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Akel M, Wright M, Aladum B, Hernandez Borges S. Beyond the Surface: A Clinical Insight Into a 60-Year-Old Male With Pemphigus vulgaris. Cureus 2024; 16:e54408. [PMID: 38505433 PMCID: PMC10948956 DOI: 10.7759/cureus.54408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2024] [Indexed: 03/21/2024] Open
Abstract
Pemphigus vulgaris, a rare and life-threatening autoimmune disorder, presents with painful skin and mucosal lesions, leading to blistering sores attributed to acantholysis. This study delves into the clinical manifestations, risk factors, and diagnostic intricacies associated with pemphigus vulgaris, with a focus on a representative case highlighting the challenges in its recognition and management. We explore the case of a 60-year-old male with pemphigus vulgaris, whose initial presentation involved yellow-crusting lesions on the scalp progressing to non-pruritic lesions on the chest, neck, and inguinal areas. A multidisciplinary medical workup was conducted, encompassing serological tests, imaging, and consultations with infectious disease and dermatology specialists. The definitive diagnosis was established through histopathological examination of three 4-mm punch biopsies. The case underscores the polymorphic nature of pemphigus vulgaris, with diverse clinical presentations and diagnostic challenges. The positive Nikolsky sign on the chest and neck lesions, coupled with oral mucosal involvement observed during a routine dental procedure, exemplifies the complexity of its manifestations. Diagnostic intricacies involved negative results for infectious diseases, declined kidney function, and elevated inflammatory markers, necessitating a collaborative approach for accurate diagnosis. Pemphigus vulgaris demands a comprehensive understanding of its varied presentations and collaboration among medical specialties for accurate diagnosis and tailored management. Treatment involves systemic glucocorticoids and immunomodulators. The presented case underscores the need for continued research to enhance diagnostic accuracy and refine therapeutic interventions for this rare autoimmune disorder.
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Affiliation(s)
- Miis Akel
- Medicine, Dr. Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Clearwater, USA
| | - Maggie Wright
- Dermatology, Dr. Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Miami, USA
| | - Bialo Aladum
- Psychiatry, Ascension Borgess Hospital, Kalamazoo, USA
| | - Sergio Hernandez Borges
- Internal Medicine, Family Medicine, Larkin Community Hospital Palm Springs Campus, Hialeah, USA
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Davarmanesh M, Zahed M, Sookhakian A, Jehbez S. Oral Pemphigus Vulgaris Treatment with Corticosteroids and Azathioprine: A Long-Term Study in Shiraz, Iran. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE : ECAM 2022; 2022:7583691. [PMID: 36164397 PMCID: PMC9509267 DOI: 10.1155/2022/7583691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 08/10/2022] [Accepted: 08/23/2022] [Indexed: 11/17/2022]
Abstract
Background Treating oral mucosal lesions of Pemphigus Vulgaris (PV) disease is usually challenging for clinicians. We studied the treatment outcomes of the oral PV patients referred to the Oral Medicine Department of Shiraz University of Medical Sciences from 2004 to 2018. Methods The medical records of 54 oral PV patients with histopathological confirmation who were treated by a single protocol were studied. The protocol consisted of initial treatment with 1 mg/kg/day of oral prednisolone for all patients. After 4-6 weeks, all patients were prescribed 40 mg of prednisolone. If lesion recovery was not observed or new lesions had developed, adjuvant therapy (maximum dose of 200 mg per day of Azathioprine (AZA)) was initiated anytime during the treatment. The oral prednisolone dosage was gradually tapered to 5 mg/alternate day in 9 months. Results 47 patients were included in the study. 34.04% were male and 65.96% were female with a mean age of 41.83 ± 12.520. The mean follow-up period was 50.806 ± 44.417 months (over 4 years). The severity of oral involvement was mild in 21.27%, moderate in 36.17%, and severe in 42.6%. During treatment, all patients except one experienced complete remission. The mean time to achieve complete remission was 150.39 ± 224.075 days. Most of the patients experienced relapse due to self-discontinuation of treatment. 55% had complete remission and 43% were in partial remission at the last follow-up session. In 65.96% of patients, treatment-associated side effects were observed. The patients treated with prednisolone alone had significantly more side effects than those using AZA as an adjuvant (80% vs 50%, respectively; P=0.030). The mean duration of follow-ups was longer for patients with side effects (P < 0.01). Topical corticosteroids were used for all patients sometime during the treatment. No deaths were recorded. Conclusion Prescribing low-dose prednisolone and adding AZA in nonresponding cases has good clinical outcomes for the treatment of oral lesions of PV. Adjuvant therapy can avoid the increase in corticosteroid dosage and side effects. The treatment method described in this study can be a helpful guide for clinicians, especially when other immunosuppressive drugs are not available.
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Affiliation(s)
- Mehdy Davarmanesh
- Department of Oral and Maxillofacial Medicine, School of Dentistry, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Maryam Zahed
- Oral and Dental Disease Research Center, Department of Oral and Maxillofacial Medicine, School of Dentistry, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Asma Sookhakian
- Student Research Committee, School of Dentistry, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Sina Jehbez
- Student Research Committee, School of Dentistry, Shiraz University of Medical Sciences, Shiraz, Iran
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Cai F, Dai P, Jiang J, Lee AY, Emerson J, Taylor MS, Kang M, Kwong K, Clark H, Wong S, Smith S, Fernandez M, Luu V, Timbol Z, Berglund LJ, Culican S, Campbell D, Smith A, Schifter M, Lin MW. Treatment and monitoring of an immunobullous disease cohort in a single centre in Sydney Australia. Australas J Dermatol 2021; 62:e437-e440. [PMID: 34250600 DOI: 10.1111/ajd.13659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Accepted: 05/30/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Fenfen Cai
- Department of Clinical Immunology and Immunopathology, Institute of Clinical Pathology and Medical Research, Westmead Hospital, Westmead, NSW, Australia
| | - Pei Dai
- Department of Clinical Immunology and Immunopathology, Institute of Clinical Pathology and Medical Research, Westmead Hospital, Westmead, NSW, Australia
| | - Jocelyn Jiang
- Department of Clinical Immunology and Immunopathology, Institute of Clinical Pathology and Medical Research, Westmead Hospital, Westmead, NSW, Australia.,Sydney Medical and Sydney Dental Schools of the Faculty of Medicine and Health, The University of Sydney, Camperdown, Sydney, NSW, Australia
| | - Adrian Ys Lee
- Department of Clinical Immunology and Immunopathology, Institute of Clinical Pathology and Medical Research, Westmead Hospital, Westmead, NSW, Australia.,Sydney Medical and Sydney Dental Schools of the Faculty of Medicine and Health, The University of Sydney, Camperdown, Sydney, NSW, Australia
| | - Jonathan Emerson
- Department of Clinical Immunology and Immunopathology, Institute of Clinical Pathology and Medical Research, Westmead Hospital, Westmead, NSW, Australia.,Sydney Medical and Sydney Dental Schools of the Faculty of Medicine and Health, The University of Sydney, Camperdown, Sydney, NSW, Australia
| | - Mark S Taylor
- Department of Clinical Immunology and Immunopathology, Institute of Clinical Pathology and Medical Research, Westmead Hospital, Westmead, NSW, Australia.,Sydney Medical and Sydney Dental Schools of the Faculty of Medicine and Health, The University of Sydney, Camperdown, Sydney, NSW, Australia
| | - Michelle Kang
- Department of Oral Medicine, Oral Pathology and Special Needs Dentistry, Westmead Hospital, Westmead, NSW, Australia
| | - Kenelm Kwong
- Department of Oral Medicine, Oral Pathology and Special Needs Dentistry, Westmead Hospital, Westmead, NSW, Australia
| | - Hadleigh Clark
- Department of Oral Medicine, Oral Pathology and Special Needs Dentistry, Westmead Hospital, Westmead, NSW, Australia
| | - Sue Wong
- Flow Cytometry Unit, Institute of Clinical Pathology and Medical Research, Westmead Hospital, Westmead, NSW, Australia
| | - Sandy Smith
- Flow Cytometry Unit, Institute of Clinical Pathology and Medical Research, Westmead Hospital, Westmead, NSW, Australia
| | - Marian Fernandez
- Flow Cytometry Unit, Institute of Clinical Pathology and Medical Research, Westmead Hospital, Westmead, NSW, Australia
| | - Vincent Luu
- Flow Cytometry Unit, Institute of Clinical Pathology and Medical Research, Westmead Hospital, Westmead, NSW, Australia
| | - Zarah Timbol
- Flow Cytometry Unit, Institute of Clinical Pathology and Medical Research, Westmead Hospital, Westmead, NSW, Australia
| | - Lucinda J Berglund
- Department of Clinical Immunology and Immunopathology, Institute of Clinical Pathology and Medical Research, Westmead Hospital, Westmead, NSW, Australia.,Sydney Medical and Sydney Dental Schools of the Faculty of Medicine and Health, The University of Sydney, Camperdown, Sydney, NSW, Australia.,Flow Cytometry Unit, Institute of Clinical Pathology and Medical Research, Westmead Hospital, Westmead, NSW, Australia
| | - Suzanne Culican
- Department of Clinical Immunology and Immunopathology, Institute of Clinical Pathology and Medical Research, Westmead Hospital, Westmead, NSW, Australia
| | - David Campbell
- Department of Clinical Immunology and Immunopathology, Institute of Clinical Pathology and Medical Research, Westmead Hospital, Westmead, NSW, Australia
| | - Annika Smith
- Department of Dermatology, Westmead Hospital, Westmead, NSW, Australia
| | - Mark Schifter
- Sydney Medical and Sydney Dental Schools of the Faculty of Medicine and Health, The University of Sydney, Camperdown, Sydney, NSW, Australia.,Department of Oral Medicine, Oral Pathology and Special Needs Dentistry, Westmead Hospital, Westmead, NSW, Australia
| | - Ming-Wei Lin
- Department of Clinical Immunology and Immunopathology, Institute of Clinical Pathology and Medical Research, Westmead Hospital, Westmead, NSW, Australia.,Sydney Medical and Sydney Dental Schools of the Faculty of Medicine and Health, The University of Sydney, Camperdown, Sydney, NSW, Australia.,Flow Cytometry Unit, Institute of Clinical Pathology and Medical Research, Westmead Hospital, Westmead, NSW, Australia
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Kumar S, De D, Handa S, Ratho RK, Bhandari S, Pal A, Kamboj P, Sarkar S. Identification of factors associated with treatment refractoriness of oral lesions in pemphigus vulgaris. Br J Dermatol 2017; 177:1583-1589. [PMID: 28498563 DOI: 10.1111/bjd.15658] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2017] [Indexed: 01/08/2023]
Abstract
BACKGROUND The oral mucosal lesions of patients with pemphigus vulgaris are known to show more treatment refractoriness than skin lesions. OBJECTIVES To identify which clinical and laboratory parameters may indicate treatment refractoriness of oral lesions in pemphigus vulgaris. METHODS This was a prospective study of 50 adults with pemphigus vulgaris and oral lesions; patients were given treatment appropriate for overall disease severity. Treatment refractoriness was defined arbitrarily as less than 75% reduction in oral objective Autoimmune Bullous Skin Disorder Intensity Score (ABSIS) after treatment for 6 months. RESULTS Of 46 patients who completed the study, 17 (37%) were treatment refractory whereas 29 (63%) were treatment responsive. At baseline, the treatment refractory group had a significantly longer mean duration of disease (P = 0·02) and mean duration of oral lesions (P = 0·01), a higher percentage of lesions in the retromolar trigone (P = 0·05) and on the occlusion line along the buccal mucosa (P = 0·04), a higher percentage of deep/crateriform ulcers (P < 0·001) and erosions with a lichenoid hue (P < 0·001). Herpes simplex virus (HSV) DNA positivity, assessed by polymerase chain reaction in oral tissue scrapings (P = 0·02), was also significantly higher in the treatment refractory group. No other factors we tested for were statistically significant. CONCLUSIONS Treatment refractoriness of oral lesions was significantly associated with duration of disease/oral lesions; specific morphology and location of oral lesions; and the presence of HSV DNA in the oral cavity. These factors may forewarn the treating physician about a refractory course of oral lesions that may help with counselling patients.
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Affiliation(s)
- S Kumar
- Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - D De
- Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - S Handa
- Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - R K Ratho
- Department of Virology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - S Bhandari
- Oral Health Sciences Center, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - A Pal
- Department of Biochemistry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - P Kamboj
- Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - S Sarkar
- Department of Virology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Abstract
INTRODUCTION Pemphigus vulgaris (PV) is a chronic, autoimmune, vesiculobullous disease. As a result of the relative rarity of PV, published randomized controlled trials (RCTs) are limited, which makes it difficult to evaluate the efficacy of different treatment regimens in this disease. This also precludes conduct of a meta-analysis. METHODS English-language publications describing treatment outcomes of patients with PV were identified by searches of electronic databases through May 2015, and additionally by review of the bibliography of these publications. A total of 89 papers, which included 21 case reports, 47 case series, 8 RCTs, and 13 observational studies, were identified. The findings from these publications, including information on disease course and prognosis, medications used, treatment responses, and side effects, are summarized in the tables and text of this review. RESULTS Prior to availability of corticosteroid therapy, PV had a high fatality rate. Early publications from the 1970s reported high-dose, prolonged corticosteroid use and significant associated side effects. Later reports described use of corticosteroids along with steroid-sparing adjuvants, which allows a reduction in the total dose of corticosteroids and a reduction in observed mortality and morbidity. For the majority of patients in these reports, a long-term course on medications lasting about 5-10 years was observed; however, subgroups of patients requiring shorter courses or needing longer-term therapy have also been described. Early diagnosis of PV and early initiation of treatment were prognostic factors. In recent publications, commonly used initial regimens include corticosteroids in combination with mycophenolate or azathioprine; whereas, for patients with inadequate response to these regimens, adjuvants such as intravenous immunoglobulin (IVIg) or rituximab are used. CONCLUSION The review findings emphasize the importance of early diagnosis, early initiation of treatment, and use of steroid-sparing adjuvants to allow a reduced total dose and duration on corticosteroids. Also highlighted is the need for more RCTs.
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