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Biondo MI, Fiorentino C, Persechino S, Tammaro A, Koverech A, Bartolazzi A, Raffa S, Canzoni M, Picchianti-Diamanti A, Di Rosa R, Di Zenzo G, Scala E, Meneguzzi G, Ferlito C, Markovic M, Caporuscio S, Sorgi ML, Salemi S, Laganà B. May Bacterial Infections Trigger Bullous Pemphigoid? Case Report and Review of Literature. Microorganisms 2021; 9:microorganisms9061235. [PMID: 34200214 PMCID: PMC8229970 DOI: 10.3390/microorganisms9061235] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 05/29/2021] [Accepted: 06/04/2021] [Indexed: 01/31/2023] Open
Abstract
Bullous pemphigoid (BP) is an autoimmune blistering skin disease, mainly observed in the elderly. Infections have been suggested as possible disease triggers. However, infections may even heavily influence the disease clinical course and mortality. A 75-year-old woman was admitted to hospital for severe erythematosus blistering disease, accompanied by hyper-eosinophilia and hyper-IgE. The culture of bullous fluid was positive for Enterococcus faecalis, the blood culture was positive for Staphylococcus aureus, and the urine culture was positive for Proteus mirabilis and Escherichia coli. Moreover, circulating anti-BP180 IgG was present and the histopathological/ultrastructural examination of a lesional skin biopsy was compatible with BP. High eosinophil levels (up to 3170/µL) were found throughout the clinical course, while values below 1000/µL were associated with clinical improvement. The total IgE was 1273 IU/mL, and specific anti-G/V-penicillin/ampicillin IgE antibodies were positive. The patient had a complete clinical recovery in two months with methyl-prednisolone (40 then 20 mg/day) and low-dose azathioprine (50 mg/day) as a steroid-sparing agent. The steroid treatment was tapered until interruption during a one-year period and intravenous immunoglobulins have been administered for three years in order for azathioprine to also be interrupted. The patient stopped any treatment five years ago and, in this period, has always been in good health. In this case, the contemporaneous onset of different bacterial infections and BP is suggestive of bacterial infections acting as BP trigger(s), with allergic and autoimmune pathways contributing to the disease pathogenesis.
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Affiliation(s)
- Michela Ileen Biondo
- Dipartimento di Medicina Clinica e Molecolare, Sapienza, Università di Roma, AOU S. Andrea, 00189 Roma, Italy; (M.I.B.); (C.F.); (A.K.); (A.B.); (S.R.); (M.C.); (A.P.-D.); (R.D.R.); (G.M.); (C.F.); (M.M.); (S.C.); (M.L.S.)
| | - Chiara Fiorentino
- Dipartimento di Medicina Clinica e Molecolare, Sapienza, Università di Roma, AOU S. Andrea, 00189 Roma, Italy; (M.I.B.); (C.F.); (A.K.); (A.B.); (S.R.); (M.C.); (A.P.-D.); (R.D.R.); (G.M.); (C.F.); (M.M.); (S.C.); (M.L.S.)
| | - Severino Persechino
- UOD di Dermatologia, Sapienza, Università di Roma, AOU S. Andrea, 00189 Roma, Italy; (S.P.); (A.T.)
| | - Antonella Tammaro
- UOD di Dermatologia, Sapienza, Università di Roma, AOU S. Andrea, 00189 Roma, Italy; (S.P.); (A.T.)
| | - Angela Koverech
- Dipartimento di Medicina Clinica e Molecolare, Sapienza, Università di Roma, AOU S. Andrea, 00189 Roma, Italy; (M.I.B.); (C.F.); (A.K.); (A.B.); (S.R.); (M.C.); (A.P.-D.); (R.D.R.); (G.M.); (C.F.); (M.M.); (S.C.); (M.L.S.)
| | - Armando Bartolazzi
- Dipartimento di Medicina Clinica e Molecolare, Sapienza, Università di Roma, AOU S. Andrea, 00189 Roma, Italy; (M.I.B.); (C.F.); (A.K.); (A.B.); (S.R.); (M.C.); (A.P.-D.); (R.D.R.); (G.M.); (C.F.); (M.M.); (S.C.); (M.L.S.)
| | - Salvatore Raffa
- Dipartimento di Medicina Clinica e Molecolare, Sapienza, Università di Roma, AOU S. Andrea, 00189 Roma, Italy; (M.I.B.); (C.F.); (A.K.); (A.B.); (S.R.); (M.C.); (A.P.-D.); (R.D.R.); (G.M.); (C.F.); (M.M.); (S.C.); (M.L.S.)
| | - Marco Canzoni
- Dipartimento di Medicina Clinica e Molecolare, Sapienza, Università di Roma, AOU S. Andrea, 00189 Roma, Italy; (M.I.B.); (C.F.); (A.K.); (A.B.); (S.R.); (M.C.); (A.P.-D.); (R.D.R.); (G.M.); (C.F.); (M.M.); (S.C.); (M.L.S.)
| | - Andrea Picchianti-Diamanti
- Dipartimento di Medicina Clinica e Molecolare, Sapienza, Università di Roma, AOU S. Andrea, 00189 Roma, Italy; (M.I.B.); (C.F.); (A.K.); (A.B.); (S.R.); (M.C.); (A.P.-D.); (R.D.R.); (G.M.); (C.F.); (M.M.); (S.C.); (M.L.S.)
| | - Roberta Di Rosa
- Dipartimento di Medicina Clinica e Molecolare, Sapienza, Università di Roma, AOU S. Andrea, 00189 Roma, Italy; (M.I.B.); (C.F.); (A.K.); (A.B.); (S.R.); (M.C.); (A.P.-D.); (R.D.R.); (G.M.); (C.F.); (M.M.); (S.C.); (M.L.S.)
| | - Giovanni Di Zenzo
- Istituto Dermopatico dell’Immacolata, 00167 Roma, Italy; (G.D.Z.); (E.S.)
| | - Enrico Scala
- Istituto Dermopatico dell’Immacolata, 00167 Roma, Italy; (G.D.Z.); (E.S.)
| | - Giorgia Meneguzzi
- Dipartimento di Medicina Clinica e Molecolare, Sapienza, Università di Roma, AOU S. Andrea, 00189 Roma, Italy; (M.I.B.); (C.F.); (A.K.); (A.B.); (S.R.); (M.C.); (A.P.-D.); (R.D.R.); (G.M.); (C.F.); (M.M.); (S.C.); (M.L.S.)
| | - Claudia Ferlito
- Dipartimento di Medicina Clinica e Molecolare, Sapienza, Università di Roma, AOU S. Andrea, 00189 Roma, Italy; (M.I.B.); (C.F.); (A.K.); (A.B.); (S.R.); (M.C.); (A.P.-D.); (R.D.R.); (G.M.); (C.F.); (M.M.); (S.C.); (M.L.S.)
| | - Milica Markovic
- Dipartimento di Medicina Clinica e Molecolare, Sapienza, Università di Roma, AOU S. Andrea, 00189 Roma, Italy; (M.I.B.); (C.F.); (A.K.); (A.B.); (S.R.); (M.C.); (A.P.-D.); (R.D.R.); (G.M.); (C.F.); (M.M.); (S.C.); (M.L.S.)
| | - Sara Caporuscio
- Dipartimento di Medicina Clinica e Molecolare, Sapienza, Università di Roma, AOU S. Andrea, 00189 Roma, Italy; (M.I.B.); (C.F.); (A.K.); (A.B.); (S.R.); (M.C.); (A.P.-D.); (R.D.R.); (G.M.); (C.F.); (M.M.); (S.C.); (M.L.S.)
| | - Maria Laura Sorgi
- Dipartimento di Medicina Clinica e Molecolare, Sapienza, Università di Roma, AOU S. Andrea, 00189 Roma, Italy; (M.I.B.); (C.F.); (A.K.); (A.B.); (S.R.); (M.C.); (A.P.-D.); (R.D.R.); (G.M.); (C.F.); (M.M.); (S.C.); (M.L.S.)
| | - Simonetta Salemi
- Dipartimento di Medicina Clinica e Molecolare, Sapienza, Università di Roma, AOU S. Andrea, 00189 Roma, Italy; (M.I.B.); (C.F.); (A.K.); (A.B.); (S.R.); (M.C.); (A.P.-D.); (R.D.R.); (G.M.); (C.F.); (M.M.); (S.C.); (M.L.S.)
- Correspondence: (S.S.); (B.L.)
| | - Bruno Laganà
- Dipartimento di Medicina Clinica e Molecolare, Sapienza, Università di Roma, AOU S. Andrea, 00189 Roma, Italy; (M.I.B.); (C.F.); (A.K.); (A.B.); (S.R.); (M.C.); (A.P.-D.); (R.D.R.); (G.M.); (C.F.); (M.M.); (S.C.); (M.L.S.)
- Correspondence: (S.S.); (B.L.)
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Rania M, Petersen LV, Benros ME, Liu Z, Diaz L, Bulik CM. Psychiatric comorbidity in individuals with bullous pemphigoid and all bullous disorders in the Danish national registers. BMC Psychiatry 2020; 20:411. [PMID: 32819315 PMCID: PMC7439544 DOI: 10.1186/s12888-020-02810-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 08/05/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Bullous pemphigoid (BP) is an autoimmune blistering skin disease that takes a profound physical and mental toll on those affected. The aim of the study was to investigate the bidirectional association between BP and all bullous disorders (ABD) with a broad array of psychiatric disorders, exploring the influence of prescribed medications. METHODS This nationwide, register-based cohort study encompassed 6,470,450 individuals born in Denmark and alive from 1994 to 2016. The hazard ratios (HRs) of a subsequent psychiatric disorder in patients with BP/ABD and the reverse exposure and outcome were evaluated. RESULTS Several psychiatric disorders were associated with increased risk of subsequent BP (4.18-fold for intellectual disorders, 2.32-fold for substance use disorders, 2.01-fold for schizophrenia and personality disorders, 1.92-1.85-1.49-fold increased risk for organic disorders, neurotic and mood disorders), independent of psychiatric medications. The association between BP and subsequent psychiatric disorders was not significant after adjusting for BP medications, except for organic disorders (HR 1.27, CI 1.04-1.54). Similar results emerged with ABD. CONCLUSION Psychiatric disorders increase the risk of a subsequent diagnosis of BP/ABD independent of medications, whereas medications used for the treatment of BP/ABD appear to account for the subsequent onset of psychiatric disorders. Clinically, an integrated approach attending to both dermatological and psychiatric symptoms is recommended, and dermatologists should remain vigilant for early symptoms of psychiatric disorders to decrease mental health comorbidity.
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Affiliation(s)
- Marianna Rania
- grid.411489.10000 0001 2168 2547Department of Health Sciences, University Magna Graecia of Catanzaro, Catanzaro, Italy ,Center for Clinical Research and Treatment of Eating Disorders, Mater Domini University Hospital, Catanzaro, Italy ,grid.4714.60000 0004 1937 0626Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Liselotte Vogdrup Petersen
- grid.7048.b0000 0001 1956 2722National Centre for Register-based Research, Aarhus BSS, Aarhus University, Aarhus, Denmark ,grid.7048.b0000 0001 1956 2722Centre for Integrated Register-based Research (CIRRAU), Aarhus University, Aarhus, Denmark
| | - Michael Erikson Benros
- grid.4973.90000 0004 0646 7373Copenhagen Research Centre for Mental Health, Mental Health Centre Copenhagen, Copenhagen University Hospital, Copenhagen, Denmark
| | - Zhi Liu
- grid.10698.360000000122483208Departments of Dermatology, Microbiology and Immunology, University of North Carolina at Chapel Hill, Chapel Hill, NC USA
| | - Luis Diaz
- grid.10698.360000000122483208Departments of Dermatology, Microbiology and Immunology, University of North Carolina at Chapel Hill, Chapel Hill, NC USA
| | - Cynthia M. Bulik
- grid.4714.60000 0004 1937 0626Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden ,grid.10698.360000000122483208Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC USA ,grid.10698.360000000122483208Department of Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, NC USA
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Abstract
Bullous pemphigoid is the most frequent autoimmune bullous disease and mainly affects elderly individuals. Increase in incidence rates in the past decades has been attributed to population aging, drug-induced cases and improvement in the diagnosis of the nonbullous presentations of the disease. A dysregulated T cell immune response and synthesis of IgG and IgE autoantibodies against hemidesmosomal proteins (BP180 and BP230) lead to neutrophil chemotaxis and degradation of the basement membrane zone. Bullous pemphigoid classically manifests with tense blisters over urticarial plaques on the trunk and extremities accompanied by intense pruritus. Mucosal involvement is rarely reported. Diagnosis relies on (1) the histopathological evaluation demonstrating eosinophilic spongiosis or a subepidermal detachment with eosinophils; (2) the detection of IgG and/or C3 deposition at the basement membrane zone using direct or indirect immunofluorescence assays; and (3) quantification of circulating autoantibodies against BP180 and/or BP230 using ELISA. Bullous pemphigoid is often associated with multiple comorbidities in elderly individuals, especially neurological disorders and increased thrombotic risk, reaching a 1-year mortality rate of 23%. Treatment has to be tailored according to the patient's clinical conditions and disease severity. High potency topical steroids and systemic steroids are the current mainstay of therapy. Recent randomized controlled studies have demonstrated the benefit and safety of adjuvant treatment with doxycycline, dapsone and immunosuppressants aiming a reduction in the cumulative steroid dose and mortality.
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Affiliation(s)
- Denise Miyamoto
- Division of Dermatology, Hospital das Clínicas,
Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP),
Brazil
| | - Claudia Giuli Santi
- Division of Dermatology, Hospital das Clínicas,
Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP),
Brazil
| | - Valéria Aoki
- Department of Dermatology, Faculdade de Medicina,
Universidade de São Paulo, São Paulo (SP), Brazil
| | - Celina Wakisaka Maruta
- Department of Dermatology, Faculdade de Medicina,
Universidade de São Paulo, São Paulo (SP), Brazil
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