs and mucosa. PAMS-associated mortality may occur as a result of autoantibody formation against internal tumors and their infiltration into organs other than the skin lesions that characterize PAMS. The most common symptoms of PAMS include pain associated with continuous oral ulceration and resistance to pharmacological treatment. The present study reports the case of a 42-year-old female patient who was admitted with an 8-month history of erosive skin lesions within the trunk region, oral mucosa and vaginal mucosa. The patient was diagnosed with PAMS based on computed tomography scans and histological analyses of the lesions. The lymphoid hyperplasia in the retroperitoneum and lesions in the vaginal mucosa and trunk area were improved following pharmacological treatment and resection of the lymph node showing hyperplasia. However, the oral lesion was treated with intraluminal brachytherapy due to its resistance to long-term pharmacological treatment. The majority of the lesions were improved following treatment, in the absence of any severe side effects. In addition, neither worsening nor progression of the oral lesion was observed during the 4-year follow-up period.
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Affiliation(s)
- Sun-Young Lee
- Department of Radiation Oncology, Institute for Medical Sciences, Chonbuk National University Medical School, Jeonju, Jeollabuk-do 561-712, Republic of Korea; Institute of Clinical Medicine of Chonbuk National University-Biomedical Research Institute, Chonbuk National University Hospital, Jeonju, Jeollabuk-do 561-712, Republic of Korea
| | - Jong-Hyun Kim
- Institute of Clinical Medicine of Chonbuk National University-Biomedical Research Institute, Chonbuk National University Hospital, Jeonju, Jeollabuk-do 561-712, Republic of Korea; Department of Obstetrics and Gynecology, Chonbuk National University Hospital, Jeonju, Jeollabuk-do 561-712, Republic of Korea
| | - Dong-Hyu Cho
- Institute of Clinical Medicine of Chonbuk National University-Biomedical Research Institute, Chonbuk National University Hospital, Jeonju, Jeollabuk-do 561-712, Republic of Korea; Department of Obstetrics and Gynecology, Chonbuk National University Hospital, Jeonju, Jeollabuk-do 561-712, Republic of Korea
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Hejna M, Wöll E, Tschandl P, Raderer M. Cutaneous paraneoplastic disorders in stomach cancer: Collaboration between oncologically active dermatologists and clinical oncologists. Crit Rev Oncol Hematol 2016; 103:78-85. [PMID: 27247117 DOI: 10.1016/j.critrevonc.2016.04.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 03/14/2016] [Accepted: 04/26/2016] [Indexed: 01/25/2023] Open
Abstract
To our knowledge this is the first systemic review that provides an overview of the cutaneous paraneoplastic syndromes (CPS) (i.e., clinical manifestations, pathomechanisms, and treatment modalities) occurring in stomach cancer. CPS are caused by substances produced by stomach cancer and may precede, coincide with, or follow the diagnosis of this malignancy. More than 20 possible CPS in association with stomach cancer have been identified. CPS mostly compromises the patient's quality of life by skin impairment plus discomfort and are often associated with a dismal prognosis on survival. Studies of these CPS not only in stomach cancer have partially contributed to the understanding of pathomechanism and since CPS may be the presenting sign of an occult cancer, cognizance of their features and clinical implications are of considerable importance. Patients with these syndromes should have an appropriate work-up for a possibly occult malignancy with consecutive successful early treatment.
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Affiliation(s)
- Michael Hejna
- Comprehensive Cancer Center-GET, Medical University of Vienna, Vienna, Austria.
| | - Ewald Wöll
- St.Vinzenz Krankenhaus Betriebs GmbH, Zams, Austria
| | - Philipp Tschandl
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - Markus Raderer
- Department of Internal Medicine I, Division of Oncology Medical University of Vienna, Vienna, Austria
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Epiplakin Is a Paraneoplastic Pemphigus Autoantigen and Related to Bronchiolitis Obliterans in Japanese Patients. J Invest Dermatol 2016; 136:399-408. [DOI: 10.1038/jid.2015.408] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Revised: 09/23/2015] [Accepted: 09/26/2015] [Indexed: 11/09/2022]
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Abstract
Paraneoplastic pemphigus (PNP) is an autoimmune mucocutaneous blistering disease driven by autoantibodies against plakins expressed in mucosal epithelium. Diagnosis can be difficult as both clinical and biopsy features overlap with other blistering disorders, thus serology is important. Indirect immunofluorescence (IIF) on rat bladder substrate is the most widely used assay, but plakin-specific autoantibody assays have recently become available.The aim of this study was to compare the performance of five PNP assays in patients with mucosal blistering disease: IIF with rat bladder, monkey bladder and rat cardiac substrates, an envoplakin enzyme-linked immunosorbent assay (ELISA), and an envoplakin-transfected HEK cell based assay (CBA).Fifty-one patient serum samples, comprising three PNP patients and 48 disease controls, were collected along with 10 healthy control samples, and analysed using the five assays.IIF on rat and monkey bladder substrates both showed high specificity (97% and 95%, respectively), and correctly identified all three PNP sera. The envoplakin ELISA was equally specific (98%) but identified only one PNP patient. The CBA was difficult to interpret, and both this assay and IIF on rat cardiac substrate lacked specificity (82% and 83%, respectively).In this study IIF using either rat or monkey bladder substrates performed strongly, whilst the envoplakin ELISA seemed to lack sensitivity, and the CBA and IIF on rat cardiac substrate were inferior. Our findings suggest that traditional IIF-based assays remain the preferred approach in the serological diagnosis of PNP.
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Lee J, Bloom R, Amber KT. A Systematic Review of Patients with Mucocutaneous and Respiratory Complications in Paraneoplastic Autoimmune Multiorgan Syndrome: Castleman’s Disease is the Predominant Malignancy. Lung 2015; 193:593-6. [DOI: 10.1007/s00408-015-9732-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2015] [Accepted: 04/17/2015] [Indexed: 10/23/2022]
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Gallo E, García-Martín P, Fraga J, Teye K, Koga H, Hashimoto T, García-Diez A. Paraneoplastic pemphigus with eosinophilic spongiosis and autoantibodies against desmocollins 2 and 3. Clin Exp Dermatol 2015; 39:323-6. [PMID: 24635070 DOI: 10.1111/ced.12296] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/25/2013] [Indexed: 01/27/2023]
Abstract
Paraneoplastic pemphigus (PNP) is an autoimmune blistering disease associated with neoplasms, typically lymphoproliferative disorders. PNP is characterized clinically by painful erosive stomatitis and polymorphous skin lesions. Histopathological findings are also very varied, and include lichen planus-like and pemphigus-like changes. These polymorphic clinicopathological findings are probably due to the complex pathogenic mechanism, in which both cellular and humoral immunity are implicated. Eosinophilic spongiosis, although infrequent, can be found with pemphigus herpetiformis and bullous pemphigoid, although this association has not been established in PNP. The presence of autoantibodies against envoplakin and periplakin in PNP has been reported, but autoantibodies against desmocollins (Dscs) have been found in only a very few cases of PNP, probably due to the lack of studies on such associations. We report the first case, to our knowledge, of PNP with eosinophilic spongiosis as the initial histopathological finding, and presence of autoantibodies to Dsc2 and Dsc3.
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Affiliation(s)
- E Gallo
- Department of Dermatology, Hospital Universitario La Princesa, Madrid, Spain
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Yin L, Qu H, Chen Q. Proliferative response of peripheral blood mononuclear cells in anti-Hu antibody-associated patients with paraneoplastic neurological syndrome and their depressant effect on small cell lung cancer cells. Mol Med Rep 2014; 11:1595-600. [PMID: 25412252 PMCID: PMC4270316 DOI: 10.3892/mmr.2014.2975] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2014] [Accepted: 08/05/2014] [Indexed: 11/05/2022] Open
Abstract
Previous studies have suggested that common antigens that exist in neurons and tumor cells trigger cross immunoreaction, which attacks the neurons and tumor cells simultaneously. This action leads to paraneoplastic symptoms and slowed tumor growth. The present study co‑cultured peripheral blood mononuclear cells (PBMCs) from anti‑Hu antibody‑associated patients with paraneoplastic neurological syndrome (PNS) and the small cell lung cancer cell line NCI‑H446 (H446) in vitro. In the PNS group, no significant difference was observed in the proliferation index of PBMCs and H446 cells between the mixed or separate cultures. The proportion of CD4+ T cells in patients with PNS (76.54±3.96%) was significantly higher (P<0.05) compared with the healthy control individuals (51.75±17.3%). In conclusion, the sensitized specific T cells in the PBMCs of PNS patients predominantly comprised of CD4+ T cells, which had no inhibitory effect on small cell lung cancer cells in vitro.
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Affiliation(s)
- Liang Yin
- Department of Neurology, The First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui 233004, P.R. China
| | - Hongdang Qu
- Department of Neurology, The First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui 233004, P.R. China
| | - Qiming Chen
- Department of Neurology, The First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui 233004, P.R. China
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Miest RY, Wetter DA, Drage LA, el-Azhary RA, Camilleri MJ. A mucocutaneous eruption. Int J Dermatol 2014; 53:1425-7. [PMID: 25310900 DOI: 10.1111/ijd.12591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Rachel Y Miest
- Department of Dermatology, Mayo Clinic, Rochester, MN, USA
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Shephard M, Hodgson T, Hegarty AM. Vesiculobullous disorders affecting the oral cavity. Br J Hosp Med (Lond) 2014; 75:502-8. [PMID: 25216166 DOI: 10.12968/hmed.2014.75.9.502] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- Martina Shephard
- Specialist Registrar in Oral Medicine, Eastman Dental Hospital, UCLH Foundation NHS Trust London, London
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Paraneoplastic pemphigus: A retrospective case series in a referral center in northern Taiwan. DERMATOL SIN 2014. [DOI: 10.1016/j.dsi.2013.04.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Ruocco E, Wolf R, Ruocco V, Brunetti G, Romano F, Lo Schiavo A. Pemphigus: associations and management guidelines: facts and controversies. Clin Dermatol 2013; 31:382-390. [PMID: 23806155 DOI: 10.1016/j.clindermatol.2013.01.005] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Pemphigus, a prototypical organ-specific human autoimmune disease, may be associated with other immunity-related disorders, viral infections, and different types of tumors. Coexistence with immune diseases is fairly frequent and, for some of them (eg, myasthenia gravis, Basedow's disease, rheumatoid arthritis, or lupus erythematosus), common pathogenic mechanisms can be considered. The association with viral infections (mainly herpesvirus infections) raises the question of whether the virus triggers the outbreak of the disease or simply complicates its clinical course. Neoplastic proliferations coexisting with pemphigus have a different histogenesis and the pathogenic link may vary according to the associated tumor (thymoma, lymphoma, carcinoma, or sarcoma). A subset of pemphigus-neoplasia association is represented by Anhalt's paraneoplastic pemphigus, with peculiar clinical, histologic, and immunologic features characterizing it. Coexistence of pemphigus with Kaposi's sarcoma, albeit not frequent, offers an intriguing speculative interest. The cornerstone of management in pemphigus is the combination of systemic corticosteroids and immunosuppressants. The conventional treatment used in most cases is based on oral administration of deflazacort and azathioprine. In selected cases, mycophenolate mofetil is preferred to azathioprine. Severe forms of pemphigus require intravenous pulse therapy with dexamethasone (or methylprednisolone) and cyclophosphamide. In the recent years, the use of high-dose intravenous immunoglobulin therapy has gained several consents. Rituximab, a monoclonal anti-CD 20 antibody, which affects both the humoral and cell-mediated responses, has proved to give a good clinical response, often paralleled by decrease of pathogenic autoantibodies. The combination with intravenous immunoglobulin offers the double advantage of better clinical results and a reduced incidence of infection. Interventional treatments, such as plasmapheresis and extracorporeal immunoadsorption, are aimed at patients with life-threatening forms of pemphigus and high levels of circulating autoantibodies, a circumstance where the medical therapy alone risks failing. Second-line treatments include gold salts (which we do not favor because of the acantholytic potential inherent in thiol structure) and the association of oral tetracyclines with nicotinamide, which is rather safe. Local treatments, supplementary to the systemic therapy, are aimed at preventing infections and stimulating reepithelialization of eroded areas. Innovative topical treatments are epidermal growth factor, nicotinamide gel, pimecrolimus, and a proteomics-derived desmoglein peptide. Pemphigus patients should be warned against over-indulging in unnecessary drug intake, prolonged exposure to ultraviolet rays, intense emotional stress, and too spiced or too hot foods. Cigarette smoking is not contraindicated in pemphigus patients because of the nicotine anti-acantholytic properties.
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Affiliation(s)
- Eleonora Ruocco
- Department of Dermatology, Second University of Naples, via S. Pansini, 5 - 80131 Naples, Italy
| | - Ronni Wolf
- Dermatology Unit, Kaplan Medical Center, Rehovot 76100 Israel; The School of Medicine, Hebrew University and Hadassah Medical Center, Jerusalem, Israel
| | - Vincenzo Ruocco
- Department of Dermatology, Second University of Naples, via S. Pansini, 5 - 80131 Naples, Italy.
| | - Giampiero Brunetti
- Department of Dermatology, Second University of Naples, via S. Pansini, 5 - 80131 Naples, Italy
| | - Francesca Romano
- Department of Dermatology, Second University of Naples, via S. Pansini, 5 - 80131 Naples, Italy
| | - Ada Lo Schiavo
- Department of Dermatology, Second University of Naples, via S. Pansini, 5 - 80131 Naples, Italy
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Maverakis E, Goodarzi H, Wehrli LN, Ono Y, Garcia MS. The etiology of paraneoplastic autoimmunity. Clin Rev Allergy Immunol 2012; 42:135-44. [PMID: 21246308 DOI: 10.1007/s12016-010-8248-5] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Although they may sometimes appear similar, paraneoplastic autoimmunity has a unique pathogenesis, different from the classical autoimmune diseases not associated with cancer. When distinguished clinically, paraneoplastic autoimmunity is more severe and often presents with a broader range of clinical signs and symptoms. Management of these patients is difficult and is usually centered in part on treatment of the underlying malignancy. Self-antigens recognized in the setting of paraneoplastic autoimmunity can be diverse, and the number of determinants recognized within a single antigen can be numerous. This review uses prototypic examples of paraneoplastic immune-mediated diseases and their associated malignancies to describe the mechanisms by which immune dysregulation can occur in the setting of cancer. Specific diseases covered include paraneoplastic pemphigus, Sweet's syndrome, pyoderma gangrenosum, thymoma-associated multiorgan autoimmunity, myasthenia gravis, autoimmune hemolytic anemia, immune thrombocytopenia, and the paraneoplastic neurological syndromes. The malignancies discussed include thymoma, non-Hodgkin's lymphoma, and chronic lymphocytic leukemia, among others. The mechanisms by which cancers induce autoimmunity are broken down into the following categories: disruption of central tolerance, peripheral immune dysregulation, and alteration of self-antigens. For each category, examples of paraneoplastic autoimmune diseases and their associated malignancies are discussed. Finally, mechanisms by which cancer treatment can lead to autoimmunity and examples of polymorphisms that are linked to both cancer and autoimmunity are discussed.
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Affiliation(s)
- Emanual Maverakis
- Department of Dermatology, School of Medicine, University of California-Davis, 3301 C Street, Sacramento, CA, 95816, USA.
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Abstract
Paraneoplastic pemphigus (PNP) is a distinct autoimmune blistering disease that can affect multiple organs other than the skin. It occurs in association with certain neoplasms, among which lymphoproliferative diseases are most commonly associated. The clinical presentation of PNP consists typically of painful, severe oral erosions that may be accompanied by a generalised cutaneous eruption and systemic involvement. The eruption may be of different morphology, consisting of lesions that resemble pemphigus, pemphigoid, erythema multiforme or graft versus host disease, as well as lesions resembling lichen planus. Similarly, the histological findings also show considerable variability. PNP is characterised by the presence of autoantibodies against various antigens: desmoplakin I (250 kd), bullous pemphigoid antigen I (230 kd), desmoplakin II (210 kd), envoplakin (210 kd), periplakin (190 kd), plectin (500 kd) and a 170-kd protein. This 170-kd protein has recently been identified as alpha-2-macroglobulin-like-1, a broad range protease inhibitor expressed in stratified epithelia and other tissue damaged in PNP. The prognosis of PNP is poor and the disease is often fatal. Immunosuppressive agents are often required to decrease blistering, and treating the underlying malignancy with chemotherapy may control autoantibody production. The prognosis is better when PNP is associated with benign tumours and these should be surgically excised when possible.
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Abstract
Linear immunoglobulin A (IgA) bullous dermatosis, also known as linear IgA disease, is an autoimmune mucocutaneous disorder characterized by subepithelial bullae, with IgA autoantibodies directed against several different antigens in the basement membrane zone. Its immunopathologic characteristic resides in the presence of a continuous linear IgA deposit along the basement membrane zone, which is clearly visible on direct immunofluorescence. This disorder shows different clinical features and distribution when adult-onset of linear IgA disease is compared with childhood-onset. Diagnosis is achieved via clinical, histopathologic, and immunopathologic examinations. Two common therapies are dapsone and sulfapyridine, which reduce the inflammatory response and achieve disease remission in a variable period of time.
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Affiliation(s)
- Giulio Fortuna
- Department of Dermatology, Program in Epithelial Biology, Stanford University School of Medicine, CA 94305, USA
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45
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Woo SB. Diseases of the oral mucosa. MCKEE'S PATHOLOGY OF THE SKIN 2012:362-436. [DOI: 10.1016/b978-1-4160-5649-2.00011-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
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Abstract
The goal of contemporary research in pemphigus vulgaris and pemphigus foliaceus is to achieve and maintain clinical remission without corticosteroids. Recent advances of knowledge on pemphigus autoimmunity scrutinize old dogmas, resolve controversies, and open novel perspectives for treatment. Elucidation of intimate mechanisms of keratinocyte detachment and death in pemphigus has challenged the monopathogenic explanation of disease immunopathology. Over 50 organ-specific and non-organ-specific antigens can be targeted by pemphigus autoimmunity, including desmosomal cadherins and other adhesion molecules, PERP cholinergic and other cell membrane (CM) receptors, and mitochondrial proteins. The initial insult is sustained by the autoantibodies to the cell membrane receptor antigens triggering the intracellular signaling by Src, epidermal growth factor receptor kinase, protein kinases A and C, phospholipase C, mTOR, p38 MAPK, JNK, other tyrosine kinases, and calmodulin that cause basal cell shrinkage and ripping desmosomes off the CM. Autoantibodies synergize with effectors of apoptotic and oncotic pathways, serine proteases, and inflammatory cytokines to overcome the natural resistance and activate the cell death program in keratinocytes. The process of keratinocyte shrinkage/detachment and death via apoptosis/oncosis has been termed apoptolysis to emphasize that it is triggered by the same signal effectors and mediated by the same cell death enzymes. The natural course of pemphigus has improved due to a substantial progress in developing of the steroid-sparing therapies combining the immunosuppressive and direct anti-acantholytic effects. Further elucidation of the molecular mechanisms mediating immune dysregulation and apoptolysis in pemphigus should improve our understanding of disease pathogenesis and facilitate development of steroid-free treatment of patients.
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Affiliation(s)
- Sergei A Grando
- Department of Dermatology, University of California, Irvine, CA 92697, USA.
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Czernik A, Camilleri M, Pittelkow MR, Grando SA. Paraneoplastic autoimmune multiorgan syndrome: 20 years after. Int J Dermatol 2011; 50:905-14. [DOI: 10.1111/j.1365-4632.2011.04868.x] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Sagi L, Baum S, Agmon-Levin N, Sherer Y, Katz BSP, Barzilai O, Ram M, Bizzaro N, SanMarco M, Trau H, Shoenfeld Y. Autoimmune bullous diseases the spectrum of infectious agent antibodies and review of the literature. Autoimmun Rev 2011; 10:527-35. [PMID: 21527361 DOI: 10.1016/j.autrev.2011.04.003] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2011] [Accepted: 04/05/2011] [Indexed: 12/14/2022]
Abstract
Pemphigus and bullous pemphigoid are two autoimmune diseases that have a similar pathogenesis. Both have a genetic predisposition which promotes the production of auto-antibodies targeted against different components of the epidermal desmosome and hemidesmosome. Environmental factors play an important role in the pathogenesis of this autoimmune disease. Among these, the role of infectious agents was debated as a causative factor. We sought to determine a possible connection between various infectious agents and autoimmune bullous disease (ABD). A cohort of 148 serum samples of patients with pemphigus, bullous pemphigoid and controls was screened for evidence of a prior infection with HBV, HCV, EBV, CMV, Helicobacter pylori, Toxoplasma gondii and Treponema pallidum, utilizing the Bio-Rad BioPlex 2200 system as well as ELISA assays to complete the panel. HBV, HCV, H. pylori, T. gondii and CMV were demonstrated to have significantly higher prevalence of antibodies in patients with pemphigus and bullous pemphigoid in comparison to controls. Among them, we found a novel association between H. pylori and ABD. Our study suggests a contributing role for HBV, HCV, H. pylori, T. gondii and CMV in inducing ABD in the genetically susceptible host.
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Affiliation(s)
- Lior Sagi
- Department of Dermatology, Sheba Medical Center, Tel Hashomer, Israel
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Dvornikov AS, Kruglova LS, Dvornikov AS, Kruglova LS. Etiology and treatment of circumscribed sclerodermarevisited. VESTNIK DERMATOLOGII I VENEROLOGII 2010. [DOI: 10.25208/vdv842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
There was a clinical and laboratory study of the efficacy of complex treatment with Longidaza, a Russian enzyme drug, in 30
patients suffering from circumscribed scleroderma. High efficacy of treatment for different clinical forms of circumscribed scleroderma
using this method was proved. A positive effect of the complex therapy on the results of ultrasonic skin examination in the
affection foci and individual blood immunology indices was revealed.
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Cervini A, Tosi V, Kim S, Bocian M, Chantada G, Nousari C, Carballo O, Pierini A. Pénfigo paraneoplásico/síndrome multiorgánico autoinmune paraneoplásico. Presentación de dos casos en la edad infantil. Revisión de la literatura. ACTAS DERMO-SIFILIOGRAFICAS 2010. [DOI: 10.1016/j.ad.2010.06.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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