Pruritic Urticarial Papules and Plaques of Pregnancy With Unusual and Extensive Palmoplantar Involvement

A review on the effect of prolyl isomerization on immune response aberration and hypersensitivity reactions: A unifying hypothesis

Little is known about the causes and mechanisms of ectopic immune responses, including different types of hypersensitivity, superantigens, and cytokine storms. Two of the most questionable phenomena observed in immunology are why the intensity and extent of immune responses to different antigens are different, and why some self-antigens are attacked as foreign. The secondary structure of the peptides involved in the immune system, such as the epitope-paratope interfaces plays a pivotal role in the resulting immune responses. Prolyl cis/trans isomerization plays a fundamental role in the form of the secondary structure and the folding of proteins. This review covers some of the emerging evidence indicating the impact of prolyl isomerization on protein conformation, aberration of immune responses, and the development of hypersensitivity reactions.

Polymorphic eruption of pregnancy: Review of literature

Polymorphic Eruption of Pregnancy (PEP) is one of the most common dermatosis related to pregnancy. PEP usually consists of pruritic papules and plaques appearing in the third trimester of pregnancy. It is more common in primigravidae and twin pregnancies. Although not associated with poorer foetal or maternal outcomes, it may be hard for pregnant women to endure. The diagnosis is easy if suspected, though sometimes it may be hard to distinguish from other dermatosis such as atopic eczema of pregnancy, pemphigoid gestationis or dermatitis. Topical treatment with emollients and low-medium potency steroids is usually effective but systemic steroid treatment may be required. PEP is self-limiting and resolves days or weeks after the first appearance or after delivery. In this article, the authors aim to review the literature published from 2000 onwards regarding the subject, either in English or Portuguese.

Pruritic urticarial papules and plaques of pregnancy

Pruritic urticarial papules and plaques of pregnancy (PUPPP) are among the most common pruritic dermatoses observed in pregnant women. PUPPP appears most frequently in the third trimester, in primigravidas, and in multiple gestation pregnancies. The eruption of changes occurs initially on the abdomen and extends over the thighs, legs, back, buttocks, arms, and breasts. Skin changes typical for PUPPP are erythematous, urticarial plaques, and papules. Rash regression is usually observed within 6 weeks postpartum. Immunologic mechanisms, hormonal abnormalities, and abdominal skin distension have been suggested as etiologic mechanisms. PUPPP is thought to be harmless for the mother and fetus and usually requires intervention only for symptom relief. In some cases, laboratory investigation, histologic examination, and immunologic study should be performed to exclude more serious disorders of pregnancy, such as herpes gestationis or intrahepatic cholestasis of pregnancy. This article reviews the epidemiology, clinical manifestation, etiology, differential diagnosis, and treatment of PUPPP.

Clinical experience in pemphigoid gestationis: Report of 10 cases

BACKGROUND

Pemphigoid gestationis is a rare autoimmune blistering disease that occurs during pregnancy.

OBJECTIVE

This study reviewed our clinical experience with pemphigoid gestationis.

METHODS

We reviewed medical records of 10 patients with pemphigoid gestationis seen at Mayo Clinic, Rochester, Minnesota, between 1976 and 2004.

RESULTS

Urticarial papules were the most frequent clinical presentation followed by blisters and rash. Pruritus was the cardinal symptom. Lesions presented initially on the legs, thighs, back, and chest. Direct immunofluorescence had the highest diagnostic test sensitivity. Systemic corticosteroids were the mainstay of treatment. Fetal and maternal outcome was good in all cases.

LIMITATIONS

This was a retrospective, single-institution study.

CONCLUSIONS

This condition can be easily confused with other dermatoses of pregnancy, for example, pruritic urticarial papules of pregnancy. Biopsy for direct immunofluorescence is the preferred test for confirmation of diagnosis. On the basis of good patient outcomes, conservative treatment seems warranted.

Case report: Epidural abscess in a parturient with pruritic urticarial papules and plaques of pregnancy (PUPPP)

PURPOSE

To describe the risk factors for epidural abscess (EA) formation following epidural analgesia in a parturient with pruritic urticarial papules and plaques of pregnancy (PUPPP).

CLINICAL FEATURES

A 33 yr-old gravida 2 nulliparous patient at 36 weeks gestation presented with severe pre-eclampsia, and PUPPP (treated with prednisone). Magnesium prophylaxis was started and labour was induced. An epidural catheter was placed at the L(3-4) level using standard aseptic technique. Bupivacaine was incrementally injected to achieve a T10 sensory level, and analgesia was maintained using a continuous infusion of 0.0625% bupivacaine with fentanyl. Nine days post-delivery, the patient developed back pain radiating to her right leg, but she was otherwise asymptomatic. She was afebrile; with a slightly tender, non-erythematous, non-draining, 1 cm nodule at the epidural catheter site. Motor and sensory examinations were normal at that time. However, the patient returned 24 hr later and further investigations revealed: WBC 17,800.mm(-3), platelets 486,000.mm(-3), erythrocyte sedimentation rate 50 mm.hr(-1), and C-reactive protein 8.8 mg.dL(-1). The magnetic resonance imaging demonstrated an EA at the L(3-4) level causing minimal cord compression. The patient underwent an emergency decompressive laminectomy. Cultures revealed methicillin-sensitive Staphylococcus aureus. Her pain improved, and she was discharged on the third postoperative day with a six-week course of iv ceftriaxone.

CONCLUSION

Causative organisms for EAs include coagulase-negative Staphylococci, S. aureus, and Gram-negative bacilli. Infection can occur either hematogenously or by direct contamination during catheter placement. Risk factors include immunocompromised states and PUPPP, as with the case of this patient.