Bullous pemphigoid triggered by influenza vaccination? Ecological study in Galicia, Spain

A Patient Develops Bullous Rash After Receiving the Second Dose of COVID-19 Vaccine

Our knowledge about the clinical spectrum of COVID-19 has continued to evolve. The clinical features of the infection and vaccine are continuously updated. We present a case of bullous pemphigoid after receiving a second dose of the COVID-19 vaccine. This case highlights autoimmune skin findings seen in a patient after COVID-19 vaccination. A 70-year-old male presented with the chief complaint of blistering skin rash. He received his second dose of Pfizer COVID-19 vaccine two days before developing a painful pruritic maculopapular rash that started on his hands and extended proximally to his trunk. Physical exam was remarkable for tense bullae with negative Nikolsky sign. Biopsy and direct immunofluorescence lead to the diagnosis of bullous pemphigoid. The lesions improved significantly with steroids. Various cutaneous eruptions have been reported with Moderna and Pfizer COVID-19 vaccines, including the new onset of bullous pemphigoid. Based on our case, we suggest that bullous pemphigoid after COVID-19 vaccination is responsive to steroids and the prognosis is excellent. Understanding the clinical course and prognosis of bullous pemphigoid from the COVID-19 vaccine is of significant importance as we strive to keep our patients and communities safe. More data is needed to better guide recommendations, but so far looking at the example from our case, the benefits of COVID-19 vaccination seem to outweigh the risks. Therefore, patients should be advised to continue with future vaccinations.

Bullous Pemphigoid Associated With COVID-19 Vaccines: An Italian Multicentre Study

Bullous pemphigoid (BP) is an autoimmune bullous disease caused by circulating autoantibodies toward the hemidesmosomal antigens BP180 and BP230. Cases of BP have been described following vaccinations against tetanus, poliomyelitis, diphtheria, influenza, pneumococcus, meningococcus, hepatitis B and rabies. The putative mechanism by which COVID-19-vaccines may induce BP has not been clarified. An Italian multicentre study was conducted to collect clinical, histopathological and immunopathological data of patients with BP associated with COVID-19-vaccines. Twenty-one cases were collected, including 9 females and 12 males (M/F = 1.3) with a median age at diagnosis of 82 years. Seventeen patients received the COMIRNATY Pfizer-BioNTech vaccine, two the Moderna mRNA-1273 vaccine, one the ChAdOx1/nCoV-19-AstraZeneca/ Vaxzevria vaccine and one received the first dose with the ChAdOx1/nCoV-19-AstraZeneca/Vaxzevria vaccine and the second dose with the COMIRNATY Pfizer-BioNTech vaccine. Median latency time between the first dose of anti-SARS-CoV-2 vaccine and the onset of cutaneous manifestations was 27 days. Median BPDAI at onset was 42. Eleven out of seventeen patients (65%) had positive titres for anti-BP180 antibodies with a median value of 106.3 U/mL on ELISA; in contrast, only five out of seventeen (29%) were positive for anti-BP230 antibodies, with a median of 35.3 U/mL. In conclusion, in terms of mean age, disease severity at diagnosis and clinical phenotype vaccine-associated BP patients seem to be similar to idiopathic BP with an overall benign course with appropriate treatment. On the other hand, the slight male predominance and the reduced humoral response to BP230 represent peculiar features of this subset of patients.

Global Incidence and Prevalence of Bullous Pemphigoid: a Systematic Review and meta-analysis

BACKGROUND

Integrated information on the global prevalence and incidence of bullous pemphigoid (BP) is lacking.

OBJECTIVE

To estimate the incidence and prevalence of BP in a systematic review and meta-analysis.

METHODS

Observational studies were included by using databases of Medline, EMBASE and Cochrane Library. Subgroup analysis was by continent, age, sex and country income level. Random-effects model was used. Between-study heterogeneity was assessed using the I² statistic.

RESULTS

The global incidence was 0.0419 per 1000 person-years (95% CI: 0.0414-0.0424). The incidence was 0.047 per 1000 person-years (95% CI: 0.0462-0.0477), 0.0419 per 1000 person-years (95% CI: 0.0411-0.0426), 0.0072 per 1000 person-years (95% CI: 0.0067-0.0078), 0.003 per 1000 person-years (95% CI: 0.0023-0.0039) in North America, Europe, Asia and Africa, respectively; 0.0202 per 1000 person-years (95% CI: 0.0196; 0.0208) and 0.0181 per 1000 person-years (95% CI: 0.0175; 0.0188) females and males; 0.001 per 1000 person-years (95% CI: 0.001-0.001), 0.002 per 1000 person-years (95% CI:0.001-0.002), 0.004 per 1000 person-years (95% CI: 0.004-0.004); 0.007 per 1000 person-years (95% CI: 0.007-0.008), 0.011 per 1000 person-years (95% CI: 0.011-0.012), 0.017 per 1000 person-years (95% CI: 0.015-0.018) for age < 50, 50-59, 60-69, 70-79, 80-89 and ≥90 years. 0.0038 per 1000 person-years (95% CI:0.0036-0.004112) (I2 = 99%, p<.05) and 0.0456 per 1000 person-years (95% CI:0.0450-0.0462) (I2 = 100%, p<.05). The pooled clinic-based prevalence was 0.79 % (95% CI: 0.75%-0.84%), and 1.13% (95% CI: 1.06%-1.21%), 0.21% (95% CI: 0.17%-0.26%), 0.13% (95% CI:0.1%-0.15%) for Asia, Africa and Europe.

CONCLUSIONS

This study identified the global incidence and prevalence of BP in terms of spatial and population distributions and among various income level. A relatively higher incidence was in Europe, females, older people and high-income level country. The prevalence was higher in Asia. These findings should be interpreted with caution due to high heterogeneity of included studies.

Bullous Pemphigoid: Trigger and Predisposing Factors

Bullous pemphigoid (BP) is the most frequent autoimmune subepidermal blistering disease provoked by autoantibodies directed against two hemidesmosomal proteins: BP180 and BP230. Its pathogenesis depends on the interaction between predisposing factors, such as human leukocyte antigen (HLA) genes, comorbidities, aging, and trigger factors. Several trigger factors, such as drugs, thermal or electrical burns, surgical procedures, trauma, ultraviolet irradiation, radiotherapy, chemical preparations, transplants, and infections may induce or exacerbate BP disease. Identification of predisposing and trigger factors can increase the understanding of BP pathogenesis. Furthermore, an accurate anamnesis focused on the recognition of a possible trigger factor can improve prognosis by promptly removing it.

Role of physical factors in the pathogenesis of bullous pemphigoid: Case report series and a comprehensive review of the published work

Bullous pemphigoid (BP) is an autoimmune subepidermal blistering disease affecting mainly the elderly. The subtype of the disease induced by physical agents represents a rare and, therefore, insufficiently characterized form. In the present study, we aimed to contribute to a better understanding of the pathogenetic mechanisms involved in the onset of BP induced by different trigger factors. We have retrospectively analyzed nine cases of BP. All patients were characterized based on clinical, epidemiological and immunological parameters. For each case, the trigger factor involved was specified. In addition to our retrospective analysis, a comprehensive review of the 59 published cases was conducted, regarding the involvement of trigger factor in BP, and clinical, epidemiological and immunological data were collected. In the local study, conducted on nine patients diagnosed with BP, various trigger factors were identified: contrast substance injection, surgical procedure, mechanical trauma, insect bite, thermal burn, radiotherapy and ultraviolet exposure associated with pre-existing psoriasis. The autoantibodies from all patients were shown to activate granulocytes and induce dermal-epidermal split. Different hypotheses regarding the pathogenetic mechanism involving the trigger factors have been discussed. In regard of the pathogenetic mechanism, we believe that the most reliable hypothesis is that BP patients already have low titers of anti-basement membrane autoantibodies which activate the granulocytes. However, more studies are needed for a better understanding of the pathogenetic mechanism of the intervention of trigger factors.

Postvaccinal, corticosteroid-resistant bullous pemphigoid in infancy: treatment with intravenous immunoglobulin

Bullous pemphigoid is an autoimmune subepidermal blistering disorder that typically affects elderly adults but can also occur in childhood. We report on a 3-month-old boy who developed bullous pemphigoid 1 week after the second routine administration of a hexavalent vaccine. The disease was resistant to standard therapies (including oral and topical corticosteroids) but was relieved by intravenous immunoglobulin treatment. There was no recurrence of bullous pemphigoid after the next vaccination (3 mos after discontinuation of steroids).

Drug-induced pemphigoid: a review of the literature

Bullous pemphigoid is an acquired autoimmune disease that is characterized by subepidermal blistering and affects mainly the elderly. The pathogenesis of the condition has not yet been fully elucidated, but it is widely accepted that a strong correlation with various medications may exist. In reality, more than 50 different drugs have been associated with the appearance of bullous pemphigoid and as new therapies emerge, this number is very likely to increase. A number of pathogenetic mechanisms have been proposed in the past. It is true that a delicate immunological balance is disturbed in all patients with the disease. The variable effects that may be exhibited by the use of biological drugs could shed some light in this complex immunological behaviour. At the same time, drug-induced bullous pemphigoid is difficult to differentially diagnose from its idiopathic counterpart, as the clinical picture and histopathological findings in both conditions may only have subtle differences. Patients who present with bullous pemphigoid and receive multiple regimens should always be suspected of suffering from the drug-induced variant of the condition. This possibility must be considered, as after the withdrawal of the suspect medication most patients respond rapidly to treatment and do not experience relapses.

Bullous pemphigoid: etiology, pathogenesis, and inducing factors: facts and controversies

The term pemphigoids includes a group of autoimmune bullous diseases characterized by subepidermal blistering. Bullous pemphigoid (BP) is not only the most common disorder within the pemphigoid group, but also represents the most frequent autoimmune blistering disease in general. The onset and course of BP depend on a variable interaction between predisposing and inducing factors. HLA genes are the most significant genetic predisposition factor to autoimmunity mechanisms. Many studies show an association between HLA-DQβ1*0301 and distinct clinical pemphigoid variants. Imbalance between autoreactive T helper (Th) and T regulatory cells, toll-like receptor activation, and Th17/IL-17 pathway are the three possible autoimmunity triggers underlying BP. The pathomechanism of BP hinges on an autoantibody response toward structural components of the hemidesmosome (BP180 and BP230). The binding of autoantibodies leads to complement activation, recruitment of inflammatory cells, and release of proteolytic enzymes. The inflammatory cascade also may be directly triggered by activation of Th17 cells with no intervention of autoantibodies. The intervention of inducing factors in BP can be identified in no more than 15% of patients. Facilitating factors in genetically predisposed individuals are various (drug intake, physical agents, and viral infections). Drugs may act as triggers by either modifying the immune response or altering the antigenic properties of the epidermal basement membrane. Cases of induction of BP by physical agents (eg, radiation therapy, ultraviolet radiation, thermal or electrical burns, surgical procedures, transplants) are rare, but well-documented events. A contributing role in inducing BP has been suggested for infections, in particular human herpes virus (HHV) infections (cytomegalovirus, Epstein-Barr virus, and HHV-6), but also hepatitis B and C viruses, Helicobacter pylori, and Toxoplasma gondii. Unlike pemphigus, no dietary triggers have been suspected of being involved in the induction of BP. In all patients who have a diagnosis of BP, an environmental agent as a potential cause should always be considered, because the prompt discontinuation of it might result in rapid improvement or even cure of the disease.

Bullous pemphigoid and percutaneous endoscopic gastrostomy

BACKGROUND

Bullous pemphigoid (BP) is an autoimmune subepidermal blistering disorder. It is rare in the general population but the prevalence was reported to be relatively high among the elderly in nursing homes. The aim of the study was to analyze the clinical characteristics and risk factor for BP in elderly patients with a long hospital stay.

METHODS

This was a retrospective survey with 36 hospitalized patients, aged 64 to 101 years, staying more than 2 years from July 2005 to April 2009. We encountered 5 newly occurring BP cases during this survey period and the remaining 31 patients were non-BP cases. All of these subjects were disabled elderly patients because of cerebral stroke, etc. We assessed the clinical variables as follows: age, sex, underling disease of hospitalization, length of hospital stay, feeding method, medication, tracheal tube indwelling and frequency of death and compared these 2 groups.

RESULTS

All of the patients underwent enteral feeding by percutaneous endoscopic gastrostomy (PEG) or nasogastric (NG) tube. In the univariate analysis, PEG and tube feeding (PEG and NG) were associated with BP (p<0.05). The multivariate logistic and Cox proportional hazard regression analysis were performed with age, sex (elderly female is well known feature of BP) and PEG or tube feeding, demonstrating only PEG was significantly and independently associated with BP (p<0.05).

CONCLUSION

We found that PEG was significant risk factor for BP. Since the sample size was small in this survey, further study is required. Greater awareness of BP is needed for physicians managing institutionalized elderly patients with PEG.

Bullous pemphigoid and pemphigus vulgaris--incidence and mortality in the UK: population based cohort study

OBJECTIVE

To determine the incidence of and mortality from bullous pemphigoid and pemphigus vulgaris in the United Kingdom.

DESIGN

Retrospective historical cohort study.

SETTING

Computerised medical records from the health improvement network, a large population based UK general practice database.

PARTICIPANTS

Patients with pemphigus vulgaris and bullous pemphigoid diagnostic codes and age, sex, and practice matched controls.

MAIN OUTCOME MEASURES

Incidence and mortality compared with the control population by calendar period, age group, sex, geographical region, and degree of social deprivation.

RESULTS

869 people with bullous pemphigoid and 138 people with pemphigus vulgaris were identified. The median age at presentation for bullous pemphigoid was 80 (range 23-102) years, and 534 (61%) patients were female. The median age at presentation for pemphigus vulgaris was 71 (21-102) years, and 91 (66%) patients were female. Incidences of bullous pemphigoid and pemphigus vulgaris were 4.3 (95% confidence interval 4.0 to 4.6) and 0.7 (0.6 to 0.8) per 100 000 person years. The incidence of bullous pemphigoid increased over time; the average yearly increase was 17% (incidence rate ratio=1.2, 95% confidence interval 1.1 to 1.2). An average yearly increase in incidence of pemphigus vulgaris of 11% (incidence rate ratio=1.1, 1.0 to 1.2) occurred. The risk of death for patients with bullous pemphigoid was twice as great as for controls (adjusted hazard ratio=2.3, 95% confidence interval 2.0 to 2.7). For pemphigus vulgaris, the risk of death was three times greater than for controls (adjusted hazard ratio=3.3, 2.2 to 5.2).

CONCLUSIONS

Incidences of bullous pemphigoid and pemphigus vulgaris are increasing. The reasons for the changes in incidence are not clearly understood but have implications for identifying causative factors. Both disorders are associated with a high risk of death. Previous estimates may have underestimated the risk of death associated with these diseases.