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Shirai T, Kiniwa Y, Ishii N, Hashimoto T, Senoo Y, Urushihata K, Ashida A, Okuyama R. Paraneoplastic pemphigus associated with Waldenström's macroglobulinemia. J Dermatol 2020; 47:e200-e201. [PMID: 32103535 DOI: 10.1111/1346-8138.15289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Takushi Shirai
- Department of Dermatology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Yukiko Kiniwa
- Department of Dermatology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Norito Ishii
- Department of Dermatology, Kurume University School of Medicine, Kurume, Japan.,Kurume University Institute of Cutaneous Cell Biology, Kurume, Japan
| | - Takashi Hashimoto
- Kurume University Institute of Cutaneous Cell Biology, Kurume, Japan.,Department of Dermatology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Yasushi Senoo
- Division of Hematology, Nagano Red Cross Hospital, Nagano, Japan
| | - Kazuhisa Urushihata
- First Department of Internal Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - Atsuko Ashida
- Department of Dermatology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Ryuhei Okuyama
- Department of Dermatology, Shinshu University School of Medicine, Matsumoto, Japan
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Alegría-Landa V, Cerroni L, Kutzner H, Requena L. Paraprotein deposits in the skin. J Am Acad Dermatol 2017; 77:1145-1158. [PMID: 28985955 DOI: 10.1016/j.jaad.2017.07.039] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 07/19/2017] [Accepted: 07/23/2017] [Indexed: 02/04/2023]
Abstract
Cutaneous manifestations secondary to paraprotein deposits in the skin include a group of different disorders that although rare, may be the first clinical manifestation of the underlying hematologic dyscrasia. In this article we review the clinical manifestations and histopathologic findings of the processes that result from specific deposition of the paraprotein in different structures of the skin. Paraneoplastic processes frequently associated with hematologic malignancies will not be covered in this review. Some of the disorders included here result from deposition of the intact paraprotein in the skin, whereas in other cases the lesions are due to deposition of modified paraproteins in the form of amyloid substance, cryoglobulins, or crystalglobulins. Cutaneous amyloidoma refers to nodular dermal deposits of amyloid derived from immunoglobulin light chains produced by local plasma cells in the absence of systemic amyloidosis. Dermatologists and dermatopathologists should be aware of the clinical and histopathologic features of these rare disorders because sometimes the cutaneous lesions are the first sign of an underlying silent hematologic malignancy with paraproteinemia.
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Affiliation(s)
| | - Lorenzo Cerroni
- Dermatopathology Research Unit, Medical University of Graz, Graz, Austria
| | - Heinz Kutzner
- Dermatopathologie Friedrichschafen, Friedrichschafen, Germany
| | - Luis Requena
- Department of Dermatology, Fundación Jiménez Diaz, Universidad Autónoma, Madrid, Spain.
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Maki N, Demitsu T, Umemoto N, Nagashima K, Nakamura T, Kakurai M, Nakamura S, Yamada T, Ishii N, Hashimoto T. Possible paraneoplastic syndrome case of bullous pemphigoid with immunoglobulin G anti-BP180 C-terminal domain antibodies associated with psoriasis and primary macroglobulinemia. J Dermatol 2016; 43:571-4. [PMID: 26507447 DOI: 10.1111/1346-8138.13170] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 09/06/2015] [Indexed: 11/28/2022]
Abstract
A 61-year-old Japanese man developed bullous skin lesions during topical therapy for psoriasis vulgaris. Physical examination demonstrated numerous tense bullae and scaly erythemas on the trunk and extremities. Histopathology of the skin biopsy demonstrated subepidermal bullae and lymphocytic infiltration with eosinophils in the dermis. Direct immunofluorescence revealed linear deposits of immunoglobulin (Ig)G, IgA and C3 along the basement membrane zone. Indirect immunofluorescence of 1 mol/L NaCl-split skin showed IgG reactivity with both epidermal and the dermal sides. IgM reactivity with both the epidermal and dermal sides was also detected. Enzyme-linked immunosorbent assays showed negative results for both BP180 and BP230. Immunoelectrophoresis of serum and bone marrow aspiration revealed underlying primary macroglobulinemia with M-proteinemia of IgM-κ type. Immunoblot analysis revealed IgG, but not IgM, antibodies to recombinant protein of BP180 C-terminal domain. We diagnosed the present case as bullous pemphigoid with IgG anti-BP180 C-terminal domain autoantibodies associated with primary macroglobulinemia and psoriasis vulgaris. Systemic administration of prednisolone 30 mg/day resulted in dramatic improvement of both bullous and psoriatic skin lesions. When the bullous and psoriatic lesions relapsed, DRC chemotherapy (dexamethasone, rituximab and cyclophosphamide) for macroglobulinemia was performed. Then, the psoriatic lesions improved and the bullous lesions disappeared. We suggested that the present case may be paraneoplastic syndrome of bullous pemphigoid associated with primary macroglobulinemia and psoriasis vulgaris.
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Affiliation(s)
- Nobuki Maki
- Department of Dermatology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Toshio Demitsu
- Department of Dermatology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Naoka Umemoto
- Department of Dermatology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Kazutaka Nagashima
- Department of Dermatology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Toshinobu Nakamura
- Department of Dermatology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Maki Kakurai
- Department of Dermatology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Satoshi Nakamura
- Department of Dermatology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Tomoko Yamada
- Department of Dermatology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Norito Ishii
- Department of Dermatology, Kurume University School of Medicine, Kurume University Institute of Cutaneous Cell Biology, Fukuoka, Japan
| | - Takashi Hashimoto
- Department of Dermatology, Kurume University School of Medicine, Kurume University Institute of Cutaneous Cell Biology, Fukuoka, Japan
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Lehman VT, Barrick BJ, Pittelkow MR, Peller PJ, Camilleri MJ, Lehman JS. Diagnostic imaging in paraneoplastic autoimmune multiorgan syndrome: retrospective single site study and literature review of 225 patients. Int J Dermatol 2014; 54:424-37. [DOI: 10.1111/ijd.12603] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Abstract
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.
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Affiliation(s)
- Suzana Ljubojevic
- University Department of Dermatology and Venereology, University Hospital Center Zagreb, School of Medicine,University of Zagreb, Croatia.
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Abstract
Autoimmune mucocutaneous blistering diseases (AMBD) are a rare group of dermatoses that can be potentially fatal. There are many subtypes and their clinical presentation can vary from being localized to general involvement. It is crucial that a diagnosis be made as early as possible and appropriate treatments are implemented. This article will discuss the diagnosis and available treatments of the major AMBDs. There are very few case-controlled studies regarding the treatments of these diseases. Most of the treatments used for these diseases are based on anecdotal reports. Hence, a synopsis of the conventional treatments and some brief recommendations will also be discussed. A brief discussion regarding "rescue" therapies that have been used for those patients with more recalcitrant cases of AMBD will also be presented.
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Affiliation(s)
- Naveed Sami
- Department of Dermatology, University of Alabama, 1720 University Blvd., Birmingham, AL 35294, USA.
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Billet SE, Grando SA, Pittelkow MR. Paraneoplastic autoimmune multiorgan syndrome: Review of the literature and support for a cytotoxic role in pathogenesis. Autoimmunity 2009; 39:617-30. [PMID: 17101506 DOI: 10.1080/08916930600972099] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Paraneoplastic autoimmune multiorgan syndrome (PAMS), first described as paraneoplastic pemphigus in 1990, is an autoimmune blistering disease associated with neoplasia. Patients with this rare disorder have severe blistering and painful erosions of the oral cavity and various other cutaneous findings ranging from classic pemphigus vulgaris-like erosions to targetoid lesions resembling erythema multiforme and papular to more confluent lichenoid eruptions. This syndrome involves multiple organ systems, and its high rate of mortality often stems from constrictive bronchiolitis obliterans. The histologic findings are as diverse as the clinical presentation, often making diagnosis difficult initially. Immunodermatologic and serologic laboratory findings typically establish the diagnosis. These results can be confirmed with immunoprecipitation profiling of specific molecular weight protein markers. The proposed pathogenesis of PAMS continues to evolve, and recent reports implicate the involvement of cell-mediated, cytotoxic immunity, in addition to humoral autoantibodies. This review characterizes and summarizes the clinical, pathologic, and immunohistologic features of PAMS and outlines the possible role of cytotoxic T lymphocytes in the pathogenesis of this syndrome.
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Affiliation(s)
- Sara E Billet
- Department of Dermatology, Mayo Clinic, Rochester, MN 55905, USA
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del Olmo J, España A, Idoate M, Panizo C. Macroglobulinemia de Waldenström asociada a lesiones cutáneas y crioglobulinemia tipo I. ACTAS DERMO-SIFILIOGRAFICAS 2008. [DOI: 10.1016/s0001-7310(08)74636-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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del Olmo J, España A, Idoate M, Panizo C. Waldenström Macroglobulinemia Associated With Cutaneous Lesions and Type I Cryoglobulinemia. ACTAS DERMO-SIFILIOGRAFICAS 2008. [DOI: 10.1016/s1578-2190(08)70214-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Abstract
Paraneoplastic pemphigus (PNP) is a life-threatening autoimmune blistering skin disease. Clinically, it is characterized by severe mucosal erosions and various cutaneous lesions associated with lymphoproliferative neoplasmas. Suprabasal acantholysis and clefts with scattered necrotic keratinocytes are the unique histopathological features. PNP patient sera recognize multiple antigens, which have been identified as the plakin protein family that includes desmoplakin, bullous pemphigoid antigen I (BPAG1), envoplakin and periplakin, and desmogleins 1 and 3. Castleman's tumor, non-Hodgkin's lymphoma, thymoma, follicular dendritic cell sarcoma and chronic lymphocytic leukemia are the commonly associated neoplasmas in PNP. We have also demonstrated that the autoantibodies reacting to epidermal proteins are directly produced by the cells in the associated tumors. Bronchiolitis obliterans is frequently found in PNP and may cause respiratory failure and death. In our experience, the early detection and removal of the tumor and i.v. administration of immunoglobulin are critical for the treatment of PNP.
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Affiliation(s)
- Xuejun Zhu
- Department of Dermatology, Peking University First Hospital, Beijing, China.
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Falagas ME, Pappas VD, Michalopoulos A. Gangrenous, Hemorrhagic, Bullous Cellulitis Associated with Pseudomonas aeruginosa in a Patient with Waldenström's Macroglobulinemia. Infection 2007; 35:370-3. [PMID: 17721738 DOI: 10.1007/s15010-007-6257-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2006] [Accepted: 12/21/2006] [Indexed: 10/22/2022]
Abstract
BACKGROUND Patients with Waldenström's macroglobulinemia may manifest several types of skin lesions. We present our experience with a patient with the disease that adds to the literature on the topic. CASE DESCRIPTION A 57-year-old man with history of multiple sclerosis and Waldenström's macroglobulinemia was admitted to the intensive care unit in shock. His family members reported that the patient had complained of fever and the gradual development of gangrenous, hemorrhagic, bullous cellulitis lesions on the abdomen and lower extremities for 7 days prior to his admission to the hospital. Pseudomonas aeruginosa was isolated from fluid specimens collected from the cutaneous lesions. Appropriate antimicrobial treatment including continuous intravenous administration of meropenem (6 g every 24 h) led to the cure of the infection. CONCLUSIONS We postulate that the underlying Waldenström's macroglobulinemia contributed to the pathophysiology of the development of the rare skin manifestations of the infection observed in our patient.
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Affiliation(s)
- M E Falagas
- Alfa Institute of Biomedical Sciences, 9 Neapoleos Street, Marousi, 151 23, Athens, Greece.
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Abstract
A paraneoplasticus pemphigus malignus vagy benignus tumorokhoz társuló autoimmun hólyagos megbetegedés diagnosztikus és immunológiai kritériumait 1990-ben fektette le
Anhalt
. Klinikailag súlyos, fájdalmas, mélyre terjedő bőr- és nyálkahártyatünetek jellemzik. A bőrtünetek polimorf jellegűek, általában dominál a hólyagképződés. Egyes esetekben, az ún. „graft-versus-host-disease” formákban előfordul, hogy kizárólag papulosus, lichenoid bőrtünetek észlelhetők, hólyagképződés nincs, vagy csak később jelenik meg. Elsősorban ezen alcsoport betegeiben a bőr- és nyálkahártyatünetek mellett súlyos dyspnoét okozó pulmonalis érintettség is kialakul, melynek hátterében bronchiolitis obliterans áll. A paraneoplasticus pemphigus diagnosztikájában alapvető fontosságú a bőr/nyálkahártyák direkt immunfluoreszcens, továbbá a szérum indirekt immunhisztológiai és immunoblot vizsgálata. Az eddig azonosított autoantigének döntő többsége a plakincsalád tagja: envoplakin (210 kDa), periplakin (190 kDa), plectin (~500 kDa), desmoplakin I (250 kDa), desmoplakin II (210 kDa), bullosus pemphigoid antigén 1 (230 kDa). A plakinok mellett a desmosomalis cadherinek közé sorolt desmoglein 1 és 3 a bullosus pemphigoid antigén 2 (180 kDa), a desmocollin 2 és 3, továbbá egy még nem azonosított, 170 kDa molekulatömegű transzmembrán fehérje szintén autoantigénje a kórképnek. A paraneoplasticus pemphigus nagy mortalitású kórkép, az esetek több mint 90%-ában halálos kimenetelű. A háttérben álló tumor eltávolítása mellett a bázisterápia továbbra is a nagy dózisú szisztémás szteroidkezelés, melyet citosztatikumok, immunmodulánsok adásával egészítenek ki. Szóba jön ezenkívül plasmapheresis, plazmacsere, photopheresis, nagy dózisú intravénás immunglobulin és anti-CD20 monoklonális antitest (rituximab) adása is.
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Affiliation(s)
- Klaudia Preisz
- Semmelweis Egyetem, Altalános Orvostudományi Kar, Bor-, Nemikórtani és Boronkológiai Klinika, Budapest.
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Abstract
The molecular and cellular pathogenesis of pemphigus remains unclear. However, the integrity of intraepidermal and dermoepidermal adhesion appears to be of special importance, and the presence of antibodies directed against desmosomal plaque proteins can provoke pemphigus-like pathologies. Antibodies reactive with various tissue antigens have been detected in pemphigus-like skin conditions. Two major factors determining the occurrence of different pemphigus subforms are antigen mimicry and epitope spreading, as these two phenomena underpin antibody generation in response to different antigens. This multiplicity of target antigens and antibody responses may lead to diagnostic problems early in the disease and may also explain the apparent transformation of one disease subform into another as time progresses.
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Affiliation(s)
- G Tchernev
- Department of Dermatology and Allergy, Skin Cancer Center, Charitè-Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin D-14195, Germany.
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