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Lockwood N, Bhullar S, Panse G, Leventhal JS. Persistent oral ulcers in a woman with thymoma. JAAD Case Rep 2023; 41:40-43. [PMID: 37842161 PMCID: PMC10568229 DOI: 10.1016/j.jdcr.2023.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2023] Open
Affiliation(s)
- Nishita Lockwood
- Department of Dermatology, Yale-New Haven Hospital, New Haven, Connecticut
| | - Shaman Bhullar
- Department of Dermatology, Yale-New Haven Hospital, New Haven, Connecticut
| | - Gauri Panse
- Department of Dermatology, Yale-New Haven Hospital, New Haven, Connecticut
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Dieudonné Y, Silvestrini MA, Dossier A, Meignin V, Jouenne F, Mahévas T, Bouaziz JD, Jackson MA, Mordant P, Poirot J, Onodi F, Calvani J, Hourseau M, Evrard D, Berisha M, Perrin F, Danel C, Borie R, Galicier L, Mourah S, Bengoufa D, Oksenhendler E, Grootenboer-Mignot S, Boutboul D. Paraneoplastic pemphigus uncovers distinct clinical and biological phenotypes of western unicentric Castleman disease. Br J Haematol 2023. [PMID: 37221131 DOI: 10.1111/bjh.18847] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 03/29/2023] [Accepted: 04/23/2023] [Indexed: 05/25/2023]
Abstract
Unicentric Castleman disease (UCD) is a lymphoproliferative disease of unknown cause. Paraneoplastic pemphigus (PNP) is a major complication shown to be associated with a poor prognosis, with particular severity in patients with bronchiolitis obliterans (BO). This study describes the clinical and biological characteristics of UCD-PNP patients in a large Western cohort. A total of 148 patients diagnosed with UCD were identified, including 14 patients with a defined PNP. PNP was significantly associated with myasthenia gravis (MG) and FDC sarcoma during follow-up (FDCS). PNP was also significantly associated with reduced survival. These data, together with a multivariate analysis by principal components, led to the identification of UCD-PNP as a group at risk of MG, FDCS and death. PDGFRB sequencing performed on UCD lesions from six patients found the gain-of-function p.N666S variant in two. Interestingly, both patients had hyaline-vascular UCD subtype, were in the UCD-PNP subgroup and had FDCS. Sera from 25 UCD-PNP patients and 6 PNP patients without UCD were tested for PNP-associated autoantibodies. Sera from UCD-PNP patients had a strong reactivity against the N-terminal domain of recombinant periplakin (rPPL, 82%) and showed reactivity against at least two domains of rPPL. These features were not found in patients with UCD alone or in the PNP group without UCD. These data indicate that UCD-PNP patients belong to a subgroup sharing strong clinical and biological identity that might help to decipher the different dynamics of UCD natural history.
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Affiliation(s)
- Yannick Dieudonné
- Department of Clinical Immunology and Internal Medicine, National Reference Centre for Systemic Autoimmune Diseases (CNR RESO), Strasbourg University Hospital, Strasbourg, France
- INSERM UMR-S1109, Université de Strasbourg, Strasbourg, France
| | | | - Antoine Dossier
- Department of Internal Medicine, Hôpital Bichat, Université Paris Cité, Paris, France
| | - Véronique Meignin
- Department of Pathology, Hôpital Saint Louis, Université Paris Cité, Paris, France
| | - Fanélie Jouenne
- Laboratoire de Génomique des Tumeurs et Pharmacologie, INSERM UMR-S976, Hôpital Saint Louis, Université Paris Cité, Paris, France
| | - Thibault Mahévas
- Department of Dermatology, Hôpital Saint Louis, Université Paris Cité, Paris, France
| | - Jean-David Bouaziz
- Department of Dermatology, Hôpital Saint Louis, Université Paris Cité, Paris, France
| | | | - Pierre Mordant
- Department of Thoracic Surgery, Vascular Surgery, and Lung Transplantation, Hôpital Bichat, Université Paris Cité, Paris, France
| | - Justine Poirot
- U976 HIPI, Hôpital Saint Louis, Université Paris Cité, Paris, France
| | - Fanny Onodi
- U976 HIPI, Hôpital Saint Louis, Université Paris Cité, Paris, France
| | - Julien Calvani
- Department of Pathology, Hôpital Saint Louis, Université Paris Cité, Paris, France
| | - Muriel Hourseau
- Department of Pathology, Hôpital Bichat, Université Paris Cité, Paris, France
| | - Diane Evrard
- Department of Otorhinolaryngology, Hôpital Bichat, Université Paris Cité, Paris, France
| | - Mirlinda Berisha
- National Reference Centre for Castleman Disease, Hôpital Saint Louis, Université Paris Cité, Paris, France
| | - François Perrin
- Department of Internal Medicine, Centre Hospitalier de Saint-Nazaire, Saint-Nazaire, France
| | - Claire Danel
- Department of Pathology, Hôpital Bichat, Université Paris Cité, Paris, France
| | - Raphael Borie
- Inserm, PHERE, F-75018 Paris, et Hôpital Bichat, APHP, Service de Pneumologie A, FHU APOLLO, Université Paris Cité, Paris, France
| | - Lionel Galicier
- National Reference Centre for Castleman Disease, Hôpital Saint Louis, Université Paris Cité, Paris, France
- Clinical Immunology Department, Hôpital Saint Louis, Université Paris Cité, Paris, France
| | - Samia Mourah
- Laboratoire de Génomique des Tumeurs et Pharmacologie, INSERM UMR-S976, Hôpital Saint Louis, Université Paris Cité, Paris, France
| | - Djaouida Bengoufa
- Immunology laboratory, Hôpital Saint Louis, Université Paris Cité, Paris, France
| | - Eric Oksenhendler
- National Reference Centre for Castleman Disease, Hôpital Saint Louis, Université Paris Cité, Paris, France
- Clinical Immunology Department, Hôpital Saint Louis, Université Paris Cité, Paris, France
| | - Sabine Grootenboer-Mignot
- Department of Immunology, Auto-Immunity and Hypersensitivity, Hôpital Bichat, Université Paris Cité, Paris, France
| | - David Boutboul
- U976 HIPI, Hôpital Saint Louis, Université Paris Cité, Paris, France
- National Reference Centre for Castleman Disease, Hôpital Saint Louis, Université Paris Cité, Paris, France
- Clinical Immunology Department, Hôpital Saint Louis, Université Paris Cité, Paris, France
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Liu SS, Howard T, Fattah YH, Adams A, Hanly AJ, Karai LJ. Lichen Planopilaris Pemphigoides: A Novel Bullous Dermatosis Due to Programmed Cell Death Protein-1 Inhibitor Therapy. Am J Dermatopathol 2023; 45:246-249. [PMID: 36825932 PMCID: PMC10018802 DOI: 10.1097/dad.0000000000002392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
ABSTRACT Lichen planus pemphigoides (LPPemph), apart from bullous pemphigoid, is a rare bullous dermatosis that can be induced by programmed cell death protein-1 (PD-1)/PD ligand 1 (PD-L1) inhibitors. The primary location of PD-1/PD-L1 inhibitor-induced LPPemph has previously only been reported at the nonfollicular dermal-epidermal junction. We present a case of nivolumab-induced LPPemph with an intense perifollicular lichenoid reaction, prominent multifocal perifollicular clefting, which in addition, was also accompanied by linear IgG and C3 immunofluorescence deposits along the dermal-epidermal junction as well as demonstrating a perifollicular pattern. Intriguingly, the serological study of BP180 and BP230 antibodies was negative, suggesting the presence of additional novel antibodies, which primarily favor hair follicles and may contribute to the pathogenesis. Therefore, we consider this entity a novel variant of PD-1/PD-L1 inhibitor-induced bullous dermatosis. To the best of our knowledge, this is the first report that highlights perifollicular bullae accompanied by immunofluorescence findings in a PD-1/PD-L1 inhibitor-induced lesion. We propose a new immunotherapy associated entity, lichen planopilaris pemphigoides, and emphasize the significance of perifollicular changes in the pathogenesis.
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Affiliation(s)
- Shuo S. Liu
- Department of Dermatology, Larkin Community Hospital, South Miami, FL
| | - Tara Howard
- University of Miami, Holy Cross Hospital, Ft. Lauderdale, FL
| | - Yasmin H. Fattah
- Department of Dermatology, Larkin Community Hospital, South Miami, FL
| | - Amy Adams
- South Central Dermatology Clinic, Laurel, MS; and
| | | | - Laszlo J. Karai
- Department of Dermatology, Larkin Community Hospital, South Miami, FL
- Global Pathology, Sonic Healthcare USA, Miami Lakes, FL
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Dermatological manifestations of hematologic neoplasms. Part II: nonspecific skin lesions/paraneoplastic diseases. An Bras Dermatol 2023; 98:141-158. [PMID: 36682966 PMCID: PMC9984718 DOI: 10.1016/j.abd.2022.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 06/22/2022] [Accepted: 08/09/2022] [Indexed: 01/21/2023] Open
Abstract
Cutaneous manifestations occur in the course of hematologic malignancies and precede, accompany or occur late in relation to the diagnosis. They result from paraneoplastic phenomena, tumor infiltrations, immunosuppression resulting from the hematologic disease itself or its treatment. The dermatologist must be aware of these conditions that may be helpful both in the diagnosis of the underlying disease and in reducing patient morbidity. This review (part II) addresses the paraneoplastic dermatological changes associated with systemic hematologic malignancies.
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[Factors associated with long-term survival in critically ill patients following surgery for solid tumors complicated with paraneoplastic pemphigus]. BEIJING DA XUE XUE BAO. YI XUE BAN = JOURNAL OF PEKING UNIVERSITY. HEALTH SCIENCES 2022; 54. [PMID: 36241242 PMCID: PMC9568377 DOI: 10.19723/j.issn.1671-167x.2022.05.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE Critically ill patients with solid tumors complicated with paraneoplastic pemphigus are usually treated in intensive care units (ICU) for perioperative management after surgical treatment. In this study, the clinical characteristics and predictors of long-term prognosis of these critically ill patients were analyzed. METHODS the clinical and laboratory data of 63 patients with solid tumors complicated with paraneoplastic pemphigus admitted to ICU from 2005 to 2020 were retrospectively analyzed, and the survival status of the patients were followed up. RESULTS Among the 63 patients, 79.4% had Castleman disease as the primary tumor, and 20.6% with other pathological types; 69.8% had severe-extensive skin lesions, and 30.2% had other skin lesions; the patients with bronchiolitis obliterans accounted for 44.4%, and 55.6% were not merged. Postoperative fungal infection occurred in 23.8% of the patients, and 76.2% without fungal infection. The median follow-up time was 95 months, and 25 patients died during the study period. The 1-year, 3-year and 5-year survival rates were 74.6% (95%CI 63.8%-85.4%), 67.4% (95%CI 55.6%-79.2%) and 55.1% (95%CI 47.9%-62.3%), respectively. The log-rank univariate analysis showed that the patients had age>40 years (P=0.042), preoperative weight loss>5 kg (P=0.002), preoperative albumin < 30 g/L (P < 0.001), paraneoplastic pemphigus complicated with bronchiolitis obliterans (P=0.002), and perioperative fungal infection (P < 0.001) had increased mortality. Cox univariate analysis showed that preoperative weight loss >5 kg (P=0.005), preoperative albumin < 30 g/L (P < 0.001), paraneoplastic pemphigus complicated with bronchiolitis obliterans (P=0.009), preoperative bacterial pulmonary infection (P=0.007), prolonged surgical time (P=0.048), postoperative oxygenation index (P=0.012) and low albumin (P=0.010) and hemoglobin concentration (P=0.035) in ICU, acute physiology and chronic health evaluation (APACHE Ⅱ) score (P=0.001); sequential organ failure assessment (SOFA) score (P=0.010), and postoperative fungal infection (P < 0.001) were risk factors for long-term survival. Cox regression model for multivariate analysis showed that preoperative weight loss > 5 kg (HR 4.44; 95%CI 1.47-13.38; P=0.008), and preoperative albumin < 30 g/L (HR 4.38; 95%CI 1.72-11.12; P=0.002), bronchiolitis obliterans (HR 2.69; 95%CI 1.12-6.50; P=0.027), and postoperative fungal infection (HR 4.85; 95%CI 2.01-11.72; P < 0.001) were independent risk factors for postoperative mortality. CONCLUSION The 5-year survival rate of critically ill patients undergoing surgery for paraneoplastic pemphigus combined with solid tumors is approximately 55.1%, with preoperative weight loss > 5 kg, albumin < 30 g/L, bronchiolitis obliterans and postoperative fungal infection were associated with an increased risk of near- and long-term postoperative mortality.
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Tekin B, Johnson EF, Wieland CN, Gibson LE, Camilleri MJ, Kalaaji AN, Comfere NI, Peters MS, Lehman JS. Histopathology of autoimmune bullous dermatoses: What's new? Hum Pathol 2022; 128:69-89. [PMID: 35764145 DOI: 10.1016/j.humpath.2022.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 06/19/2022] [Accepted: 06/21/2022] [Indexed: 11/25/2022]
Abstract
Autoimmune bullous dermatoses are characterized by the presence of tissue-bound and often circulating pathogenic autoantibodies targeting structural components of the skin and/or mucous membranes. The diagnostic workup for this heterogeneous group of disorders consists of a multi-step process, of which the light microscopic examination is a crucial component. This review is organized following a classification scheme that is based on two main histopathologic features, namely level of intraepithelial split and composition of the inflammatory infiltrate. Overall, we aim to place emphasis on the histopathologic clues that can assist pathologists in differential diagnosis and review the updates in the literature.
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Affiliation(s)
- Burak Tekin
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Emma F Johnson
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA; Department of Dermatology, Mayo Clinic, Rochester, MN, USA
| | - Carilyn N Wieland
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA; Department of Dermatology, Mayo Clinic, Rochester, MN, USA
| | - Lawrence E Gibson
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA; Department of Dermatology, Mayo Clinic, Rochester, MN, USA
| | - Michael J Camilleri
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA; Department of Dermatology, Mayo Clinic, Rochester, MN, USA
| | - Amer N Kalaaji
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA; Department of Dermatology, Mayo Clinic, Rochester, MN, USA
| | - Nneka I Comfere
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA; Department of Dermatology, Mayo Clinic, Rochester, MN, USA
| | - Margot S Peters
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA; Department of Dermatology, Mayo Clinic, Rochester, MN, USA
| | - Julia S Lehman
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA; Department of Dermatology, Mayo Clinic, Rochester, MN, USA.
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Du X, Zhang M, Zhang S, Tian F, Wen T, Liu L. Myocardial Damage in a Highly Suspected Case With Paraneoplastic Pemphigus: A Case Report and Literature Review. Front Med (Lausanne) 2022; 9:917050. [PMID: 35770015 PMCID: PMC9234257 DOI: 10.3389/fmed.2022.917050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Accepted: 05/12/2022] [Indexed: 11/18/2022] Open
Abstract
Paraneoplastic pemphigus (PNP) is a rare mucocutaneous autoimmune disease. It has multiple clinical accompanied symptoms by affecting various types of epithelia, including the gastrointestinal and respiratory tract. However, an extensive review of the literature found no cases of PNP associated with myocardial damage. Here, we present a 56-year-old male patient with clinically and histopathologically typical paraneoplastic pemphigus (PNP), who had sustained myocardial injury due to non-cardiac disease involvement. Therefore, we suppose that, when persistent cardiac necrosis markers are elevated in patients with paraneoplastic pemphigus (PNP), the possibility of concomitant myocardial damage should get more attention from clinicians to obtain quick diagnosis and treatment.
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Affiliation(s)
- Xiao Du
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, China
- Research Institute of Blood Lipid and Atherosclerosis, Central South University, Changsha, China
- Modern Cardiovascular Disease Clinical Technology Research Center of Hunan Province, Changsha, China
- Cardiovascular Disease Research Center of Hunan Province, Changsha, China
| | - Miao Zhang
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, China
- Research Institute of Blood Lipid and Atherosclerosis, Central South University, Changsha, China
- Modern Cardiovascular Disease Clinical Technology Research Center of Hunan Province, Changsha, China
- Cardiovascular Disease Research Center of Hunan Province, Changsha, China
| | - Shilan Zhang
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, China
- Research Institute of Blood Lipid and Atherosclerosis, Central South University, Changsha, China
- Modern Cardiovascular Disease Clinical Technology Research Center of Hunan Province, Changsha, China
- Cardiovascular Disease Research Center of Hunan Province, Changsha, China
| | - Feng Tian
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, China
- Research Institute of Blood Lipid and Atherosclerosis, Central South University, Changsha, China
- Modern Cardiovascular Disease Clinical Technology Research Center of Hunan Province, Changsha, China
- Cardiovascular Disease Research Center of Hunan Province, Changsha, China
| | - Tie Wen
- Department of Emergency Medicine, Second Xiangya Hospital, Central South University, Changsha, China
- Emergency Medicine and Difficult Diseases Institute, Second Xiangya Hospital, Central South University, Changsha, China
- Tie Wen
| | - Ling Liu
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, China
- Research Institute of Blood Lipid and Atherosclerosis, Central South University, Changsha, China
- Modern Cardiovascular Disease Clinical Technology Research Center of Hunan Province, Changsha, China
- Cardiovascular Disease Research Center of Hunan Province, Changsha, China
- *Correspondence: Ling Liu
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Tagliati C, Rizzetto G, Lanni G, Marcucci M, Argalia G, Lucidi Pressanti G, Simonetti O, Offidani A. Thoracoabdominal computed tomography neoplasia detection in patients with paraneoplastic pemphigus: the importance of collaboration between specialists. ACTA DERMATOVENEROLOGICA ALPINA PANNONICA ET ADRIATICA 2022. [DOI: 10.15570/actaapa.2022.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Costan VV, Popa C, Hâncu MF, Porumb-Andrese E, Toader MP. Comprehensive review on the pathophysiology, clinical variants and management of pemphigus (Review). Exp Ther Med 2021; 22:1335. [PMID: 34630689 PMCID: PMC8495539 DOI: 10.3892/etm.2021.10770] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 08/09/2021] [Indexed: 12/16/2022] Open
Abstract
Pemphigus represents a group of chronic inflammatory disorders characterized by autoantibodies that target components of desmosomes, leading to the loss of intercellular adhesion between keratinocytes and causing intraepithelial blistering. The pemphigus group consists of four main clinical types with several variants: pemphigus vulgaris (with pemphigus vegetans and pemphigus herpetiformis as variants), pemphigus foliaceus, paraneoplastic pemphigus and IgA pemphigus (with two clinical variants: intraepidermal neutrophilic IgA dermatosis and subcorneal pustular dermatosis). Genetic factors are involved in the pathogenesis, with HLA-DR4 (DRB1*0402) and HLA-DRw6 (DQB1*0503) allele more common in patients with pemphigus vulgaris, HLA class II DRB1*0344 and HLA Cw*1445 correlated with paraneoplastic pemphigus, and HLA-DRB1*04:01, HLA-DRB1*04:06, HLA-DRB1*01:01, HLA-DRB1*14, associated with a higher risk of developing pemphigus foliaceus. Autoantibodies are conducted against structural desmosomal proteins in the skin and mucous membranes, mainly desmogleins, desmocollins and plakins. Cell-mediated immunity may also play a role, especially in paraneoplastic pemphigus. Patients may present erythema, blisters, erosions, and ulcers that may affect the skin, as well as mucosal surfaces of the oral cavity, eyes, nose, leading to severe complaints including pain, dysphagia, and fetor. Oral mucosal postbullous erosive lesions are frequently the first sign of disease in pemphigus vulgaris and in paraneoplastic pemphigus, without skin involvement, making the diagnosis difficult. Treatment options classically include immunosuppressive agents, such as corticosteroids and corticosteroid-sparing agents such as azathioprine, mycophenolate mofetil, cyclophosphamide, methotrexate or dapsone. Newer therapies focus on blocking cell signaling events induced by pathogenic autoantibodies and/or targeting specific autoantibodies. The disease evolution is conditioned by the treatment with maximum doses of corticosteroids and the side effects associated with long-term immunosuppressive therapy, which is why patients need a multidisciplinary approach in following the treatment. In this review, we provide a comprehensive overview of the epidemiology, pathophysiology, clinical aspect, diagnosis and management of the main intraepidermal blistering diseases from the pemphigus group.
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Affiliation(s)
- Victor-Vlad Costan
- Department of Oral and Maxillofacial Surgery, 'Grigore T. Popa' University of Medicine and Pharmacy, 700115 Iași, Romania
| | - Cristina Popa
- Department of Oral Medicine and Oral Dermatology, 'Grigore T. Popa' University of Medicine and Pharmacy, 700115 Iași, Romania
| | - Mădălina Florina Hâncu
- Department of Dermatology, 'Sf. Spiridon' Clinical Emergency County Hospital, 700111 Iași, Romania
| | - Elena Porumb-Andrese
- Department of Dermatology, 'Grigore T. Popa' University of Medicine and Pharmacy, 700115 Iași, Romania
| | - Mihaela Paula Toader
- Department of Oral Medicine and Oral Dermatology, 'Grigore T. Popa' University of Medicine and Pharmacy, 700115 Iași, Romania
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Sathishkumar D, Agrawal P, Baitule AM, Thomas M, Eapen A, Kumar S, George R. Paraneoplastic Autoimmune Multiorgan Syndrome: A Retrospective Study from a Tertiary Care Center in South India. Indian Dermatol Online J 2021; 12:572-576. [PMID: 34430462 PMCID: PMC8354390 DOI: 10.4103/idoj.idoj_640_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 10/09/2020] [Accepted: 12/20/2020] [Indexed: 11/23/2022] Open
Abstract
Background: Paraneoplastic autoimmune multiorgan syndrome (PAMS), first described as paraneoplastic pemphigus (PNP) is a heterogeneous autoimmune syndrome with a diverse spectrum of clinical and immunopathological features associated with an internal neoplasm. Materials and Methods: The details of the patients diagnosed with PAMS/PNP from an Indian tertiary center between January 2010 to December 2019 were retrieved from the hospital database. The clinical manifestations, histopathological features, immunofluorescence findings, and other relevant clinical details were obtained. Results: There were eight patients (4 males, 4 females) with PAMS, age ranging from 8 to 46 years (mean 31 years), of whom two were 8-year-old children. The mucocutaneous manifestations were polymorphic and all had recalcitrant oral mucosal involvement. The most common mucosal presentation was pemphigus-like (5/8), and the cutaneous presentation was lichen planus-like (5/8). Castleman's disease (5/8) was the commonest neoplasm followed by thymoma (2/8). Interface dermatitis was seen in all biopsies and three different patterns of direct immunofluorescence were seen, which were intercellular “fish-net” fluorescence in the epidermis (2/8), granular/linear deposition along the basement membrane (4/8) and a combination of both patterns (1/8). Indirect immunofluorescence done on rat bladder in 3 patients showed intercellular “fish-net” fluorescence. Desmoglein levels were not elevated in any of our patients. The follow-up period ranged from 1 to 112.5 months (mean, 23.6 months) with a mortality rate of 12.5%. Conclusion: In our study, Castleman's disease was the most common associated malignancy, and the mucocutaneous and histopathological findings were heterogeneous. Timely diagnosis and early intervention improved the outcome in our patients.
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Affiliation(s)
- Dharshini Sathishkumar
- Department of Dermatology, Venereology and Leprosy, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Poonam Agrawal
- Department of Dermatology, Venereology and Leprosy, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Amey Madhav Baitule
- Department of Pathology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Meera Thomas
- Department of Pathology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Anu Eapen
- Department of Radiology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Sathish Kumar
- Department of Paediatric Rheumatology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Renu George
- Department of Dermatology, Venereology and Leprosy, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
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11
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Almater AI, Abusayf MM, Alshahrani S, Alfawaz AM, Alkatan HM, Al-Faky YH. Paraneoplastic pemphigus associated with rapidly progressing endophthalmitis caused by Morganella Morganii: A case report. Eur J Ophthalmol 2021; 32:NP69-NP72. [PMID: 34269096 DOI: 10.1177/11206721211033465] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION The ocular presentation of paraneoplastic pemphigus (PNP) has rarely been reported in the literature. In this report, we describe a 61-year-old male presenting with eruptive skin lesions associated with underlying non-Hodgkin's lymphoma who had rapid progressive corneal perforation with secondary endophthalmitis in the setting of PNP. CASE DESCRIPTION A 61-year-old male presented to the emergency department complaining of skin eruption mimicking Stevens-Johnson syndrome, which was later found to be related to PNP. Initially, the patient complained of progressive ocular surface dryness in both eyes. Meanwhile, he developed mild pain in the right eye associated with blurry vision in both eyes and was managed with lubricants and topical antibiotics. A few days later, he was found to have corneal perforation with features suggestive of left endophthalmitis with possible early panophthalmitis. Intravenous antibiotic was administered, and primary evisceration of the left globe was performed. Histopathology revealed acute necrotizing keratitis and endophthalmitis. Vitreous analysis showed numerous gram-negative bacilli and a positive culture of Morganella morganii. The patient continued to be managed with frequent lubrications and punctual plugs in the fellow eye during the follow-up period. CONCLUSION We describe the first case of endophthalmitis developing secondary to PNP-induced corneal melting and perforation. Anticipating unusual infectious sequelae in the setting of PNP might be warranted to actively detect and successfully manage dry eye disease before devastating complications develop.
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Affiliation(s)
- Abdullah I Almater
- Department of Ophthalmology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Mohammed M Abusayf
- Department of Ophthalmology, College of Medicine, King Saud University, Riyadh, Saudi Arabia.,King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Saeed Alshahrani
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Abdullah M Alfawaz
- Department of Ophthalmology, College of Medicine, King Saud University, Riyadh, Saudi Arabia.,King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Hind M Alkatan
- Department of Ophthalmology, College of Medicine, King Saud University, Riyadh, Saudi Arabia.,King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia.,Department of Pathology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Yasser H Al-Faky
- Department of Ophthalmology, College of Medicine, King Saud University, Riyadh, Saudi Arabia.,King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
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12
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Rubin A, Ashforth G, Chamorro P, Blaszczyk MB, Maghari A, Pappert A. Paraneoplastic pemphigus without mucosal lesions in a patient with ovarian cancer. Int J Dermatol 2021; 61:611-612. [PMID: 33974274 DOI: 10.1111/ijd.15667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 04/12/2021] [Accepted: 04/21/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Alexandra Rubin
- Center for Dermatology, Department of Pathology and Laboratory Medicine, Rutgers Robert Wood Johnson Medical School, Somerset, NJ, USA
| | - Gina Ashforth
- Center for Dermatology, Department of Pathology and Laboratory Medicine, Rutgers Robert Wood Johnson Medical School, Somerset, NJ, USA
| | - Paola Chamorro
- Center for Dermatology, Department of Pathology and Laboratory Medicine, Rutgers Robert Wood Johnson Medical School, Somerset, NJ, USA
| | - Maryjka B Blaszczyk
- Department of Pathology and Laboratory Medicine, Rutgers Robert Wood Johnson Medical School, Somerset, NJ, USA
| | - Amin Maghari
- Department of Pathology and Laboratory Medicine, Rutgers Robert Wood Johnson Medical School, Somerset, NJ, USA
| | - Amy Pappert
- Center for Dermatology, Department of Pathology and Laboratory Medicine, Rutgers Robert Wood Johnson Medical School, Somerset, NJ, USA
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13
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Juratli HA, Avci P, Horváth B. Clinicians' pearls and myths in pemphigus. Ital J Dermatol Venerol 2021; 156:142-146. [PMID: 33960749 DOI: 10.23736/s2784-8671.21.06810-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Pemphigus comprises a heterogeneous group of autoimmune blistering diseases, which can affect both skin and mucous membranes, especially oral mucosa. This group of diseases shows usually a chronic-relapsing course. Since pemphigus is a rare disease, the diagnosis is often delayed, because it is based upon the recognition of consistent clinical, histologic, and direct immunofluorescence findings, as well as indirect immunofluorescence, and/or enzyme-linked immunosorbent assay. Usually the patients are treated for multiple other conditions before starting the correct therapy, leading to a critical reduction of the patients' quality of life. This review is a succinct compilation of pearls gathered from clinical experience in pemphigus and the myths that may have influenced everyday practice but have been proven false. This review provided a selection of such dilemmas and controversies, focusing on myths and pearls that can help young dermatologist in the clinic, while also dispelling them.
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Affiliation(s)
- Hazem A Juratli
- Department of Dermatology and Allergology, Philipps University, Marburg, Germany -
| | - Pinar Avci
- Department of Dermatology and Allergology, Philipps University, Marburg, Germany
| | - Barbara Horváth
- Department of Dermatology, Center for Blistering Diseases, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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14
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Abstract
Paraneoplastic skin manifestations associated with malignancies are extremely polymorphous. Clinicians should be familiar with paraneoplastic dermatoses to establish an early diagnosis of the underlying neoplasm. Lack of familiarity with cutaneous clues for internal malignancies may delay diagnosis and treatment of cancer. In this review, we describe several paraneoplastic autoimmune dermatoses, including paraneoplastic autoimmune multiorgan syndrome, paraneoplastic bullous pemphigoid, and paraneoplastic dermatomyositis.
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Affiliation(s)
- D Didona
- Klinik für Dermatologie und Allergologie, Philipps-Universität Marburg, Baldingerstr., 35043, Marburg, Deutschland.
| | - M Hertl
- Klinik für Dermatologie und Allergologie, Philipps-Universität Marburg, Baldingerstr., 35043, Marburg, Deutschland
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15
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Abstract
Originally described by Anhalt as paraneoplastic pemphigus in 1990, paraneoplastic autoimmune multiorgan syndrome (PAMS) is a potentially lethal blistering disease, characterized by polymorphous clinical features, including mucocutaneous erosions, blisters, lichenoid papules, and erythemas. Several autoantibodies have been detected in serum of PAMS patients, including antiplakins, anti-alpha-2-macroglobulin like 1, and antidesmogleins autoantibodies. The mortality rate of PAMS is up to 90%. This is due on the one hand to the poor response to treatments and on the other hand to the delay in the diagnosis and to the prognosis of the underlying neoplasia.
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Affiliation(s)
- Dario Didona
- Department of Dermatology and Allergology, Philipps University, Marburg, Germany -
| | | | - Pascal Joly
- Department of Dermatology, Rouen University Hospital and INSERM U905, Reference center for autoimmune bullous diseases, Normandie University, Rouen, France
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16
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18F-FDG PET/CT in Follicular Dendritic Cell Sarcoma With Paraneoplastic Pemphigus as the First Manifestation. Clin Nucl Med 2020; 45:572-574. [PMID: 32371617 DOI: 10.1097/rlu.0000000000003065] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
A 48-year-old woman presented with refractory oral ulcers and skin rashes on the palms and trunk, diagnosed as paraneoplastic pemphigus. The chest x-ray revealed a mass in the right lower chest, and the F-FDG PET/CT scan showed the lesion in the right anterior-inferior mediastinum with intense F-FDG uptake, accompanied by right parasternal adenopathy and pleural effusion. The surgical pathology proved a follicular dendritic cell sarcoma, with right parasternal lymph node metastasis.
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17
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Chronic lymphocytic leukemia-associated paraneoplastic pemphigus: potential cause and therapeutic strategies. Sci Rep 2020; 10:16357. [PMID: 33004832 PMCID: PMC7529904 DOI: 10.1038/s41598-020-73131-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 09/11/2020] [Indexed: 11/17/2022] Open
Abstract
Paraneoplastic pemphigus (PNP) is a severe autoimmune syndrome commonly triggered by neoplasms. The prognosis of CLL-associated PNP is dismal due to its refractory course and secondary infection and no standard treatment was recommended. We retrospectively reported six CLL with PNP cases from 842 cases of CLL including diagnosis, treatment and prognosis. The median time between the initial of CLL to PNP was 36 months while the median overall survival from the diagnosis of PNP was 26 months. And three cases died of lung infection while 5 developed pulmonary symptoms. And 5 cases received fludarabine-based chemotherapy before developing PNP, which suggesting fludarabine was one of potential causes of PNP. For the treatment, five patients were rescued by combined regimens including rituximab, methylprednisolone, immunoglobulin, fresh frozen plasma and the last received ibrutinib combined with short-term prednisone. Fludarabine-based regimen may be one of the potential causes of PNP. The combined regimen might shed a new light, while ibrutinib is a promising drug for CLL with PNP, but needs much more evidence. PNP should be carefully treated to guide early diagnosis and intervention for a better prognosis.
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18
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Pons Benavent M, García Vázquez A, Guillén Climent S, Porcar Saura S, Ramón Quiles D. Thymoma-associated multiorgan autoimmunity with prominent muco-cutaneous involvement: two cases and review of the literature. Int J Dermatol 2020; 60:e47-e49. [PMID: 32989745 DOI: 10.1111/ijd.15199] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 08/09/2020] [Accepted: 08/27/2020] [Indexed: 01/07/2023]
Affiliation(s)
- Martí Pons Benavent
- Department of Dermatology, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | | | | | - Saray Porcar Saura
- Department of Dermatology, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - Dolores Ramón Quiles
- Department of Dermatology, Hospital Clínico Universitario de Valencia, Valencia, Spain
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19
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Onukogu I, Ramachandran P, Narh J, Sahni S, Joseph G. Paraneoplastic Pemphigus: An Indication for Treatment in Chronic Lymphocytic Leukemia. Cureus 2020; 12:e8316. [PMID: 32607299 PMCID: PMC7320649 DOI: 10.7759/cureus.8316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Paraneoplastic disorders are rare multiorgan diseases associated with hematological malignancies such as chronic lymphocytic leukemia (CLL). Some of these paraneoplasms manifest as cutaneous lesions, appearing as a simple rash, ulcers or skin thickening. The pathogenesis for this process has been described as development of certain autoimmune reactions against cell wall antigens and proteins. An example is paraneoplastic pemphigus (PNP) which manifests as cutaneous bullae. Bullae may occur anytime during the course of the malignancy i.e. acute phase or remission. Diagnosis involves evaluation of clinical findings, serology and presence of characteristic histological findings. Its pathogenesis is described as development of auto-antibodies against cell junctional and basement membrane proteins. Presence of paraneoplasms has been associated with poorer prognosis and increased mortality in hematological malignancies including CLL. Currently, there are established indications for the treatment of CLL; however, presence of paraneoplasms as an indication for treatment is unclear. Patients with paraneoplasms who underwent expeditious treatment have exhibited better clinical outcomes. Herein we describe a case of a CLL patient in remission presenting with PNP and its response to treatment.
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Affiliation(s)
| | | | - Joshua Narh
- Internal Medicine, Brookdale University Hospital and Medical Center, New York, USA
| | - Sonu Sahni
- Internal Medicine, Brookdale University Hospital Medical Center, New York, USA.,Research Medicine, New York Institute of Technology College of Osteopathic Medicine, New York, USA.,Primary Care, Touro College of Osteopathic Medicine, New York, USA
| | - Gardith Joseph
- Oncology, Mount Sinai Medical Center, Brooklyn, USA.,Hematology and Oncology, Brookdale University Hospital and Medical Center, Brooklyn, USA
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20
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Lepekhova AA, Teplyuk NP, Bolotova IM. Modern diagnostic methods of paraneoplastic pemphigus. VESTNIK DERMATOLOGII I VENEROLOGII 2019. [DOI: 10.25208/0042-4609-2019-95-5-7-16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Paraneoplastic pemphigus (PNP) is one of the least investigated and rare forms of bullous dermatoses, which comes from underlying neoplasm. The article presents a literature review of dermatologist`s longstanding international experience about etiology, pathogenesis, diagnostics and treatment of this disease. According to the research results of native and foreign authors systematization of modern diagnostic methods of PNP and detectable antigens was performed.Conflict of interest: the authors state that there is no potential conflict of interest requiring disclosure in this article.
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Affiliation(s)
- A. A. Lepekhova
- I. M. Sechenov First Moscow State Medical University, Ministry of Health of the Russian Federation
| | - N. P. Teplyuk
- I. M. Sechenov First Moscow State Medical University, Ministry of Health of the Russian Federation
| | - I. M. Bolotova
- Pirogov Russian National Research Medical University, Ministry of Health of the Russian Federation
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21
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Rashid H, Lamberts A, Diercks GFH, Pas HH, Meijer JM, Bolling MC, Horváth B. Oral Lesions in Autoimmune Bullous Diseases: An Overview of Clinical Characteristics and Diagnostic Algorithm. Am J Clin Dermatol 2019; 20:847-861. [PMID: 31313078 PMCID: PMC6872602 DOI: 10.1007/s40257-019-00461-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Autoimmune bullous diseases are a group of chronic inflammatory disorders caused by autoantibodies targeted against structural proteins of the desmosomal and hemidesmosomal plaques in the skin and mucosa, leading to intra-epithelial or subepithelial blistering. The oral mucosa is frequently affected in these diseases, in particular, in mucous membrane pemphigoid, pemphigus vulgaris, and paraneoplastic pemphigus. The clinical symptoms are heterogeneous and may present with erythema, blisters, erosions, and ulcers localized anywhere on the oral mucosa, and lead to severe complaints for the patients including pain, dysphagia, and foetor. Therefore, a quick and proper diagnosis with adequate treatment is needed. Clinical presentations of autoimmune bullous diseases often overlap and diagnosis cannot be made based on clinical features alone. Immunodiagnostic tests are of great importance in differentiating between the different diseases. Direct immunofluorescence microscopy shows depositions of autoantibodies along the epithelial basement membrane zone in mucous membrane pemphigoid subtypes, or depositions on the epithelial cell surface in pemphigus variants. Additional immunoserological tests are useful to discriminate between the different subtypes of pemphigoid, and are essential to differentiate between pemphigus and paraneoplastic pemphigus. This review gives an overview of the clinical characteristics of oral lesions and the diagnostic procedures in autoimmune blistering diseases, and provides a diagnostic algorithm for daily practice.
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Affiliation(s)
- Hanan Rashid
- Department of Dermatology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands.
| | - Aniek Lamberts
- Department of Dermatology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
| | - Gilles F H Diercks
- Department of Dermatology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
- Department of Pathology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Hendri H Pas
- Department of Dermatology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
| | - Joost M Meijer
- Department of Dermatology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
| | - Maria C Bolling
- Department of Dermatology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
| | - Barbara Horváth
- Department of Dermatology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
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22
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Maruta CW, Miyamoto D, Aoki V, de Carvalho RGR, Cunha BM, Santi CG. Paraneoplastic pemphigus: a clinical, laboratorial, and therapeutic overview. An Bras Dermatol 2019; 94:388-398. [PMID: 31644609 PMCID: PMC7007015 DOI: 10.1590/abd1806-4841.20199165] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Accepted: 06/17/2019] [Indexed: 12/27/2022] Open
Abstract
Paraneoplastic pemphigus is a rare and severe autoimmune blistering disease characterized by mucocutaneous lesions associated with benign and malignant neoplasms. Diagnostic criteria include the presence of chronic mucositis and polymorphic cutaneous lesions with occult or confirmed neoplasia; histopathological analysis exhibiting intraepidermal acantholysis, necrotic keratinocytes, and vacuolar interface dermatitis; direct immunofluorescence with intercellular deposits (IgG and C3) and at the basement membrane zone (IgG); indirect immunofluorescence with intercellular deposition of IgG (substrates: monkey esophagus and simple, columnar, and transitional epithelium); and, autoreactivity to desmogleins 1 and 3, desmocollins 1, 2, and 3, desmoplakins I and II, envoplakin, periplakin, epiplakin, plectin, BP230, and α-2-macroglobulin-like protein 1. Neoplasias frequently related to paraneoplastic pemphigus include chronic lymphocytic leukemia, non-Hodgkin lymphoma, carcinomas, Castleman disease, thymoma, and others. Currently, there is no standardized treatment for paraneoplastic pemphigus. Systemic corticosteroids, azathioprine, mycophenolate mofetil, cyclosporine, rituximab, cyclophosphamide, plasmapheresis, and intravenous immunoglobulin have been used, with variable outcomes. Reported survival rates in 1, 2, and 5 years are 49%, 41%, and 38%, respectively.
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Affiliation(s)
- Celina Wakisaka Maruta
- Department of Dermatology, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Denise Miyamoto
- Department of Dermatology, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Valeria Aoki
- Department of Dermatology, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | | | - Breno Medeiros Cunha
- Department of Dermatology, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Claudia Giuli Santi
- Department of Dermatology, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
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23
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Keller JJ, Fett NM, Morrison LH. Dermatology in the Diagnosis of Noncutaneous Malignancy. Dermatol Clin 2019; 37:537-544. [DOI: 10.1016/j.det.2019.05.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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24
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Deschaine MA, Lehman JS. The interface reaction pattern in the skin: an integrated review of clinical and pathological features. Hum Pathol 2019; 91:86-113. [DOI: 10.1016/j.humpath.2019.06.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 06/18/2019] [Accepted: 06/20/2019] [Indexed: 12/14/2022]
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25
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26
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Didona D, Maglie R, Eming R, Hertl M. Pemphigus: Current and Future Therapeutic Strategies. Front Immunol 2019; 10:1418. [PMID: 31293582 PMCID: PMC6603181 DOI: 10.3389/fimmu.2019.01418] [Citation(s) in RCA: 125] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Accepted: 06/05/2019] [Indexed: 12/16/2022] Open
Abstract
Pemphigus encompasses a heterogeneous group of autoimmune blistering diseases, which affect both mucous membranes and the skin. The disease usually runs a chronic-relapsing course, with a potentially devastating impact on the patients' quality of life. Pemphigus pathogenesis is related to IgG autoantibodies targeting various adhesion molecules in the epidermis, including desmoglein (Dsg) 1 and 3, major components of desmosomes. The pathogenic relevance of such autoantibodies has been largely demonstrated experimentally. IgG autoantibody binding to Dsg results in loss of epidermal keratinocyte adhesion, a phenomenon referred to as acantholysis. This in turn causes intra-epidermal blistering and the clinical appearance of flaccid blisters and erosions at involved sites. Since the advent of glucocorticoids, the overall prognosis of pemphigus has largely improved. However, mortality persists elevated, since long-term use of high dose corticosteroids and adjuvant steroid-sparing immunosuppressants portend a high risk of serious adverse events, especially infections. Recently, rituximab, a chimeric anti CD20 monoclonal antibody which induces B-cell depletion, has been shown to improve patients' survival, as early rituximab use results in higher disease remission rates, long term clinical response and faster prednisone tapering compared to conventional immunosuppressive therapies, leading to its approval as a first line therapy in pemphigus. Other anti B-cell therapies targeting B-cell receptor or downstream molecules are currently tried in clinical studies. More intriguingly, a preliminary study in a preclinical mouse model of pemphigus has shown promise regarding future therapeutic application of Chimeric Autoantibody Receptor T-cells engineered using Dsg domains to selectively target autoreactive B-cells. Conversely, previous studies from our group have demonstrated that B-cell depletion in pemphigus resulted in secondary impairment of T-cell function; this may account for the observed long-term remission following B-cell recovery in rituximab treated patients. Likewise, our data support the critical role of Dsg-specific T-cell clones in orchestrating the inflammatory response and B-cell activation in pemphigus. Monitoring autoreactive T-cells in patients may indeed provide further information on the role of these cells, and would be the starting point for designating therapies aimed at restoring the lost immune tolerance against Dsg. The present review focuses on current advances, unmet challenges and future perspectives of pemphigus management.
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Affiliation(s)
- Dario Didona
- Department of Dermatology and Allergology, Philipps University, Marburg, Germany
| | - Roberto Maglie
- Department of Dermatology and Allergology, Philipps University, Marburg, Germany.,Surgery and Translational Medicine, Section of Dermatology, University of Florence, Florence, Italy.,Section of Dermatology, Departement of Health Sciences, University of Florence, Florence, Italy
| | - Rüdiger Eming
- Department of Dermatology and Allergology, Philipps University, Marburg, Germany
| | - Michael Hertl
- Department of Dermatology and Allergology, Philipps University, Marburg, Germany
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27
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Solimani F, Maglie R, Pollmann R, Schmidt T, Schmidt A, Ishii N, Tackenberg B, Kirschbaum A, Didona D, Pickert J, Eming R, Hashimoto T, Hertl M. Thymoma-Associated Paraneoplastic Autoimmune Multiorgan Syndrome-From Pemphigus to Lichenoid Dermatitis. Front Immunol 2019; 10:1413. [PMID: 31293579 PMCID: PMC6598597 DOI: 10.3389/fimmu.2019.01413] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 06/04/2019] [Indexed: 12/25/2022] Open
Abstract
Introduction: Paraneoplastic autoimmune multi-organ syndrome (PAMS) is a rare clinical condition characterized by variable and heterogeneous clinical phenotypes in the presence of neoplasias which largely depend on the activation of humoral and cellular immune responses. Clinically, these patients present with a spectrum of antibody-driven pemphigus-like lesions to graft-vs.-host-disease-like exanthemas with a lichenoid inflammatory infiltrate in the skin. PAMS is occasionally associated with thymoma, in which altered immune surveillance eventually leads to multiorgan autoimmunity which often includes variable cutaneous symptoms. This disorder is associated with a profound disturbance of peripheral immune tolerance against human autoantigens. Objectives: We here present a patient with relapsing thymoma who developed PAMS with several cutaneous and extracutaneous autoimmune disorders. Materials: Peripheral blood mononuclear cells (PBMC), sera, and lesional skin biopsies were obtained at different clinical disease stages. Peripheral T cell subsets were characterized phenotypically and the cytokine profile of the peripheral blood T cellular response against distinct epidermal and dermal autoantigens of the skin was analyzed by ELISpot assay. Serological screening was performed by ELISA and immunoblot analysis. Skin biopsies were subjected to immunohistochemical analysis of distinct T cell subsets. Thymoma tissue was analyzed for the presence of T regulatory cells and compared with adult thymus and indolent thymoma. Results and Conclusions: In the present case, thymoma was the cause of the observed multi-organ autoimmune syndromes as its recurrence and surgical removal was associated with the relapse and regression of the cutaneous symptoms, respectively. Initially, the patient presented with two autoimmune disorders with Th2/Th1 imbalance, myasthenia gravis (MG) and pemphigus foliaceus (PF), which regressed upon immunosuppressive treatment. Months later, the patient developed a lichenoid exanthema with a Th1-dominated skin infiltrate. Further clinical evaluation revealed the recurrence of the thymoma and the lichenoid exanthema gradually regressed upon thymectomy. Our contention that T cell recognition against distinct cutaneous autoantigens, such as desmoglein 1 (Dsg1), shifted from a Th2 to a Th1-dominated immune response could not be fully substantiated as the patient was on a stringent immunosuppressive treatment regimen. We could only observe a decrease of the initially present serum IgG autoantibodies against Dsg1. Phenotypic analysis of the associated thymoma showed a lower number of T regulatory cells compared to adult thymus and indolent thymoma, suggesting that impaired thymus-derived immune surveillance had a direct impact on the outcome of the observed cutaneous autoimmune disorders.
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Affiliation(s)
- Farzan Solimani
- Department of Dermatology and Allergology, Philipps-University, Marburg, Germany
| | - Roberto Maglie
- Department of Dermatology and Allergology, Philipps-University, Marburg, Germany
| | - Robert Pollmann
- Department of Dermatology and Allergology, Philipps-University, Marburg, Germany
| | - Thomas Schmidt
- Department of Dermatology and Allergology, Philipps-University, Marburg, Germany
| | - Ansgar Schmidt
- Institute of Pathology, Philipps-University, Marburg, Germany
| | - Norito Ishii
- Department of Dermatology, Kurume University School of Medicine, and Kurume University Institute of Cutaneous Cell Biology, Kurume, Japan
| | - Björn Tackenberg
- Department of Neuroimmunology, Philipps-University, Marburg, Germany
| | | | - Dario Didona
- Department of Dermatology and Allergology, Philipps-University, Marburg, Germany
| | - Julia Pickert
- Department of Dermatology and Allergology, Philipps-University, Marburg, Germany
| | - Rüdiger Eming
- Department of Dermatology and Allergology, Philipps-University, Marburg, Germany
| | - Takashi Hashimoto
- Department of Surgery, Philipps-University, Marburg, Germany
- Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Michael Hertl
- Department of Dermatology and Allergology, Philipps-University, Marburg, Germany
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28
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Buonavoglia A, Leone P, Dammacco R, Di Lernia G, Petruzzi M, Bonamonte D, Vacca A, Racanelli V, Dammacco F. Pemphigus and mucous membrane pemphigoid: An update from diagnosis to therapy. Autoimmun Rev 2019; 18:349-358. [PMID: 30738958 DOI: 10.1016/j.autrev.2019.02.005] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Accepted: 11/02/2018] [Indexed: 12/23/2022]
Abstract
Pemphigus diseases (PDs) and mucous membrane pemphigoid (MMP) are a group of immune-mediated mucocutaneous disorders clinically characterized by the formation of blisters, erosions and ulcers. The skin and mucous membranes are predominantly affected, with the oropharyngeal mucosa as the initially involved site. Ocular involvement is also a frequent feature of these diseases. Because of the considerable overlap in their clinical presentations, the diagnosis of PDs vs. MMP can be challenging. A recognition of their specific immunological and histopathologic features is crucial in the differential diagnosis. Treatment modalities include systemically administered corticosteroids, steroid-sparing immunosuppressive agents, and biologic therapies (rituximab, intravenous immunoglobulins, and anti-tumor necrosis factor agents). Topical, oral, conjunctival, or intralesional corticosteroids as well as anti-inflammatory drugs and antibiotics are prescribed as needed.
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Affiliation(s)
- Alessio Buonavoglia
- Department of Biomedical Sciences and Human Oncology, Unit of Internal Medicine "Guido Baccelli", University of Bari Medical School, Bari, Italy
| | - Patrizia Leone
- Department of Biomedical Sciences and Human Oncology, Unit of Internal Medicine "Guido Baccelli", University of Bari Medical School, Bari, Italy
| | - Rosanna Dammacco
- Department of Ophthalmology and Neuroscience, University of Bari Medical School, Bari, Italy
| | - Giuseppe Di Lernia
- Department of Biomedical Sciences and Human Oncology, Unit of Internal Medicine "Guido Baccelli", University of Bari Medical School, Bari, Italy
| | - Massimo Petruzzi
- Interdisciplinary Department of Medicine, Section of Dentistry, University of Bari Medical School, Bari, Italy
| | - Domenico Bonamonte
- Department of Biomedical Sciences and Human Oncology, Dermatology Unit, University of Bari Medical School, Bari, Italy
| | - Angelo Vacca
- Department of Biomedical Sciences and Human Oncology, Unit of Internal Medicine "Guido Baccelli", University of Bari Medical School, Bari, Italy
| | - Vito Racanelli
- Department of Biomedical Sciences and Human Oncology, Unit of Internal Medicine "Guido Baccelli", University of Bari Medical School, Bari, Italy.
| | - Franco Dammacco
- Department of Biomedical Sciences and Human Oncology, Unit of Internal Medicine "Guido Baccelli", University of Bari Medical School, Bari, Italy.
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Abstract
Pemphigus forms a group of rare autoimmune bullous diseases that affect the skin and mucous membranes. This group has a chronic course leading to high morbidity and mortality. It is characterized by the production of pathogenic autoantibodies directed against different proteins of the desmosome, leading histologically to intraepidermal cleavage, and clinically to vesicles and erosions on the epithelium of the mucous membranes and/or the skin. The diagnosis of the subtype of pemphigus is based on clinical features, the level of histologic cleavage, and the identification of the antigens recognized by circulating autoantibodies by immunoserological analyses. The epidemiological features of pemphigus vary considerably in different regions of the world. Observational studies examining comorbidities and associations among patients with pemphigus are scarce and sometimes inconclusive. The prognosis, mortality, and clinical outcomes in pemphigus have undergone dramatic change throughout the years. This review provides a brief overview about the different subtypes of pemphigus: pemphigus vulgaris, pemphigus foliaceus, paraneoplastic pemphigus, pemphigus herpetiformis, and IgA pemphigus. In addition, it summarizes the most recent understanding of the epidemiology, mortality data, and comorbidities of this group of organ-specific autoimmune diseases.
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Chen WS, Tetzlaff MT, Diwan H, Jahan-Tigh R, Diab A, Nelson K, Glitza IC, Kaunitz GJ, Johnson D, Torres-Cabala C, Pacha O, Taube JM, Maloney K, Prieto VG, Curry JL. Suprabasal acantholytic dermatologic toxicities associated checkpoint inhibitor therapy: A spectrum of immune reactions from paraneoplastic pemphigus-like to Grover-like lesions. J Cutan Pathol 2018; 45:764-773. [PMID: 29943453 DOI: 10.1111/cup.13312] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Revised: 06/15/2018] [Accepted: 06/20/2018] [Indexed: 12/31/2022]
Abstract
Checkpoint inhibitors (CPIs) restore the function of effector immunocytes to target and destroy cancer cells. Immune-related adverse events (irAEs) are a consequence of immune reactivation, with unpredictable inflammatory response, loss of self-tolerance, and development of autoimmunity. Adverse events from CPIs that present as dermatologic toxicities have diverse clinical and histopathologic features. CPI-associated dermatologic toxicities may exhibit histopathologic features of lichenoid dermatitis, bullous pemphigoid, and granulomatous/sarcoid-like reactions. Suprabasal acantholytic dermatologic toxicities associated with CPIs are particularly rare but represent an emerging histopathologic pattern and include lichenoid dermatitis with suprabasal acantholysis/vesicle formation to Grover disease (transient acantholytic dermatosis). Here, we report two patients who developed suprabasal acantholytic dermatologic toxicities during CPI therapy. One patient exhibited a CPI-associated autoimmune blistering disease with paraneoplastic pemphigus (PNP)-like features restricted to histopathology and immunofluorescence, while the other patient had Grover-like lesions. A review of the literature revealed a spectrum of suprabasal acantholytic dermatologic toxicities associated CPIs that may present as lichenoid dermatitis with acantholysis/vesicle formation, Grover-like eruptions, and lesions with PNP-like features restricted to histopathology and immunofluorescence. It is important for clinicians and pathologists to recognize the types of dermatologic toxicities associated with CPIs to direct appropriate therapeutic strategies.
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Affiliation(s)
- Wei-Shen Chen
- Section of Dermatopathology, Department of Pathology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Michael T Tetzlaff
- Section of Dermatopathology, Department of Pathology, University of Texas MD Anderson Cancer Center, Houston, Texas
- Department of Translational Molecular Pathology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Hafeez Diwan
- Department of Pathology, Baylor College of Medicine, Houston, Texas
| | - Richard Jahan-Tigh
- Department of Dermatology, University of Texas Health Science, Houston, Texas
| | - Adi Diab
- Department of Melanoma Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Kelly Nelson
- Department of Dermatology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Isabella C Glitza
- Department of Melanoma Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Genevieve J Kaunitz
- Department of Dermatology, Johns Hopkins University School of Medicine and Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland
| | - Daniel Johnson
- Department of Melanoma Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Carlos Torres-Cabala
- Section of Dermatopathology, Department of Pathology, University of Texas MD Anderson Cancer Center, Houston, Texas
- Department of Dermatology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Omar Pacha
- Department of Dermatology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Janis M Taube
- Department of Dermatology, Johns Hopkins University School of Medicine and Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland
- Department of Pathology and Oncology, Johns Hopkins University School of Medicine and Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland
| | - Kudakwashe Maloney
- Department of Dermatology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Victor G Prieto
- Section of Dermatopathology, Department of Pathology, University of Texas MD Anderson Cancer Center, Houston, Texas
- Department of Dermatology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jonathan L Curry
- Section of Dermatopathology, Department of Pathology, University of Texas MD Anderson Cancer Center, Houston, Texas
- Department of Translational Molecular Pathology, University of Texas MD Anderson Cancer Center, Houston, Texas
- Department of Dermatology, University of Texas MD Anderson Cancer Center, Houston, Texas
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Amber KT, Valdebran M, Grando SA. Paraneoplastic autoimmune multiorgan syndrome (PAMS): Beyond the single phenotype of paraneoplastic pemphigus. Autoimmun Rev 2018; 17:1002-1010. [DOI: 10.1016/j.autrev.2018.04.008] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 04/15/2018] [Indexed: 12/20/2022]
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Fournet M, Roblot P, P Levillain, Guillet G, Machet L, Misery L. [Paraneoplastic pemphigus: Retrospective study of a case series]. Ann Dermatol Venereol 2018; 145:564-571. [PMID: 30126641 DOI: 10.1016/j.annder.2018.01.050] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 09/04/2017] [Accepted: 01/19/2018] [Indexed: 01/31/2023]
Abstract
CONTEXT Paraneoplastic pemphigus (PNP) is a rare condition associated with poor prognosis. It associates polymorphic mucocutaneous manifestations with neoplasia. Diagnosis is difficult because of the various clinical and histological features involved and the lack of specificity of immunological examinations. METHODS We retrospectively analyzed the records of patients presenting with PNP in the Poitou-Charentes region between 2000 and 2015. RESULTS Seven patients were included. They presented 9 neoplasias (1 lymphoma, 1 melanoma, and 7 carcinomas) diagnosed from 4 months before to 25 months after the occurrence of cutaneous (6/7) and/or mucosal (6/7) polymorphic lesions. Histological examination revealed epidermal acantholysis (7/7), keratinocytic necrosis (4/7), and interface lichenoid dermatitis (5/7). Intercellular deposits of IgG and C3 or along the dermo-epidermal junction were detected with direct immunofluorescence (IF) (7/7). Four of 6 patients tested had positive indirect IF on rat bladder epithelium. Follow-up ranged from 1-132 months with a one-year survival of 85.7%. DISCUSSION The clinical and histopathological presentations observed in our patients were polymorphic, with overlap between the clinical and histological features of PNP and classical pemphigus. Prognosis and survival appear better in our series than in the literature. It is possible that in some cases, the association of pemphigus with neoplasia was fortuitous, which might account for the better prognosis. A new consensus on the diagnostic criteria for PNP is needed to help practitioners to consensually diagnose it for prognostic or therapeutic trials.
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Affiliation(s)
- M Fournet
- Service de dermatologie, centre hospitalier universitaire de Poitiers, 2, rue de la Milétrie, 86021 Poitiers, France
| | - P Roblot
- Service de médecine Interne, centre hospitalier universitaire de Poitiers, 2, rue de la Milétrie, 86021 Poitiers, France
| | - P Levillain
- Service d'anatomo-pathologie, centre hospitalier universitaire de Poitiers, 2, rue de la Milétrie, 86021 Poitiers, France
| | - G Guillet
- Service de dermatologie, centre hospitalier universitaire de Poitiers, 2, rue de la Milétrie, 86021 Poitiers, France
| | - L Machet
- Service de dermatologie, centre hospitalier régional universitaire de Tours, 2, boulevard Tonnellé, 37000 Tours, France
| | - L Misery
- Service de dermatologie, centre hospitalier régional universitaire de Brest, 2, avenue Foch, 29200 Brest, France.
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Decaux J, Ferreira I, Van Eeckhout P, Dachelet C, Magremanne M. Buccal paraneoplastic pemphigus multi-resistant: Case report and review of diagnostic and therapeutic strategies. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2018; 119:506-509. [PMID: 29885912 DOI: 10.1016/j.jormas.2018.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 05/11/2018] [Accepted: 06/01/2018] [Indexed: 10/14/2022]
Abstract
Paraneoplastic pemphigus is a rare autoimmune blistering disease generally associated with malignancy. The clinical presentation consists typically of painful and diffuse erosive stomatitis that may be accompanied by polymorphic skin lesions and systemic involvement. Diagnosis is based on clinical manifestations and confirmed by histology and immunological testing. The current first-line treatment is systemic corticosteroids and adjuvant therapies, including immunosuppressive agents. We report a case of buccal paraneoplastic pemphigus resistant to ibrutinib and rituximab successfully treated with azathioprine and polyclonal immunoglobulins.
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Affiliation(s)
- J Decaux
- Department of oral and maxillofacial surgery, cliniques universitaires Saint-Luc, université catholique de Louvain, avenue Hippocrate 10, 1200 Woluwe-Saint-Lambert, Belgium.
| | - I Ferreira
- Department of pathology, cliniques universitaires Saint-Luc, université catholique de Louvain, avenue Hippocrate 10, 1200 Woluwe-Saint-Lambert, Belgium
| | - P Van Eeckhout
- Department of pathology, cliniques universitaires Saint-Luc, université catholique de Louvain, avenue Hippocrate 10, 1200 Woluwe-Saint-Lambert, Belgium
| | - C Dachelet
- Department of pathology, cliniques universitaires Saint-Luc, université catholique de Louvain, avenue Hippocrate 10, 1200 Woluwe-Saint-Lambert, Belgium
| | - M Magremanne
- Department of oral and maxillofacial surgery, cliniques universitaires Saint-Luc, université catholique de Louvain, avenue Hippocrate 10, 1200 Woluwe-Saint-Lambert, Belgium
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Paraneoplastic Pemphigus Associated With Castleman Disease Detected by 18F-FDG PET/CT. Clin Nucl Med 2018; 43:464-465. [DOI: 10.1097/rlu.0000000000002072] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Allenova A, Lepekhova A, Olisova O, Teplyuk N, Kolkhir P. Paraneoplastic pemphigus in Russian patients: a single center case series. Int J Dermatol 2018; 57:e44-e46. [PMID: 29797440 DOI: 10.1111/ijd.14056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Revised: 03/06/2018] [Accepted: 04/24/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Anastasiia Allenova
- Division of Immune-mediated Skin Diseases, Department of Dermatology and Venereology, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Anfisa Lepekhova
- Division of Immune-mediated Skin Diseases, Department of Dermatology and Venereology, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Olga Olisova
- Division of Immune-mediated Skin Diseases, Department of Dermatology and Venereology, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Natalya Teplyuk
- Division of Immune-mediated Skin Diseases, Department of Dermatology and Venereology, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Pavel Kolkhir
- Division of Immune-mediated Skin Diseases, Department of Dermatology and Venereology, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
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Maderal AD, Lee Salisbury P, Jorizzo JL. Desquamative gingivitis. J Am Acad Dermatol 2018; 78:839-848. [DOI: 10.1016/j.jaad.2017.05.056] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 05/30/2017] [Accepted: 05/31/2017] [Indexed: 12/13/2022]
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Paraneoplastic autoimmune multi-organ syndrome is a distinct entity from traditional pemphigus subtypes. Nat Rev Dis Primers 2018; 4:18012. [PMID: 29469089 DOI: 10.1038/nrdp.2018.12] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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38
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Paraneoplastic Pemphigus. A Life-Threatening Autoimmune Blistering Disease. ACTAS DERMO-SIFILIOGRAFICAS 2017; 108:902-910. [DOI: 10.1016/j.ad.2017.04.024] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2016] [Revised: 04/16/2017] [Accepted: 04/18/2017] [Indexed: 11/18/2022] Open
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Tirado-Sánchez A, Bonifaz A. Paraneoplastic Pemphigus. A Life-Threatening Autoimmune Blistering Disease. ACTAS DERMO-SIFILIOGRAFICAS 2017. [DOI: 10.1016/j.adengl.2017.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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40
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Paraneoplastic Pemphigus: Insight into the Autoimmune Pathogenesis, Clinical Features and Therapy. Int J Mol Sci 2017; 18:ijms18122532. [PMID: 29186863 PMCID: PMC5751135 DOI: 10.3390/ijms18122532] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 11/09/2017] [Accepted: 11/24/2017] [Indexed: 11/17/2022] Open
Abstract
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.
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41
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Li AW, Yin ES, Stahl M, Kim TK, Panse G, Zeidan AM, Leventhal JS. The skin as a window to the blood: Cutaneous manifestations of myeloid malignancies. Blood Rev 2017; 31:370-388. [DOI: 10.1016/j.blre.2017.07.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 05/26/2017] [Accepted: 07/11/2017] [Indexed: 12/18/2022]
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42
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Patel S, Miteva M. SnapshotDx Quiz: November 2017. J Invest Dermatol 2017; 137:e193. [PMID: 29055416 DOI: 10.1016/j.jid.2017.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Shailee Patel
- Department of Dermatology and Cutaneous Surgery, University of Miami L. Miller School of Medicine
| | - Mariya Miteva
- Department of Dermatology and Cutaneous Surgery, University of Miami L. Miller School of Medicine.
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Lee A, Sandhu S, Imlay-Gillespie L, Mulligan S, Shumack S. Successful use of Bruton's kinase inhibitor, ibrutinib, to control paraneoplastic pemphigus in a patient with paraneoplastic autoimmune multiorgan syndrome and chronic lymphocytic leukaemia. Australas J Dermatol 2017; 58:e240-e242. [PMID: 28295171 DOI: 10.1111/ajd.12615] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2016] [Accepted: 12/18/2016] [Indexed: 12/22/2022]
Abstract
We present the case of a 51-year-old man who developed paraneoplastic pemphigus (PNP) in the context of chronic lymphocytic leukemia (CLL). His CLL was successfully controlled with ibrutinib. Concurrently, there was significant improvement of his PNP, suggesting that ibrutinib may be a very useful addition to the treatment options in this potentially life-threatening autoimmune disorder.
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Affiliation(s)
- Andrew Lee
- Department of Dermatology, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Sydney Medical School Northern, University of Sydney, Sydney, New South Wales, Australia
| | - Suneet Sandhu
- Department of Haematology, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Northern Blood Research Centre, Kolling Institute, Northern Sydney Local Health District, Sydney, New South Wales, Australia
| | - Louise Imlay-Gillespie
- Department of Haematology, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Stephen Mulligan
- Sydney Medical School Northern, University of Sydney, Sydney, New South Wales, Australia.,Department of Haematology, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Northern Blood Research Centre, Kolling Institute, Northern Sydney Local Health District, Sydney, New South Wales, Australia
| | - Stephen Shumack
- Department of Dermatology, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Sydney Medical School Northern, University of Sydney, Sydney, New South Wales, Australia
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Wang YZ, Gao ZY, Lei FM, Zhang JX, Gu J. A Case Report on Paraneoplastic Pemphigus Associated Colonic Carcinoma. Chin Med J (Engl) 2017; 129:1501-2. [PMID: 27270550 PMCID: PMC4910378 DOI: 10.4103/0366-6999.183422] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Affiliation(s)
- Yan-Zhao Wang
- Department of General Surgery, Peking University Shougang Hospital, Beijing 100144, China
| | - Zhao-Ya Gao
- Department of General Surgery, Peking University Shougang Hospital, Beijing 100144, China
| | - Fu-Ming Lei
- Department of General Surgery, Peking University Shougang Hospital, Beijing 100144, China
| | - Jin-Xia Zhang
- Department of Pathology, Peking University Shougang Hospital, Beijing 100144, China
| | - Jin Gu
- Department of General Surgery, Peking University Shougang Hospital, Beijing 100144, China
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Kartan S, Shi VY, Clark AK, Chan LS. Paraneoplastic Pemphigus and Autoimmune Blistering Diseases Associated with Neoplasm: Characteristics, Diagnosis, Associated Neoplasms, Proposed Pathogenesis, Treatment. Am J Clin Dermatol 2017; 18:105-126. [PMID: 27878477 DOI: 10.1007/s40257-016-0235-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
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.
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46
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[Para-neoplastic autoimmune multi-organ syndrome associated with follicular lymphoma: a case report and literature review]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2016; 37:1049-1053. [PMID: 28088968 PMCID: PMC7348497 DOI: 10.3760/cma.j.issn.0253-2727.2016.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Objective: To broaden our knowledge of para-neoplastic autoimmune multi-organ syndrome (PAMS). Methods: A patient with PAMS associated with follicular lymphoma and bronchiolitis obliterans treated in our hospital was retrospectively analyzed and the clinical features of PAMS were reviewed. Results: A 49-year-old female patient suffered from painful ulcers in the oral cavity and vagina, dry cough and dyspnea. Imaging examinations suggested multiple lymph node enlargements. Inguinal lymph node biopsy revealed follicular lymphoma. Although the oral and vaginal ulcers went into remission with glucocorticoid and thalidomide therapy and follicular lymphoma gained partial remission with six cycles of R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisolone) chemotherapy, respiratory failure still progressed. Conclusion: PAMS should be considered in patients with unexplained oral mucosa ulcers and dyspnea, which didn't match with the chest image manifestations. Extensive work-up should be performed to find out the potential tumor after diagnosis of PAMS. Early diagnosis and complete removal of tumor were essential to PAMS treatment.
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Abstract
Paraneoplastic pemphigus (PNP) is a fatal autoimmune blistering disease associated with an underlying malignancy. It is a newly recognized blistering disease, which was first recognized in 1990 by Dr Anhalt who described an atypical pemphigus with associated neoplasia. In 2001, Nguyen proposed the term paraneoplastic autoimmune multiorgan syndrome because of the recognition that the condition affects multiple organ systems. PNP presents most frequently between 45 and 70 years old, but it also occurs in children and adolescents. A wide variety of lesions (florid oral mucosal lesions, a generalized polymorphous cutaneous eruption, and pulmonary involvement) may occur in patients with PNP. The earliest and most consistent finding is severe stomatitis. There is a spectrum of at least five clinical variants with different morphology. Similarly, the histological findings are very variable. Investigations to diagnose PNP should include checking for systemic complications (to identify tumor), skin biopsies (for histopathological and immunofluorescence studies), and serum immunological studies. PNP is characterized by the presence of autoantibodies against antigens such as desmoplakin I (250 kD), bullous pemphigoid aniygen I (230 kD), desmoplakin II (210 kD), envoplakin (210 kD), periplakin (190 kD), plectin (500 kD), and a 170 kD protein. Unlike other forms of pemphigus, PNP can affect other types of epithelia, such as gastrointestinal and respiratory tract. Treatment of PNP is difficult, and the best outcomes have been reported with benign neoplasms that have been surgically excised. The first-line treatment is high-dose corticosteroids with the addition of steroid-sparing agents. Treatment failures are often managed with rituximab with or without concomitant intravenous immunoglobulin. In general, the prognosis is poor, not only because of eventual progression of malignant tumors but also because treatment with aggressive immunosuppression therapy often results in infectious complications, which is unfortunately at this time the most common cause of death in PNP.
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Affiliation(s)
- Marta Wieczorek
- Clinical Department of Dermatology, Central Clinical Hospital of the Ministry of the Interior and Administration, Warsaw, Poland
| | - Annette Czernik
- Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Piscopo R, Romano M, Maria AD, Vinciguerra R, Vinciguerra P. Ocular Onset of Paraneoplastic Pemphigus Presenting as Hyperemic Conjunctivitis and Massive Bilateral Eyelid Ulceration: A Case Report and Literature Review. Ocul Immunol Inflamm 2016; 26:265-268. [PMID: 27537424 DOI: 10.1080/09273948.2016.1203958] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Paraneoplastic clinical signs are characterized by a large and heterogeneous variety of manifestations due to several possible underlying neoplasms. Paraneoplastic pemphigus (PNP) is a particular paraneoplastic variety that usually primarily affects the dermic and/or oral mucosa and is characterized by a high rate of mortality (90%). Therefore, it is important to recognize its possible signs early. This report describes a case of ocular paraneoplastic pemphigus (PNP) presenting with recalcitrant eyelid ulceration and hyperemic conjunctivitis caused by an undiagnosed prostate cancer. METHODS A 77-year-old man was admitted to our department because of recalcitrant hyperemic conjunctivitis in both eyes, complicated with large ulceration of both upper eyelids in spite of topical therapy. After 3 weeks, oral mucositis and bullous dermatitis on the chest and arms developed. RESULTS Complete slit lamp ocular study, conjunctival swabs, routine hematologic tests, serum neoplasm markers, indirect immunofluorescence study, immunoblotting, and oral mucose biopsy with direct immunofluorescence were performed under the hypothesis of a paraneoplastic sign. Total body computed tomography scan and ultrasound-guided needle prostate biopsy completed the diagnostic process and confirmed the diagnosis of prostate PNP. Complete remission of ocular clinical signs was achieved by treatment of the prostate malignancy with systemic immunosuppressive therapy and chemotherapy.
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Affiliation(s)
- Raffaele Piscopo
- a Department of Ophthalmology , Humanitas Clinical and Research Institute , Rozzano , Milan , Italy
| | - Mary Romano
- b Department of Ophthalmology , Second University of Naples , Napoli , Italy
| | - Alessandra Di Maria
- a Department of Ophthalmology , Humanitas Clinical and Research Institute , Rozzano , Milan , Italy
| | - Riccardo Vinciguerra
- a Department of Ophthalmology , Humanitas Clinical and Research Institute , Rozzano , Milan , Italy
| | - Paolo Vinciguerra
- a Department of Ophthalmology , Humanitas Clinical and Research Institute , Rozzano , Milan , Italy
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Poot A, Siland J, Jonkman M, Pas H, Diercks G. Direct and indirect immunofluorescence staining patterns in the diagnosis of paraneoplastic pemphigus. Br J Dermatol 2016; 174:912-5. [DOI: 10.1111/bjd.14282] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- A.M. Poot
- Center for Blistering Diseases; Department of Dermatology; University Medical Center Groningen; University of Groningen; Hanzeplein 1 9700 RB Groningen the Netherlands
| | - J. Siland
- Center for Blistering Diseases; Department of Dermatology; University Medical Center Groningen; University of Groningen; Hanzeplein 1 9700 RB Groningen the Netherlands
| | - M.F. Jonkman
- Center for Blistering Diseases; Department of Dermatology; University Medical Center Groningen; University of Groningen; Hanzeplein 1 9700 RB Groningen the Netherlands
| | - H.H. Pas
- Center for Blistering Diseases; Department of Dermatology; University Medical Center Groningen; University of Groningen; Hanzeplein 1 9700 RB Groningen the Netherlands
| | - G.F.H. Diercks
- Center for Blistering Diseases; Department of Dermatology; University Medical Center Groningen; University of Groningen; Hanzeplein 1 9700 RB Groningen the Netherlands
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Abstract
Paraneoplastic pemphigus (PNP) is an autoimmune mucocutaneous blistering disease driven by autoantibodies against plakins expressed in mucosal epithelium. Diagnosis can be difficult as both clinical and biopsy features overlap with other blistering disorders, thus serology is important. Indirect immunofluorescence (IIF) on rat bladder substrate is the most widely used assay, but plakin-specific autoantibody assays have recently become available.The aim of this study was to compare the performance of five PNP assays in patients with mucosal blistering disease: IIF with rat bladder, monkey bladder and rat cardiac substrates, an envoplakin enzyme-linked immunosorbent assay (ELISA), and an envoplakin-transfected HEK cell based assay (CBA).Fifty-one patient serum samples, comprising three PNP patients and 48 disease controls, were collected along with 10 healthy control samples, and analysed using the five assays.IIF on rat and monkey bladder substrates both showed high specificity (97% and 95%, respectively), and correctly identified all three PNP sera. The envoplakin ELISA was equally specific (98%) but identified only one PNP patient. The CBA was difficult to interpret, and both this assay and IIF on rat cardiac substrate lacked specificity (82% and 83%, respectively).In this study IIF using either rat or monkey bladder substrates performed strongly, whilst the envoplakin ELISA seemed to lack sensitivity, and the CBA and IIF on rat cardiac substrate were inferior. Our findings suggest that traditional IIF-based assays remain the preferred approach in the serological diagnosis of PNP.
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