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Diercks GFH, Meijer JM, Bolling MC, Scholtens-Jaegers SMHJ, Bremer J, Horvath B. Absence of Epidermal Antibodies in Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis Patients but Beware of Single Positive Results. Dermatol Res Pract 2024; 2024:5504462. [PMID: 38803350 PMCID: PMC11129901 DOI: 10.1155/2024/5504462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 04/30/2024] [Accepted: 05/02/2024] [Indexed: 05/29/2024] Open
Abstract
Background Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare and potentially life-threatening mucocutaneous blistering diseases that clinically can resemble autoimmune bullous diseases. Moreover, it has been shown that autoantibodies against epidermal proteins are present in SJS/TEN. Objectives To establish the presence of antibodies against desmosomal and hemidesmosomal proteins in confirmed SJS/TEN patients. Methods Serum of SJS/TEN patients diagnosed based on clinical criteria, e.g., epidermal detachment with erosions and severe mucosal lesions, (suspicion of) a culprit drug, and matching histologic results was evaluated by various techniques, e.g., indirect immunofluorescence on monkey esophagus, salt split skin and rat bladder, immunoblotting (IB) and immunoprecipitation (IP), ELISAs against desmogleins and BP180, keratinocyte footprint assay, and keratinocyte binding assay. Results A total of 28 patients were included in this study, 15 men and 13 women with a mean age of 56 years. In most patients, none of the serological tests were positive. In two patients, an elevated DSG3 titer was found suspicious for pemphigus vulgaris. Three patients had elevated NC16a titers, suggesting bullous pemphigoid. However, in all these patients, no other tests were positive and in these patients, the biopsy for direct immunofluorescence showed no evidence for an autoimmune bullous disease. Three patients showed reactivity against rat bladder rat bladder; these were, however, completely negative for A2ML1, envoplakin, and periplakin in the IB as well as the IP. Conclusions Serological analysis for desmosomal and hemidesmosomal antibodies is reliable to rule an autoimmune bullous disease in patients with suspected SJS/TEN. However, one should not rely on one single test method since false positive results can occur. Moreover, this study also makes it less plausible that antibodies against desmosomal and/or hemidesmosomal components are involved in the pathogenesis of SJS/TEN.
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Affiliation(s)
- Gilles F. H. Diercks
- University of Groningen, University Medical Center Groningen, Department of Dermatology, Center of Blistering Diseases, European Reference Networks-Skin Member, Groningen, Netherlands
- European Reference Networks (ERN)—SKIN Center, Paris, France
| | - Joost M. Meijer
- University of Groningen, University Medical Center Groningen, Department of Dermatology, Center of Blistering Diseases, European Reference Networks-Skin Member, Groningen, Netherlands
- European Reference Networks (ERN)—SKIN Center, Paris, France
| | - Maria C. Bolling
- University of Groningen, University Medical Center Groningen, Department of Dermatology, Center of Blistering Diseases, European Reference Networks-Skin Member, Groningen, Netherlands
- European Reference Networks (ERN)—SKIN Center, Paris, France
| | | | - Jeroen Bremer
- University of Groningen, University Medical Center Groningen, Department of Dermatology, Center of Blistering Diseases, European Reference Networks-Skin Member, Groningen, Netherlands
- European Reference Networks (ERN)—SKIN Center, Paris, France
| | - Barbara Horvath
- University of Groningen, University Medical Center Groningen, Department of Dermatology, Center of Blistering Diseases, European Reference Networks-Skin Member, Groningen, Netherlands
- European Reference Networks (ERN)—SKIN Center, Paris, France
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Didona D, Schmidt MF, Maglie R, Solimani F. Pemphigus and pemphigoids: Clinical presentation, diagnosis and therapy. J Dtsch Dermatol Ges 2023; 21:1188-1209. [PMID: 37587612 DOI: 10.1111/ddg.15174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 06/11/2023] [Indexed: 08/18/2023]
Abstract
Pemphigus and pemphigoid are two potentially life-threatening groups of autoimmune diseases, characterized by autoantibodies targeting structural components of desmosomes or hemidesmosomes, respectively. Affected patients typically show itchy/painful plaques or blistering skin lesions and/or impairing mucosal blistering and erosions, which may strongly impact their quality of life. Since the milestone work of Walter Lever in 1953, who differentiated these two groups of diseases by histopathological analysis of the level of antibody-mediated skin cleavage, enormous progresses occurred. Achievements made in laboratory diagnostics now allow to identify antigen specific structural proteins of the skin that are targeted by pathogenic autoantibodies. These progresses were accompanied by an increased understanding of the pathogenesis of these diseases thanks to the establishment of animal models reproducing disease and on studies on skin and blood of affected individuals, which have been leading to novel and disease-specific treatments. Yet, given their phenotypical overlap with more common dermatological diseases, correct diagnosis and appropriate treatment are often delayed, in some cases leading to irreversible sequelae, including organ dysfunction (i.e., loss of vision in mucous membrane pemphigoid). Here, we provide a concise overview of the clinical appearance, diagnosis and therapeutic management of pemphigus and pemphigoid diseases.
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Affiliation(s)
- Dario Didona
- Department of Dermatology and Allergology, Philipps-Universität Marburg, Marburg, Germany
| | - Morna F Schmidt
- Department of Dermatology and Allergology, University Hospital RWTH Aachen, Aachen, Germany
| | - Roberto Maglie
- Department of Dermatology and Allergology, Philipps-Universität Marburg, Marburg, Germany
- Department of Health Sciences, Section of Dermatology, University of Florence, Florence, Italy
| | - Farzan Solimani
- Department of Dermatology, Venereology and Allergology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Clinician Scientist Program, Germany
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Didona D, Schmidt MF, Maglie R, Solimani F. Pemphigus- und Pemphigoid-Erkrankungen: Klinik, Diagnostik und Therapie: Pemphigus and pemphigoids: Clinical presentation, diagnosis and therapy. J Dtsch Dermatol Ges 2023; 21:1188-1211. [PMID: 37845066 DOI: 10.1111/ddg.15174_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 06/11/2023] [Indexed: 10/18/2023]
Abstract
ZusammenfassungPemphigus und Pemphigoid sind seltene Autoimmunkrankheiten der Haut mit potenziell lebensbedrohlichem Verlauf. Autoantikörper gegen epidermale und junktionale Strukturproteine (Desmosomen sowie Hemidesmosomen) führen bei Betroffenen typischerweise zu juckenden, schmerzhaften Plaques oder Blasen an der Haut und/oder Blasenbildung und Erosionen der Schleimhäute mit möglicher Einschränkung der Lebensqualität. Seit der bahnbrechenden Arbeit von Walter Lever im Jahr 1953, dem es gelang, mittels histopathologischer Untersuchung diese beiden Krankheitsgruppen anhand des Musters der Antikörper‐vermittelten Blasenbildung zu differenzieren, wurden enorme Fortschritte im Verständnis der Erkrankungen erzielt. Die Errungenschaften in der Labordiagnostik ermöglichten die Identifikation von Zielstrukturen zur präzisen Unterscheidung verschiedener Varianten der bullösen Autoimmunerkrankungen. Diese Fortschritte gingen dank der Entwicklung von Tiermodellen mit einem besseren Verständnis der Pathogenese einher. Außerdem haben Studien an Haut und Blut betroffener Patienten zu neuen und krankheitsspezifischen Behandlungen geführt. Aufgrund ihrer Seltenheit und der klinischen Ähnlichkeit mit anderen dermatologischen Erkrankungen verzögern sich die korrekte Diagnosestellung und die Einleitung einer entsprechenden Therapie häufig, was in einigen Fällen zu irreversiblen Folgeerscheinungen, einschließlich Funktionsstörungen von Organen (zum Beispiel Verlust des Sehvermögens beim Schleimhautpemphigoid) führt. Wir geben hier einen Überblick über das klinische Erscheinungsbild, den Diagnosealgorithmus und das therapeutische Management von Pemphigus‐ und Pemphigoid‐Erkrankungen.
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Affiliation(s)
- Dario Didona
- Klinik für Dermatologie und Allergologie, Philipps-Universität Marburg, Marburg, Deutschland
| | - Morna F Schmidt
- Klinik für Dermatologie und Allergologie, Uniklinik RWTH Aachen, Aachen, Deutschland
| | - Roberto Maglie
- Klinik für Dermatologie und Allergologie, Philipps-Universität Marburg, Marburg, Deutschland
- Abteilung für Gesundheitswissenschaften, Abteilung für Dermatologie, Universität Florenz, Florenz, Italien
| | - Farzan Solimani
- Klinik für Dermatologie, Venerologie und Allergologie, Charité - Universitätsmedizin Berlin, Korporatives Mitglied der Freien Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Deutschland
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Clinician Scientist Program, Berlin, Deutschland
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4
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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: 16] [Impact Index Per Article: 16.0] [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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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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Zaheri F, Pas HH, Bremer J, Meijer JM, Bolling MC, Horvath B, Diercks GFH. Paraneoplastic pemphigus: A detailed case series from the Netherlands revealing atypical cases. J Eur Acad Dermatol Venereol 2023; 37:147-153. [PMID: 35993495 PMCID: PMC10087213 DOI: 10.1111/jdv.18557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 07/27/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Paraneoplastic pemphigus (PNP) is an extremely rare life-threatening blistering autoimmune disease that is associated with an underlying neoplasm. There is a set diagnostic criterion for PNP, which is primarily based on a severe stomatitis and the detection of specific antibodies against envoplakin, periplakin and alpha-2-macroglobulin-like protein 1. However, it has become increasingly evident that there are patients with PNP that do not meet all the diagnostic criteria requirements. OBJECTIVES The aim of this study was to analyse our cohort of Dutch patients and to define the atypical cases that did not meet the diagnostic criteria. METHODS A retrospective case study of all known Dutch PNP patients of the past 25 years. Patients' clinical and immunological variables were thoroughly analysed and described. RESULTS Twenty-four patients were included in this study. The results revealed several atypical patient cases that did not completely meet the set diagnostic criteria. Of the 24 patients, two patients presented without stomatitis, in three patients an underlying neoplasm could not be detected, and in two patients the presence of specific autoantibodies could not be demonstrated, although all other criteria for PNP were met. Finally, three of the 24 patients survived the disease. CONCLUSION Although our findings showed similarities to previous studies and most of the patients met the criteria, there were a few atypical patient cases; highlighting the importance of not strictly adhering to the set criteria when making a diagnosis, as this can lead to a missed or late diagnosis. Thus, it is of crucial importance to combine clinical and elaborate laboratory results to confirm the diagnosis of PNP in suspected patients. Although PNP harbours an unfavourable prognosis in most cases, it might be resolved by timely treatment of the underlying cause.
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Affiliation(s)
- Farhat Zaheri
- Department of Dermatology, Expertise Center for Blistering Diseases, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Hendri H Pas
- Department of Dermatology, Expertise Center for Blistering Diseases, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Jeroen Bremer
- Department of Dermatology, Expertise Center for Blistering Diseases, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.,ERN-SKIN Expertise Center, Groningen, the Netherlands
| | - Joost M Meijer
- Department of Dermatology, Expertise Center for Blistering Diseases, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.,ERN-SKIN Expertise Center, Groningen, the Netherlands
| | - Marieke C Bolling
- Department of Dermatology, Expertise Center for Blistering Diseases, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.,ERN-SKIN Expertise Center, Groningen, the Netherlands
| | - Barbara Horvath
- Department of Dermatology, Expertise Center for Blistering Diseases, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.,ERN-SKIN Expertise Center, Groningen, the Netherlands
| | - Gilles F H Diercks
- Department of Dermatology, Expertise Center for Blistering Diseases, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.,ERN-SKIN Expertise Center, Groningen, the Netherlands.,Department of Pathology and Medical Biology, Division of Pathology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
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7
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Tekin B, Johnson EF, Wieland CN, Gibson LE, Camilleri MJ, Kalaaji AN, Comfere NI, Peters MS, Lehman JS. Histopathology of autoimmune bullous dermatoses: What's new? Hum Pathol 2022; 128:69-89. [PMID: 35764145 DOI: 10.1016/j.humpath.2022.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 06/19/2022] [Accepted: 06/21/2022] [Indexed: 11/25/2022]
Abstract
Autoimmune bullous dermatoses are characterized by the presence of tissue-bound and often circulating pathogenic autoantibodies targeting structural components of the skin and/or mucous membranes. The diagnostic workup for this heterogeneous group of disorders consists of a multi-step process, of which the light microscopic examination is a crucial component. This review is organized following a classification scheme that is based on two main histopathologic features, namely level of intraepithelial split and composition of the inflammatory infiltrate. Overall, we aim to place emphasis on the histopathologic clues that can assist pathologists in differential diagnosis and review the updates in the literature.
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Affiliation(s)
- Burak Tekin
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Emma F Johnson
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA; Department of Dermatology, Mayo Clinic, Rochester, MN, USA
| | - Carilyn N Wieland
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA; Department of Dermatology, Mayo Clinic, Rochester, MN, USA
| | - Lawrence E Gibson
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA; Department of Dermatology, Mayo Clinic, Rochester, MN, USA
| | - Michael J Camilleri
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA; Department of Dermatology, Mayo Clinic, Rochester, MN, USA
| | - Amer N Kalaaji
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA; Department of Dermatology, Mayo Clinic, Rochester, MN, USA
| | - Nneka I Comfere
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA; Department of Dermatology, Mayo Clinic, Rochester, MN, USA
| | - Margot S Peters
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA; Department of Dermatology, Mayo Clinic, Rochester, MN, USA
| | - Julia S Lehman
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA; Department of Dermatology, Mayo Clinic, Rochester, MN, USA.
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8
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Tagliati C, Rizzetto G, Lanni G, Marcucci M, Argalia G, Lucidi Pressanti G, Simonetti O, Offidani A. Thoracoabdominal computed tomography neoplasia detection in patients with paraneoplastic pemphigus: the importance of collaboration between specialists. ACTA DERMATOVENEROLOGICA ALPINA PANNONICA ET ADRIATICA 2022. [DOI: 10.15570/actaapa.2022.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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9
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Wang D, Chen Z. Paraneoplastic pemphigus associated with small lymphocytic lymphoma: A case report. Medicine (Baltimore) 2021; 100:e24039. [PMID: 33466152 PMCID: PMC7808545 DOI: 10.1097/md.0000000000024039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 10/28/2020] [Accepted: 12/04/2020] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION Paraneoplastic pemphigus (PNP) is a life-threatening autoimmune blistering disease associated with underlying neoplasms. Currently, this disease is very difficult to treat. PATIENT CONCERNS We reported a rare case of paraneoplastic pemphigus associated with small lymphocytic lymphoma responsive to desmoglein 3 (Dsg3) and bullous pemphigoid (BP) antigen 180. DIAGNOSES The initial diagnosis was hypothesized to be Stevens-Johnson syndrome based on the severe mucosal erosion and polymorphous skin lesions. However, the histopathological examination of the skin biopsy and immunology revealed PNP. INTERVENTIONS Anti-tumor therapy, immunosuppression and anti-infective therapy were administered. OUTCOMES After a series of treatments, the skin lesions had been alleviated remarkably. Enzyme-linked immunoassays indices for Dsg3 and bullous pemphigoid antigen 180 decreased (Dsg3, 32; bullous pemphigoid antigen 180, 70.44). Unfortunately, 2 months later, the patient suffered respiratory failure due to the lung impairment of small lymphocytic lymphoma and infection. Eventually, the patient chose to be discharged from the hospital and lost the opportunity for follow-up treatment as he could not afford the expensive treatment costs. LESSONS It is highly susceptible to misdiagnosis due to polymorphous skin lesions. In this case, it was also initially misdiagnosed as Stevens-Johnson syndrome. Therefore, we should pay great attention to differential diagnosis. When refractory stomatitis and mucosal erosions occur, the possibility of PNP should be considered first. At the same time, pathology, immunology and other related tests as well as the examination of primary tumors should be carried out as soon as possible.
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Affiliation(s)
- Dafen Wang
- The second Clinical Medical College of Zhejiang Chinese Medical University, Hangzhou, China
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10
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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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Abstract
Direct immunofluorescence (DIF) remains a valuable tool that may be underused because of perceived challenges in the interpretation, limitations, and processing of DIF specimens. The aim of this review is to provide a practical guide for appropriately incorporating DIF in a variety of clinical diseases, such as autoimmune blistering disorders. In vasculitis, the role of DIF continues to evolve, particularly in the setting of IgA vasculitis. Although typically not indicated for the workup of connective tissue disease, DIF may be helpful in cases with negative serologies, nondiagnostic histologic findings, or scarring alopecia. Practical pearls for biopsy technique, specimen handling, and storage are also discussed.
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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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13
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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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14
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Rashid H, Lamberts A, Diercks GFH, Pas HH, Meijer JM, Bolling MC, Horváth B. Oral Lesions in Autoimmune Bullous Diseases: An Overview of Clinical Characteristics and Diagnostic Algorithm. Am J Clin Dermatol 2019; 20:847-861. [PMID: 31313078 PMCID: PMC6872602 DOI: 10.1007/s40257-019-00461-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Autoimmune bullous diseases are a group of chronic inflammatory disorders caused by autoantibodies targeted against structural proteins of the desmosomal and hemidesmosomal plaques in the skin and mucosa, leading to intra-epithelial or subepithelial blistering. The oral mucosa is frequently affected in these diseases, in particular, in mucous membrane pemphigoid, pemphigus vulgaris, and paraneoplastic pemphigus. The clinical symptoms are heterogeneous and may present with erythema, blisters, erosions, and ulcers localized anywhere on the oral mucosa, and lead to severe complaints for the patients including pain, dysphagia, and foetor. Therefore, a quick and proper diagnosis with adequate treatment is needed. Clinical presentations of autoimmune bullous diseases often overlap and diagnosis cannot be made based on clinical features alone. Immunodiagnostic tests are of great importance in differentiating between the different diseases. Direct immunofluorescence microscopy shows depositions of autoantibodies along the epithelial basement membrane zone in mucous membrane pemphigoid subtypes, or depositions on the epithelial cell surface in pemphigus variants. Additional immunoserological tests are useful to discriminate between the different subtypes of pemphigoid, and are essential to differentiate between pemphigus and paraneoplastic pemphigus. This review gives an overview of the clinical characteristics of oral lesions and the diagnostic procedures in autoimmune blistering diseases, and provides a diagnostic algorithm for daily practice.
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Affiliation(s)
- Hanan Rashid
- Department of Dermatology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands.
| | - Aniek Lamberts
- Department of Dermatology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
| | - Gilles F H Diercks
- Department of Dermatology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
- Department of Pathology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Hendri H Pas
- Department of Dermatology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
| | - Joost M Meijer
- Department of Dermatology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
| | - Maria C Bolling
- Department of Dermatology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
| | - Barbara Horváth
- Department of Dermatology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
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15
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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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16
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Harrell J, Rubio XB, Nielson C, Hsu S, Motaparthi K. Advances in the diagnosis of autoimmune bullous dermatoses. Clin Dermatol 2019; 37:692-712. [PMID: 31864451 DOI: 10.1016/j.clindermatol.2019.09.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Autoimmune bullous dermatoses are defined by autoantibodies directed against adhesion proteins in the epidermis or basement membrane zone, resulting in blister formation on the skin and mucosa. Diagnosis depends on lesional biopsy for histopathology and perilesional biopsy for direct immunofluorescence. Additional diagnostic methods include indirect immunofluorescence, enzyme-linked immunosorbent assay, and immunoblot (Western blot), which may be selected in specific clinical scenarios due to improved sensitivity and/or specificity. This contribution reviews the available evidence supporting the use of each method to provide a practical reference for clinicians when diagnosing autoimmune bullous disorders. Techniques and cost are reviewed, and newer diagnostic techniques with potential for clinical application are.
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Affiliation(s)
- Jane Harrell
- University of Florida College of Medicine, Gainesville, Florida, USA
| | | | - Colton Nielson
- Department of Dermatology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Sylvia Hsu
- Department of Dermatology, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, USA
| | - Kiran Motaparthi
- Department of Dermatology, University of Florida College of Medicine, Gainesville, Florida, USA.
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17
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Sun S, Zhong B, Li W, Jin X, Yao Y, Wang J, Liu J, Dan H, Chen Q, Zeng X. Immunological methods for the diagnosis of oral mucosal diseases. Br J Dermatol 2019; 181:23-36. [PMID: 30585301 DOI: 10.1111/bjd.17589] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2018] [Indexed: 02/05/2023]
Abstract
Immunological methods, which have been widely used in autoimmune blistering diseases (AIBDs) of the oral mucosa, can also be adopted as auxiliary diagnostic tools in oral lichen planus (OLP) and discoid lupus erythematosus (DLE). AIBDs, characterized by autoantibodies against structural proteins of keratinocytes or the basement membrane zone, clinically present as blisters and erosions of the oral mucosa. When atypical lesions occur, OLP or DLE may be confused with AIBDs. The improvement of diagnostic accuracy is necessary due to the significant differences in treatment and prognosis among these diseases. A variety of immunological methods are used for qualitative and quantitative detection of target antigens and autoantibodies. These methods can evaluate efficacy of treatment, monitor diseases and guide treatment decisions. In this review, we discuss the application of immunofluorescence, biochemical tests, and protein microarrays for AIBDs, OLP and DLE, as well as the differential diagnostic methods using immunological tests.
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Affiliation(s)
- S Sun
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Chinese Academy of Medical Sciences Research Unit of Oral Carcinogenesis and Management, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, 610041, China
| | - B Zhong
- Department of Otolaryngology, Head and Neck Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - W Li
- Department of Dermatovenereology, Rare Disease Center, West China Hospital, Sichuan University, Chengdu, China
| | - X Jin
- Chongqing Key Laboratory of Oral Diseases and Biomedical Sciences and College of Stomatology, Chongqing Medical University, Chongqing, China
| | - Y Yao
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Chinese Academy of Medical Sciences Research Unit of Oral Carcinogenesis and Management, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, 610041, China.,Department of Oral Medicine, Affiliated Hospital of Stomatology, Zunyi Medical University, Zunyi, China
| | - J Wang
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Chinese Academy of Medical Sciences Research Unit of Oral Carcinogenesis and Management, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, 610041, China
| | - J Liu
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Chinese Academy of Medical Sciences Research Unit of Oral Carcinogenesis and Management, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, 610041, China
| | - H Dan
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Chinese Academy of Medical Sciences Research Unit of Oral Carcinogenesis and Management, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, 610041, China
| | - Q Chen
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Chinese Academy of Medical Sciences Research Unit of Oral Carcinogenesis and Management, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, 610041, China
| | - X Zeng
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Chinese Academy of Medical Sciences Research Unit of Oral Carcinogenesis and Management, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, 610041, China
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18
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Palleria C, Bennardo L, Dastoli S, Iannone LF, Silvestri M, Manti A, Nisticò SP, Russo E, De Sarro G. Angiotensin-converting-enzyme inhibitors and angiotensin II receptor blockers induced pemphigus: A case series and literature review. Dermatol Ther 2018; 32:e12748. [PMID: 30238580 DOI: 10.1111/dth.12748] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 09/04/2018] [Accepted: 09/16/2018] [Indexed: 11/30/2022]
Abstract
Pemphigus is a group of autoimmune diseases characterized by the formation of erosions and/or flaccid bullae of the skin and/or mucosae. The definition "drug-induced pemphigus" has been coined to indicate cases of pemphigus with clinical, histological and immunopathologic features similar to those of the idiopathic disease but induced by systemic ingestion or local use of some drugs. The present authors analyzed a case series of three case reports with clinical and pharmacological features compatible with the diagnosis of angiotensin converting enzyme inhibitors or angiotensin II receptor blocker drug-induced pemphigus. The patients were visited by the dermatological Unit of Magna Graecia University in Catanzaro. All suspected drug induced pemphigus were treated by suspending the suspected drug and by starting a treatment with systemic corticosteroid drugs, leading to a remission of the clinical manifestations in some months. When a drug induced bullous disease is probable, it is necessary to interrupt the suspected substance and to start a high dose treatment with corticosteroid drugs to resolve the clinical case in a short period of time.
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Affiliation(s)
- Caterina Palleria
- Pharmacology Unit, Department of Science of Health, Magna Graecia University, Catanzaro, Italy
| | - Luigi Bennardo
- Dermatology Unit, Department of Science of Health, Magna Graecia University, Catanzaro, Italy
| | - Stefano Dastoli
- Dermatology Unit, Department of Science of Health, Magna Graecia University, Catanzaro, Italy
| | - Luigi F Iannone
- Pharmacology Unit, Department of Science of Health, Magna Graecia University, Catanzaro, Italy
| | - Martina Silvestri
- Dermatology Unit, Department of Science of Health, Magna Graecia University, Catanzaro, Italy
| | - Antonia Manti
- Pharmacology Unit, Department of Science of Health, Magna Graecia University, Catanzaro, Italy
| | - Steven P Nisticò
- Dermatology Unit, Department of Science of Health, Magna Graecia University, Catanzaro, Italy
| | - Emilio Russo
- Pharmacology Unit, Department of Science of Health, Magna Graecia University, Catanzaro, Italy
| | - Giovambattista De Sarro
- Pharmacology Unit, Department of Science of Health, Magna Graecia University, Catanzaro, Italy
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Chen WS, Tetzlaff MT, Diwan H, Jahan-Tigh R, Diab A, Nelson K, Glitza IC, Kaunitz GJ, Johnson D, Torres-Cabala C, Pacha O, Taube JM, Maloney K, Prieto VG, Curry JL. Suprabasal acantholytic dermatologic toxicities associated checkpoint inhibitor therapy: A spectrum of immune reactions from paraneoplastic pemphigus-like to Grover-like lesions. J Cutan Pathol 2018; 45:764-773. [PMID: 29943453 DOI: 10.1111/cup.13312] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Revised: 06/15/2018] [Accepted: 06/20/2018] [Indexed: 12/31/2022]
Abstract
Checkpoint inhibitors (CPIs) restore the function of effector immunocytes to target and destroy cancer cells. Immune-related adverse events (irAEs) are a consequence of immune reactivation, with unpredictable inflammatory response, loss of self-tolerance, and development of autoimmunity. Adverse events from CPIs that present as dermatologic toxicities have diverse clinical and histopathologic features. CPI-associated dermatologic toxicities may exhibit histopathologic features of lichenoid dermatitis, bullous pemphigoid, and granulomatous/sarcoid-like reactions. Suprabasal acantholytic dermatologic toxicities associated with CPIs are particularly rare but represent an emerging histopathologic pattern and include lichenoid dermatitis with suprabasal acantholysis/vesicle formation to Grover disease (transient acantholytic dermatosis). Here, we report two patients who developed suprabasal acantholytic dermatologic toxicities during CPI therapy. One patient exhibited a CPI-associated autoimmune blistering disease with paraneoplastic pemphigus (PNP)-like features restricted to histopathology and immunofluorescence, while the other patient had Grover-like lesions. A review of the literature revealed a spectrum of suprabasal acantholytic dermatologic toxicities associated CPIs that may present as lichenoid dermatitis with acantholysis/vesicle formation, Grover-like eruptions, and lesions with PNP-like features restricted to histopathology and immunofluorescence. It is important for clinicians and pathologists to recognize the types of dermatologic toxicities associated with CPIs to direct appropriate therapeutic strategies.
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Affiliation(s)
- Wei-Shen Chen
- Section of Dermatopathology, Department of Pathology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Michael T Tetzlaff
- Section of Dermatopathology, Department of Pathology, University of Texas MD Anderson Cancer Center, Houston, Texas
- Department of Translational Molecular Pathology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Hafeez Diwan
- Department of Pathology, Baylor College of Medicine, Houston, Texas
| | - Richard Jahan-Tigh
- Department of Dermatology, University of Texas Health Science, Houston, Texas
| | - Adi Diab
- Department of Melanoma Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Kelly Nelson
- Department of Dermatology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Isabella C Glitza
- Department of Melanoma Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Genevieve J Kaunitz
- Department of Dermatology, Johns Hopkins University School of Medicine and Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland
| | - Daniel Johnson
- Department of Melanoma Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Carlos Torres-Cabala
- Section of Dermatopathology, Department of Pathology, University of Texas MD Anderson Cancer Center, Houston, Texas
- Department of Dermatology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Omar Pacha
- Department of Dermatology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Janis M Taube
- Department of Dermatology, Johns Hopkins University School of Medicine and Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland
- Department of Pathology and Oncology, Johns Hopkins University School of Medicine and Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland
| | - Kudakwashe Maloney
- Department of Dermatology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Victor G Prieto
- Section of Dermatopathology, Department of Pathology, University of Texas MD Anderson Cancer Center, Houston, Texas
- Department of Dermatology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jonathan L Curry
- Section of Dermatopathology, Department of Pathology, University of Texas MD Anderson Cancer Center, Houston, Texas
- Department of Translational Molecular Pathology, University of Texas MD Anderson Cancer Center, Houston, Texas
- Department of Dermatology, University of Texas MD Anderson Cancer Center, Houston, Texas
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20
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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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21
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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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Ferguson L, Fearfield L. Paraneoplastic pemphigus foliaceus related to underlying breast cancer. Clin Exp Dermatol 2018; 43:817-818. [PMID: 29770472 DOI: 10.1111/ced.13602] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/01/2017] [Indexed: 11/29/2022]
Affiliation(s)
- L Ferguson
- Department of Dermatology, Chelsea and Westminster Hospital, 369 Fulham Road, London, SW10 9NH, UK
| | - L Fearfield
- Department of Dermatology, Chelsea and Westminster Hospital, 369 Fulham Road, London, SW10 9NH, UK
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McLarney RM, Valdes-Rodriguez RH, Isaza-Gonzalez G, Miller JH, Hsu S, Motaparthi K. Paraneoplastic pemphigus mimicking toxic epidermal necrolysis: An underdiagnosed entity? JAAD Case Rep 2017; 4:67-71. [PMID: 29387753 PMCID: PMC5771756 DOI: 10.1016/j.jdcr.2017.11.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- R Matthew McLarney
- Department of Dermatology, Temple University Lewis Katz School of Medicine, Philadelphia, Pennsylvania
| | | | - Gabriel Isaza-Gonzalez
- Department of Dermatology, Temple University Lewis Katz School of Medicine, Philadelphia, Pennsylvania
| | - Jason H Miller
- Department of Dermatology, Rutgers University Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Sylvia Hsu
- Department of Dermatology, Temple University Lewis Katz School of Medicine, Philadelphia, Pennsylvania
| | - Kiran Motaparthi
- Department of Dermatology, University of Florida College of Medicine, Gainesville, Florida
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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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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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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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Magliocca KR, Fitzpatrick SG. Autoimmune Disease Manifestations in the Oral Cavity. Surg Pathol Clin 2016; 10:57-88. [PMID: 28153136 DOI: 10.1016/j.path.2016.11.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Immune-related disorders of the oral cavity may occur as primary disease process, secondary to systemic disease or neoplasm, or as a reaction to medications and other agents. The entities represented within this group may vary significantly by severity, clinical presentation, microscopic presentation, and special testing results. The selected immune-related conditions of the oral cavity in this article are categorized and presented by their prototypical tissue reaction patterns: vesiculobullous, including acantholytic and subepithelial separation; psoriasiform; spongiotic; and lichenoid reaction patterns.
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Affiliation(s)
- Kelly R Magliocca
- Department of Pathology and Laboratory Medicine, Emory University, 500 Peachtree Street Northeast, Atlanta, GA 30308, USA.
| | - Sarah G Fitzpatrick
- Department of Oral and Maxillofacial Diagnostic Sciences, University of Florida, 1395 Center Drive, Gainesville, FL 32610, USA
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