Paraneoplastic pemphigus mimicking erosive mucosal lichen planus associated with primary hepatocellular carcinoma

S2k guidelines on the management of paraneoplastic pemphigus/paraneoplastic autoimmune multiorgan syndrome initiated by the European Academy of Dermatology and Venereology (EADV)

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.

An integrative analysis of enhancer of yellow 2 homolog (ENY2) as a molecular biomarker in pan-cancer

ENY2 (Enhancer of yellow 2 transcription factor) is a transcription nuclear protein and primarily participates in the course of mRNA export and histone deubiquitination to influence gene expression. Current studies have shown that the expression of ENY2 is significantly upregulated in multiple cancers. However, the exact association between ENY2 and pan-cancers has not been fully established. Here, we comprehensively analyzed ENY2 from the online public database and The Cancer Genome Atlas (TCGA) database, including gene expression level in pan-cancer, comparison of ENY2 expression in different molecular and immune subtypes of pan-cancer, targeted protein, biological functions, molecular signatures, diagnostic and prognostic value in pan-cancer. Moreover, we focused on head and neck squamous cell carcinoma (HNSC) and explored ENY2 from the perspective of the correlations with clinical characteristics, prognosis, co-expression genes, differentially expressed genes (DEGs) and immune Infiltration. Our findings showed that the expression of ENY2 differed enormously not only in most cancer types but also in different molecular and immune subtypes of cancers. High accuracy in predicting cancers and notable correlations with prognosis of certain cancers suggested that ENY2 might be a potential diagnostic and prognostic biomarker of cancers. In addition, ENY2 was identified to be significantly correlated with clinical stage, gender, histologic grade and lymphovascular invasion in HNSC. Overexpression of ENY2 could lead to a worse overall survival (OS), disease-specific survival (DSS), and progression-free interval (PFI) in HNSC, especially in different clinical subgroups of HNSC. Taken together, ENY2 showed strong correlation with the diagnosis and prognosis of pan-cancer, and was an independent prognostic risk factor of HNSC, which may serve as a potential target for cancer management.

Severe digital ischemia coexists with thrombocytopenia in malignancy-associated antiphospholipid syndrome: A case report and review of literature

BACKGROUND

Paraneoplastic syndromes are characterized by atypical clinical manifestations. Several reports of hepatocellular carcinoma (HCC) paraneoplastic phenomena have been reported. They usually manifest as one type in an individual, but it is not common for the two clinical manifestations to occur simultaneously.

CASE SUMMARY

A 52-year-old female patient was admitted to hospital with pale skin and numbness of the second to fifth fingers in the left hand, which rapidly developed into severe digital ischemia. Computed tomography angiography revealed uneven thickness of the left ulnar artery with severe local luminal stenosis. Blood analysis during hospitalization showed persistent mild to medium thrombocytopenia and insensitive to hormonal therapy. Antiphospholipid antibody testing showed high titer of IgG anticardiolipin antibodies (aCLs), IgA aCLs, IgG anti-β2-glycoprotein-I (anti-β2 GPI), and IgA anti-β2 GPI. The exact diagnosis was HCC when the high a-fetoprotein levels, computed tomography findings, and the history of chronic hepatitis B came together. This was a rare case of coexisting manifestations as presenting symptoms of malignancy-associated antiphospholipid syndrome. The patient underwent several operations, antithrombotic treatments and hormonal therapy. However, the patient refused chemotherapy and died 8 wk after diagnosis.

CONCLUSION

This report highlights the importance of atypical clinical changes that could alert the physicians to vigilance for a concomitant underlying malignancy.

Paraneoplastic Pemphigus: Insight into the Autoimmune Pathogenesis, Clinical Features and Therapy

Paraneoplastic pemphigus is a rare autoimmune skin disease that is always associated with a neoplasm. Usually, oral, skin, and mucosal lesions are the earliest manifestations shown by paraneoplastic pemphigus patients. The pathogenesis of paraneoplastic pemphigus is not yet completely understood, although some immunological aspects have been recently clarified. Because of its rarity, several diagnostic criteria have been proposed. Besides, several diagnostic procedures have been used for the diagnosis, including indirect immunofluorescence, direct immunofluorescence, and ELISA. We reviewed the most recent literature, searching on PubMed "paraneoplastic pemphigus". We included also papers in French, German, and Spanish. We found 613 papers for "paraneoplastic pemphigus". Among them, 169 were review papers. Because of its varying clinical features, paraneoplastic pemphigus still represents a challenge for clinicians. Furthermore, diagnosis and management of paraneoplastic pemphigus requires close collaboration between physicians, including dermatologist, oncologist, and otorhinolaryngologist.

Paraneoplastic Pemphigus and Autoimmune Blistering Diseases Associated with Neoplasm: Characteristics, Diagnosis, Associated Neoplasms, Proposed Pathogenesis, Treatment

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.

A potential peptide pathway from viruses to oral lichen planus

Oral lichen planus is an idiopathic inflammatory disease of oral mucous membranes, characterized by an autoimmune epidermis attack by T cells. It remains unknown, however, how such aggressive T cells are activated in vivo to cause epidermal damage. This study analyzes the relationship at the peptide level between viruses and oral lichen planus disease. Four potentially immunogenic peptides (SSSSSSS, QEQLEKA, LLLLLLA, and MLSGNAG) are found to be shared between HCV, EBV, HHV-7, HSV-1, and CMV and three human proteins (namely pinin, desmoglein-3, and plectin). The described peptide sharing might be of help in deciphering the still unexplained immunopathogenic pathway that leads to oral lichen planus.

Cutaneous manifestations of systemic malignancies: part 2

The skin can be key to early diagnosis of systemic malignancies. In the second part of this review, we present various skin conditions that can, in certain contexts, reveal the presence of malignancy. The skin conditions are presented in groups based on a diverse range of morphological characteristics. Specifically, the following groups are analyzed: erosive and blistering lesions; inflammatory papules and nodules; xerosis, ichthyosis, and generalized exfoliative dermatitis; symptoms such as pruritus; abnormal hair distribution patterns; sweating disorders; benign tumors that can form part of hereditary syndromes associated with a risk of visceral cancer; and finally, oral and nail abnormalities. This review highlights the importance of the skin in the study of systemic malignancies.

Paraneoplastic pemphigus presenting with a single oral lesion

Paraneoplastic pemphigus (PNP) is recognised in most cases after diagnosis of malignant and benign haematological tumours. PNP usually presents with severe and diffuse oral ulcerations, ocular lesions, lichen planus-like skin lesions and frequently genital ulcerations. We describe the uncommon case of a patient unaware of any neoplasia with a unique ulcerated oral lesion with histological (acantholysis of the basal epithelial layer, necrotic keratinocytes and pronounced regenerative hyperplasia) and immunofluorescent (direct immunofluorescence test exhibited immunoglobulin IgG, fibrinogen and C3 deposition in intercellular areas and along the basement membrane; indirect immunofluorescence test performed on rat bladder showed bright fluorescence) features suggestive of PNP. Diagnosis of PNP was strengthened by the subsequent discovery of monoclonal gammopathy. The reported case is quite unusual if we consider the clinical appearance of the oral lesions and the patient's negative medical history. Following serological examinations, the patient proved to have monoclonal gammopathy of undetermined significance (MGUS), one of the most common premalignant plasma cell disorders.

Paraneoplastic pemphigus presenting with a single oral lesion

Paraneoplastic pemphigus (PNP) is recognised in most cases after diagnosis of malignant and benign haematological tumours. PNP usually presents with severe and diffuse oral ulcerations, ocular lesions, lichen planus-like skin lesions and frequently genital ulcerations. We describe the uncommon case of a patient unaware of any neoplasia with a unique ulcerated oral lesion with histological (acantholysis of the basal epithelial layer, necrotic keratinocytes and pronounced regenerative hyperplasia) and immunofluorescent (direct immunofluorescence test exhibited immunoglobulin IgG, fibrinogen and C3 deposition in intercellular areas and along the basement membrane; indirect immunofluorescence test performed on rat bladder showed bright fluorescence) features suggestive of PNP. Diagnosis of PNP was strengthened by the subsequent discovery of monoclonal gammopathy. The reported case is quite unusual if we consider the clinical appearance of the oral lesions and the patient's negative medical history. Following serological examinations, the patient proved to have monoclonal gammopathy of undetermined significance (MGUS), one of the most common premalignant plasma cell disorders.

Autoimmune bullous diseases associations

The presence of one autoimmune disorder helps lead to the discovery of other autoimmune conditions. It is thought that diseases in which autoimmunity is a feature tend to be associated together more often than one can ascribe to chance. A variety of diseases have been implicated in the onset of intraepidermal and subepidermal autoimmune diseases. The presence of one autoimmune disease should alert the physician to watch for a second immunologic disorder. A list of autoimmune bullous diseases associations includes autoimmune bullous diseases, pemphigus, pemphigoid, epidermolysis bullosa acquisita, dermatitis herpetiformis (Duhring), linear immunoglobulin A disease, and multiple autoimmune syndrome.

Oral manifestations of internal malignancy and paraneoplastic syndromes

Malignant tumors of visceral organs are a fundamental feature of familial cancer and paraneoplastic syndromes. In many instances, the presence of an internal and often occult malignancy may be forewarned by various external manifestations. Several of these findings are preferentially localized to the head and neck region, including the oral cavity proper. This places the dental practitioner in a unique position to detect these "markers" of occult neoplastic involvement. Because these markers may present before an established syndrome or cancer diagnosis, even representing the first expression of disease in some cases, early recognition by a dentist may lead to timely diagnosis and management of these cancer-associated syndromes.