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van Beek N, Holtsche MM, Atefi I, Olbrich H, Schmitz MJ, Pruessmann J, Vorobyev A, Schmidt E. State-of-the-art diagnosis of autoimmune blistering diseases. Front Immunol 2024; 15:1363032. [PMID: 38903493 PMCID: PMC11187241 DOI: 10.3389/fimmu.2024.1363032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 02/15/2024] [Indexed: 06/22/2024] Open
Abstract
Autoimmune blistering disorders (AIBDs) are a heterogeneous group of approximately a dozen entities comprising pemphigus and pemphigoid disorders and dermatitis herpetiformis. The exact diagnosis of AIBDs is critical for both prognosis and treatment and is based on the clinical appearance combined with the detection of tissue-bound and circulating autoantibodies. While blisters and erosions on the skin and/or inspectable mucosal surfaces are typical, lesions may be highly variable with erythematous, urticarial, prurigo-like, or eczematous manifestations. While direct immunofluorescence microscopy (IFM) of a perilesional biopsy is still the diagnostic gold standard, the molecular identification of the major target antigens opened novel therapeutic avenues. At present, most AIBDs can be diagnosed by the detection of autoantigen-specific serum antibodies by enzyme-linked immunosorbent assay (ELISA) or indirect IFM when the clinical picture is known. This is achieved by easily available and highly specific and sensitive assays employing recombinant immunodominant fragments of the major target antigens, i.e., desmoglein 1 (for pemphigus foliaceus), desmoglein 3 (for pemphigus vulgaris), envoplakin (for paraneoplastic pemphigus), BP180/type XVII collagen (for bullous pemphigoid, pemphigoid gestationis, and mucous membrane pemphigoid), laminin 332 (for mucous membrane pemphigoid), laminin β4 (for anti-p200 pemphigoid), type VII collagen (for epidermolysis bullosa acquisita and mucous membrane pemphigoid), and transglutaminase 3 (for dermatitis herpetiformis). Indirect IFM on tissue substrates and in-house ELISA and immunoblot tests are required to detect autoantibodies in some AIBD patients including those with linear IgA disease. Here, a straightforward modern approach to diagnosing AIBDs is presented including diagnostic criteria according to national and international guidelines supplemented by long-term in-house expertise.
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Affiliation(s)
- Nina van Beek
- Department of Dermatology, Allergology and Venerology, University of Lübeck, Lübeck, Germany
| | - Maike M. Holtsche
- Department of Dermatology, Allergology and Venerology, University of Lübeck, Lübeck, Germany
| | - Ingeborg Atefi
- Department of Dermatology, Allergology and Venerology, University of Lübeck, Lübeck, Germany
| | - Henning Olbrich
- Department of Dermatology, Allergology and Venerology, University of Lübeck, Lübeck, Germany
| | - Marie J. Schmitz
- Department of Dermatology, Allergology and Venerology, University of Lübeck, Lübeck, Germany
| | - Jasper Pruessmann
- Department of Dermatology, Allergology and Venerology, University of Lübeck, Lübeck, Germany
| | - Artem Vorobyev
- Department of Dermatology, Allergology and Venerology, University of Lübeck, Lübeck, Germany
| | - Enno Schmidt
- Department of Dermatology, Allergology and Venerology, University of Lübeck, Lübeck, Germany
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
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Liu F, Ryan ST, Fahnoe KC, Morgan JG, Cheung AE, Storek MJ, Best A, Chen HA, Locatelli M, Xu S, Schmidt E, Schmidt-Jiménez LF, Bieber K, Henderson JM, Lian CG, Verschoor A, Ludwig RJ, Benigni A, Remuzzi G, Salant DJ, Kalled SL, Thurman JM, Holers VM, Violette SM, Wawersik S. C3d-Targeted factor H inhibits tissue complement in disease models and reduces glomerular injury without affecting circulating complement. Mol Ther 2024; 32:1061-1079. [PMID: 38382529 PMCID: PMC11163200 DOI: 10.1016/j.ymthe.2024.02.001] [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] [Received: 06/30/2023] [Revised: 01/02/2024] [Accepted: 02/01/2024] [Indexed: 02/23/2024] Open
Abstract
Complement-mediated diseases can be treated using systemic inhibitors. However, complement components are abundant in circulation, affecting systemic inhibitors' exposure and efficacy. Furthermore, because of complement's essential role in immunity, systemic treatments raise infection risk in patients. To address these challenges, we developed antibody fusion proteins combining the alternative-pathway complement inhibitor factor H (fH1-5) with an anti-C3d monoclonal antibody (C3d-mAb-2fH). Because C3d is deposited at sites of complement activity, this molecule localizes to tissue complement while minimizing circulating complement engagement. These fusion proteins bind to deposited complement in diseased human skin sections and localize to activated complement in a primate skin injury model. We further explored the pharmacology of C3d-mAb-2fH proteins in rodent models with robust tissue complement activation. Doses of C3d-mAb-2fH >1 mg/kg achieved >75% tissue complement inhibition in mouse and rat injury models while avoiding circulating complement blockade. Glomerular-specific complement inhibition reduced proteinuria and preserved podocyte foot-process architecture in rat membranous nephropathy, indicating disease-modifying efficacy. These data indicate that targeting local tissue complement results in durable and efficacious complement blockade in skin and kidney while avoiding systemic inhibition, suggesting broad applicability of this approach in treating a range of complement-mediated diseases.
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Affiliation(s)
- Fei Liu
- Q32 Bio, Waltham, MA 02451, USA
| | | | | | | | | | | | | | - Hui A Chen
- Department of Pathology and Laboratory Medicine, Chobanian and Avedisian School of Medicine at Boston University and Boston Medical Center, Boston, MA 02118, USA
| | - Monica Locatelli
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, 24126 Bergamo, Italy
| | - Shuyun Xu
- Department of Pathology, Brigham & Women's Hospital/Harvard Medical School, Boston, MA 02115, USA
| | - Enno Schmidt
- Lübeck Institute of Experimental Dermatology, University of Lübeck, 23562 Lübeck, Germany
| | - Leon F Schmidt-Jiménez
- Lübeck Institute of Experimental Dermatology, University of Lübeck, 23562 Lübeck, Germany
| | - Katja Bieber
- Lübeck Institute of Experimental Dermatology, University of Lübeck, 23562 Lübeck, Germany
| | - Joel M Henderson
- Department of Pathology and Laboratory Medicine, Chobanian and Avedisian School of Medicine at Boston University and Boston Medical Center, Boston, MA 02118, USA
| | - Christine G Lian
- Department of Pathology, Brigham & Women's Hospital/Harvard Medical School, Boston, MA 02115, USA
| | - Admar Verschoor
- Department of Otorhinolaryngology, Technische Universität München and Klinikum Rechts der Isar, 81675 Munich, Germany; Department of Dermatology, University Hospital Schleswig-Holstein, University of Lübeck, 23562 Lübeck, Germany
| | - Ralf J Ludwig
- Lübeck Institute of Experimental Dermatology, University of Lübeck, 23562 Lübeck, Germany
| | - Ariela Benigni
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, 24126 Bergamo, Italy
| | - Giuseppe Remuzzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, 24126 Bergamo, Italy
| | - David J Salant
- Department of Medicine, Chobanian and Avedisian School of Medicine at Boston University and Section of Nephrology, Boston Medical Center, Boston, MA 02118, USA
| | | | - Joshua M Thurman
- Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO 80045, USA
| | - V Michael Holers
- Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO 80045, USA
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Sneha Muppala R, Basavaraj V. Role of C4d immunohistochemical marker in the diagnosis of bullous pemphigoid: A cross-sectional study. Indian J Dermatol Venereol Leprol 2024; 0:1-6. [PMID: 38595011 DOI: 10.25259/ijdvl_124_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 09/15/2023] [Indexed: 04/11/2024]
Abstract
Objective To determine the diagnostic utility of C4d immunohistochemical marker in cases of bullous pemphigoid by calculating the sensitivity, specificity, positive predictive value and negative predictive value. Methods We conducted an exploratory study (retrospectively and prospectively) from January 2017 to June 2022. All direct immunofluorescence proven cases of bullous pemphigoid were included in the study while cases with inadequate tissue for immunohistochemistry studies were excluded. Results Among the 57 cases of bullous pemphigoid, 49 showed positivity for C4d marker. All the ten control cases of inflammatory dermatoses were negative for C4d staining. A sensitivity of 86%, a specificity of 100%, a positive predictive value of 100% and a negative predictive value of 55.56% were calculated with a confidence interval of 95%. Conclusion Direct immunofluorescence on fresh or frozen skin tissue remains the gold standard. But in circumstances where direct immunofluorescence facilities are not available, C4d immunohistochemistry marker staining on formalin-fixed paraffin-embedded material submitted for standard microscopic investigation can, in most cases, confirm the diagnosis of bullous pemphigoid, obviating the need for a second biopsy. Limitation It is a single centre study. Selection bias may come into play.
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Affiliation(s)
- Raaga Sneha Muppala
- Department of Pathology, Jagadguru Sri Shivarathreeshwara Medical College, JSS Academy of Higher Education and Research, Mysuru, India
| | - Vijaya Basavaraj
- Department of Pathology, Jagadguru Sri Shivarathreeshwara Medical College, JSS Academy of Higher Education and Research, Mysuru, India
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Hreško S, Maďarová M, Dobošová M, Palušeková N, Niznerová P, Žiaran S, Varga I. The Diagnostic Significance of C3d Antigen in Kidney and Skin Histopathology - The Current State-Of-The-Art and Practical Examples. Physiol Res 2023; 72:S225-S232. [PMID: 37888966 PMCID: PMC10669952 DOI: 10.33549/physiolres.935175] [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] [Received: 06/21/2023] [Accepted: 06/27/2023] [Indexed: 12/01/2023] Open
Abstract
The aim of this narrative review is to summarize recent knowledge about the diagnostic significance of immunobiological detection of C3d with a focus on renal and skin tissue biopsies. We completed the present narrative review with our own experiences with preparation and practical use of monoclonal C3d antibodies at a small national level.
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Affiliation(s)
- S Hreško
- DB Biotech, a.s., Košice, Slovak Republic.
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Zhao W, Zhu H, Zhao X, Wu X, Sun F, Pan M, Zhou S. Direct Immunofluorescence of IgG on Formalin-Fixed Paraffin-Embedded Tissue by Heat-Induced Antigen Retrieval as a Sensitive Method for the Diagnosis of Pemphigus. Clin Cosmet Investig Dermatol 2023; 16:1233-1241. [PMID: 37197669 PMCID: PMC10183353 DOI: 10.2147/ccid.s408613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 04/27/2023] [Indexed: 05/19/2023]
Abstract
Purpose Direct immunofluorescence (DIF) on frozen sections (DIF-F) plays a key role in the identification and differential diagnosis of bullous dermatoses, which are a group of critical autoimmune diseases that include pemphigus, bullous pemphigoid (BP), and epidermolysis bullosa acquisita (EBA). However, this technique requires specialized laboratory equipment conditions, sample acquisition and sample preservation. In this study, the application value of DIF on paraffin-embedded tissue sections (DIF-P) detecting IgG using heat-induced antigen retrieval (HIAR) in the diagnosis of bullous dermatosis was explored. Patients and Methods Samples from 12 patients with pemphigus vulgaris (PV), 10 patients with pemphigus foliaceus (PF), 17 patients with BP, and 4 patients with EBA were retrospectively studied for DIF-P IgG detection. Formalin-fixed, paraffin-embedded tissue (FFPE) was used, and the antigen retrieval method used in the experiment was HIAR. All patients were diagnosed with the autoimmune bullous disease (AIBD) based on clinical presentation, histopathology, DIF-F, and enzyme-linked immunosorbent assay (ELISA). Results Intercellular staining for IgG in the epidermis was successful in paraffin-embedded tissue sections in 11 of 12 PV samples and in all 10 PF samples. IgG at the basement membrane zone (BMZ) was not detected by immunofluorescent staining in 17 BP samples and 4 EBA samples. Conclusion The detection of IgG by DIF-P using HIAR can be used for the diagnosis of pemphigus as an alternative method to DIF-F.
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Affiliation(s)
- Wenzhe Zhao
- Department of Dermatology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, People’s Republic of China
| | - Haiqin Zhu
- Department of Dermatology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, People’s Republic of China
| | - Xiaoqing Zhao
- Department of Dermatology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, People’s Republic of China
| | - Xinyi Wu
- Department of Dermatology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, People’s Republic of China
| | - Fei Sun
- Department of Dermatology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, People’s Republic of China
| | - Meng Pan
- Department of Dermatology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, People’s Republic of China
| | - Shengru Zhou
- Department of Dermatology, Dushu Lake Hospital Affiliated to Soochow University (Medical Center of Soochow University, Suzhou Dushu Lake Hospital), Suzhou, 215123, People’s Republic of China
- Correspondence: Shengru Zhou, Department of Dermatology, Dushu Lake Hospital Affiliated to Soochow University, (Medical Center of Soochow University, Suzhou Dushu Lake Hospital), No. 9, Chongwen Road, Suzhou, 215123, People’s Republic of China, Tel +86-17717453465, Fax +86-2164669691, Email
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Papara C, Karsten CM, Ujiie H, Schmidt E, Schmidt-Jiménez LF, Baican A, Freire PC, Izumi K, Bieber K, Peipp M, Verschoor A, Ludwig RJ, Köhl J, Zillikens D, Hammers CM. The relevance of complement in pemphigoid diseases: A critical appraisal. Front Immunol 2022; 13:973702. [PMID: 36059476 PMCID: PMC9434693 DOI: 10.3389/fimmu.2022.973702] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 07/26/2022] [Indexed: 11/13/2022] Open
Abstract
Pemphigoid diseases are autoimmune chronic inflammatory skin diseases, which are characterized by blistering of the skin and/or mucous membranes, and circulating and tissue-bound autoantibodies. The well-established pathomechanisms comprise autoantibodies targeting various structural proteins located at the dermal-epidermal junction, leading to complement factor binding and activation. Several effector cells are thus attracted and activated, which in turn inflict characteristic tissue damage and subepidermal blistering. Moreover, the detection of linear complement deposits in the skin is a diagnostic hallmark of all pemphigoid diseases. However, recent studies showed that blistering might also occur independently of complement. This review reassesses the importance of complement in pemphigoid diseases based on current research by contrasting and contextualizing data from in vitro, murine and human studies.
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Affiliation(s)
- Cristian Papara
- Department of Dermatology, University of Lübeck, Lübeck, Germany
- Department of Dermatology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Christian M. Karsten
- Institute of Systemic Inflammation Research, University of Lübeck, Lübeck, Germany
| | - Hideyuki Ujiie
- Department of Dermatology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Enno Schmidt
- Department of Dermatology, University of Lübeck, Lübeck, Germany
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | | | - Adrian Baican
- Department of Dermatology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Patricia C. Freire
- Institute of Systemic Inflammation Research, University of Lübeck, Lübeck, Germany
| | - Kentaro Izumi
- Department of Dermatology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Katja Bieber
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Matthias Peipp
- Division of Antibody-Based Immunotherapy, Department of Medicine II, Christian-Albrechts-University of Kiel and University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Admar Verschoor
- Department of Dermatology, University of Lübeck, Lübeck, Germany
- Department of Otorhinolaryngology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Ralf J. Ludwig
- Department of Dermatology, University of Lübeck, Lübeck, Germany
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Jörg Köhl
- Institute of Systemic Inflammation Research, University of Lübeck, Lübeck, Germany
- Division of Immunobiology, Cincinnati Children’s Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Detlef Zillikens
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Christoph M. Hammers
- Department of Dermatology, University of Lübeck, Lübeck, Germany
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
- *Correspondence: Christoph M. Hammers,
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Bullous pemphigoid diagnosis: the role of routine formalin-fixed paraffin-embedded skin tissue immunochemistry. Sci Rep 2022; 12:10519. [PMID: 35732698 PMCID: PMC9217790 DOI: 10.1038/s41598-022-14950-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 06/15/2022] [Indexed: 11/08/2022] Open
Abstract
The gold standard for diagnosing bullous pemphigoid (BP) is the detection of linear deposition of IgG and/or C3 at the dermoepidermal junction using direct immunofluorescence (DIF). Because DIF has several disadvantages, primarily the requirement for frozen specimens, we assessed the diagnostic value of immunohistochemical (IHC) staining for BP detection. Eighty-eight patients with bullous lesions were included in this study. IHC staining for C3d, C4d, and IgG was performed on 88 samples, which included specimens from patients with DIF-confirmed BP (n = 43), clinicopathologically suspected BP with negative DIF results (n = 9), and other bullous diseases (n = 36). Diagnosis based on positive results for C3d, C4d, or IgG in IHC staining detected 86% of DIF-confirmed BP cases. The sensitivity of IHC staining for the detection of DIF-confirmed BP cases and clinicopathologically suspected BP cases was similar to that of DIF (80.8% vs. 84.3%), but the specificity was higher (83.3% vs. 75.0%). Five of the nine clinicopathologically suspected BP cases were diagnosed using IHC staining. Thus, IHC staining of routine biopsy material could be an alternative method for diagnosing BP. IHC staining has considerable diagnostic potential, especially in cases with a high suspicion of BP, but negative or suboptimal DIF results.Please check and confirm the author names and initials are correct. Author 2: Given name: [Chul Hwan] Family name: [Kim], Author 3: Given name: [Yoo Jin] Family name: [Lee].Checked it.
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Fahnoe KC, Liu F, Morgan JG, Ryan ST, Storek M, Stark EG, Taylor FR, Holers VM, Thurman JM, Wawersik S, Kalled SL, Violette SM. Development and Optimization of Bifunctional Fusion Proteins to Locally Modulate Complement Activation in Diseased Tissue. Front Immunol 2022; 13:869725. [PMID: 35784298 PMCID: PMC9244803 DOI: 10.3389/fimmu.2022.869725] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 05/06/2022] [Indexed: 11/13/2022] Open
Abstract
Sustained complement activation is an underlying pathologic driver in many inflammatory and autoimmune diseases. Currently approved anti-complement therapies are directed at the systemic blockade of complement. Consequently, these therapies provide widespread inhibition of complement pathway activity, beyond the site of ongoing activation and the intended pharmacodynamic (PD) effects. Given the essential role for complement in both innate and adaptive immunity, there is a need for therapies that inhibit complement in diseased tissue while limiting systemic blockade. One potential approach focuses on the development of novel fusion proteins that enable tissue-targeted delivery of complement negative regulatory proteins. These therapies are expected to provide increased potency and prolonged tissue PD, decreased dosing frequency, and the potential for improved safety profiles. We created a library of bifunctional fusion proteins that direct a fragment of the complement negative regulator, complement receptor type 1 (CR1) to sites of tissue injury. Tissue targeting is accomplished through the binding of the fusion protein to complement C3 fragments that contain a surface-exposed C3d domain and which are covalently deposited on tissues where complement is being activated. To that end, we generated a fusion protein that contains an anti-C3d monoclonal antibody recombinantly linked to the first 10 consensus repeats of CR1 (CR11-10) with the intention of delivering high local concentrations of this complement negative regulatory domain to tissue-bound complement C3 fragments iC3b, C3dg and C3d. Biochemical and in vitro characterization identified several fusion proteins that inhibit complement while maintaining the C3d domain binding properties of the parent monoclonal antibody. Preclinical in vivo studies further demonstrate that anti-C3d fusion proteins effectively distribute to injured tissue and reduce C3 fragment deposition for periods beyond 14 days. The in vitro and in vivo profiles support the further evaluation of C3d mAb-CR11-10 as a novel approach to restore proper complement activation in diseased tissue in the absence of continuous systemic complement blockade.
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Affiliation(s)
- Kelly C. Fahnoe
- Preclinical Research Q32 Bio Inc., Waltham, MA, United States
- *Correspondence: Kelly C. Fahnoe,
| | - Fei Liu
- Preclinical Research Q32 Bio Inc., Waltham, MA, United States
| | | | - Sarah T. Ryan
- Preclinical Research Q32 Bio Inc., Waltham, MA, United States
| | - Michael Storek
- Preclinical Research Q32 Bio Inc., Waltham, MA, United States
| | | | - Fred R. Taylor
- Preclinical Research Q32 Bio Inc., Waltham, MA, United States
| | - V. Michael Holers
- Division of Rheumatology, University of Colorado School of Medicine, Aurora, CO, United States
| | - Joshua M. Thurman
- Division of Renal Diseases and Hypertension, University of Colorado School of Medicine, Aurora, CO, United States
| | - Stefan Wawersik
- Preclinical Research Q32 Bio Inc., Waltham, MA, United States
| | - Susan L. Kalled
- Preclinical Research Q32 Bio Inc., Waltham, MA, United States
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Immunoglobulin and Complement Immunohistochemistry on Paraffin Sections in Autoimmune Bullous Diseases: A Systematic Review and Meta-analysis. Am J Dermatopathol 2021; 43:689-699. [PMID: 33055534 DOI: 10.1097/dad.0000000000001817] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
ABSTRACT Immunohistochemistry (IHC) on formalin-fixed, paraffin-embedded tissue has been proposed as a potential tool in the diagnosis of autoimmune bullous diseases (AIBDs) in lieu of standard direct immunofluorescence (DIF) microscopy. To comprehensively determine the diagnostic accuracy of immunoglobulin and complement IHC for diagnosis of AIBDs, we conducted a systematic review and multivariate Bayesian model-based meta-analysis of the literature. Quality and heterogeneity assessment of studies was performed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) checklist and the I2 index, respectively. Electronic searches using PubMed from April 1964 to July 2020 identified 14 articles meeting predetermined inclusion and exclusion criteria. Median sensitivities with 95% credible intervals in pemphigus and pemphigoid were 0.24 (0.01-0.89) and 0.22 (0.02-0.77) with immunoglobulin G (IgG), 0.77 (0.39-0.95) and 0.25 (0.02-0.85) with IgG4, 0.11 (0.02-0.32) and 0.86 (0.56-0.98) with C3d, and 0.84 (0.56-0.97) and 0.75 (0.37-0.94) with C4d, respectively. Specificities were 1.00 (0.00-1.00) with IgG, 0.98 (0.89-1.00) with IgG4, 0.99 (0.97-1.00) with C3d, and 0.99 (0.97-1.00) with C4d. The risk of bias and heterogeneity among studies was a serious problem, decreasing the level of evidence. Our work suggests that, in selected cases, paraffin-based IHC may be a helpful procedure to screen for AIBDs, especially when specialized laboratories and/or biopsy specimens for DIF do not exist. Nevertheless, more studies with a refined quality design are needed to explore the true usefulness of this diagnostic method in AIBDs.
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Nili A, Salehi Farid A, Asgari M, Tavakolpour S, Mahmoudi H, Daneshpazhooh M. Current status and prospects for the diagnosis of pemphigus vulgaris. Expert Rev Clin Immunol 2021; 17:819-834. [PMID: 34162306 DOI: 10.1080/1744666x.2021.1945925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Pemphigus vulgaris (PV) is an intraepidermal autoimmune bullous disease (AIBD) characterized by autoantibodies against desmosomal adhesion proteins, most commonly desmoglein (Dsg)3, leading to the suprabasal cleft formation and acantholysis.Areas covered: Direct immunofluorescence (DIF) and indirect immunofluorescence (IIF) studies display the intercellular deposition of IgG/C3 throughout the epidermis and presence of circulating autoantibodies respectively, as a net-like pattern. However, the target antigen remains unknown using immunofluorescence techniques. Thanks to the development of Dsg ELISA, using recombinant technology, circulating antibodies against Dsg1 and 3 could be detected sensitively. It is possible to differentiate PV from pemphigus foliaceus (PF) using this assay. BIOCHIP mosaic and multivariant ELISA are two novel serologic methods with the added value of the ability to screen several AIBDs simultaneously.Non-Dsg1/3 antigens are also involved in the pathogenesis of PV and investigated more deeply thanks to the protein microarrays technique. Additionally, patients with high values of anti-Dsg1/3 may be lesion-free, suggesting the presence of nonpathogenic autoantibodies.Expert opinion: Newer diagnostic methods to replace traditional techniques should possess high sensitivity and specificity and be widely available, noninvasive, and relatively cheap. The newly developed methods need to be further evaluated before being recommended for routine use.
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Affiliation(s)
- Ali Nili
- Department of Dermatology, Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Salehi Farid
- Department of Dermatology, Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Masoud Asgari
- Department of Pathology and Laboratory Medicine, Yosemite Pathology Medical Group, San Ramon Regional Medical Center, San Ramon, CA, USA
| | - Soheil Tavakolpour
- Department of Dermatology, Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran.,Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Hamidreza Mahmoudi
- Department of Dermatology, Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Daneshpazhooh
- Department of Dermatology, Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran
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Abstract
Blisters and erosions of skin and mucous membranes are key features of the clinically heterogeneous group of autoimmune bullous diseases (AIBDs). These can be divided into pemphigoid diseases with autoantibodies against structural proteins of the dermal-epidermal junction, pemphigus diseases with autoantibodies against desmosomal proteins, and dermatitis herpetiformis with autoantibodies against transglutaminases 1 and 2. A differentiation based only on clinical features is often not sufficient. After researching the literature in PubMed, the current diagnostic tools for AIBDs are summarized.AIBD diagnostics are performed using histology, direct and indirect immunofluorescence, as well as ELISA and immunoblotting. For serological diagnosis, the conventional multistep approach or multivariant assays for the analysis of autoantibodies against several target antigens in parallel can be applied. These allow a precise classification of AIBD and therefore a tailored use of different therapeutic regimens, e.g., for bullous pemphigoid or pemphigus foliaceus/vulgaris, as well as identification of disease entities with a known association with neoplasia.Direct immunofluorescence is still the diagnostic mainstay of AIBDs. However, novel serological assays, such as target-antigen-specific ELISA or indirect immunofluorescence systems using BIOCHIP™ mosaic technology, allow serologic diagnosis in most AIBD patients and the exact classification of the disease entity at the molecular level.
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12
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Wang LL, Moshiri AS, Novoa R, Simpson CL, Takeshita J, Payne AS, Chu EY. Comparison of C3d immunohistochemical staining to enzyme-linked immunosorbent assay and immunofluorescence for diagnosis of bullous pemphigoid. J Am Acad Dermatol 2020; 83:172-178. [PMID: 32068042 DOI: 10.1016/j.jaad.2020.02.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Revised: 01/22/2020] [Accepted: 02/06/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Bullous pemphigoid (BP), the most common autoimmune blistering disease, may be diagnostically challenging. Direct immunofluorescence (DIF), indirect immunofluorescence (IIF), enzyme-linked immunosorbent assay (ELISA), and recently, C3d immunohistochemistry (IHC), are used as adjuncts to diagnosis. OBJECTIVE To compare C3d IHC to DIF, IIF, and ELISA testing in BP diagnosis. METHODS C3d IHC was performed on skin biopsy specimens from 51 patients (27 with BP and 24 with other blistering diseases) and compared to DIF and IIF, with anti-BP180 or anti-BP230 ELISA results used as the gold standard. RESULTS We found C3d IHC, DIF, and IIF had similar sensitivity (74.1%, 63.1%, and 70.4%), specificity (95.8%, 100%, and 100%), positive predictive value (95.2%, 100%, and 100%), and negative predictive value (76.7%, 70.6%, and 75%) for BP. Cases with positive C3d IHC, DIF, and IIF had significantly higher anti-BP180 and anti-BP230 by ELISA than cases with negative testing (P < .0001). False-negative IIF results were associated with lower BP230 compared with true-positive results (P = .03). LIMITATIONS This was a single-center, retrospective study. CONCLUSION Our study compared C3d IHC to DIF and IIF in BP diagnosis, demonstrating C3d IHC on fixed tissue provides similar diagnostic utility to immunofluorescence and ELISA.
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Affiliation(s)
- Leo L Wang
- Department of Dermatology, the University of Pennsylvania, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ata S Moshiri
- Division of Dermatology, University of Washington, Seattle, Washington
| | - Roberto Novoa
- Department of Pathology and Dermatology, Stanford University, Perelman School of Medicine, University of Pennsylvania, Stanford, California
| | - Cory L Simpson
- Department of Dermatology, the University of Pennsylvania, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Junko Takeshita
- Department of Dermatology, the University of Pennsylvania, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Biostatistics Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Aimee S Payne
- Department of Dermatology, the University of Pennsylvania, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Emily Y Chu
- Department of Dermatology, the University of Pennsylvania, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
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13
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van Beek N, Zillikens D, Schmidt E. Diagnosis of autoimmune bullous diseases. J Dtsch Dermatol Ges 2019; 16:1077-1091. [PMID: 30179336 DOI: 10.1111/ddg.13637] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 01/28/2018] [Indexed: 12/25/2022]
Abstract
Autoimmune bullous disorders (AIBDs) are a heterogeneous group of rare diseases clinically characterized by erosions and/or blisters on the skin and mucous membranes. AIBDs can be categorized into two groups: pemphigus diseases, characterized by intraepidermal blistering and autoantibodies against desmosomal proteins such as desmoglein (Dsg) 1, Dsg3, members of the plakin family, and subepidermal AIBDs, comprised of pemphigoid diseases and dermatitis herpetiformis. Autoantibodies in dermatitis herpetiformis target transglutaminases 2 and 3, while in pemphigoid disease, autoantibodies are directed against structural proteins of the dermal-epidermal junction. Although analysis of a perilesional biopsy with direct immunofluorescence (IF) microscopy is still the diagnostic gold standard, several assays have become widely available that allow serological diagnosis in the majority of patients. Standard serological diagnosis includes indirect IF on monkey esophagus and salt-split human skin. Assays to further characterize autoantibody specificity include ELISA systems based on recombinant forms of the immunodominant regions of the target antigens as well as multivariant indirect IF microscopy tests with several miniature substrates. These serological assays are complemented by various in-house assays using immunoblotting and ELISA, which are only available in specialized laboratories. Here we review new developments in the diagnosis of AIBDs and describe state-of-the-art diagnostic procedures for this group of diseases.
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Affiliation(s)
- Nina van Beek
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Detlef Zillikens
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Enno Schmidt
- Department of Dermatology, University of Lübeck, Lübeck, Germany.,Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
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14
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van Beek N, Zillikens D, Schmidt E. Diagnostik blasenbildender Autoimmundermatosen. J Dtsch Dermatol Ges 2019; 16:1077-1092. [PMID: 30179341 DOI: 10.1111/ddg.13637_g] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 01/28/2018] [Indexed: 01/07/2023]
Abstract
Blasenbildende Autoimmundermatosen (BAIDs) sind eine heterogene Gruppe seltener Erkrankungen, die klinisch durch Erosionen und/oder Blasen an Haut und Schleimhäuten charakterisiert sind. BAIDs können in zwei Gruppen eingeteilt werden: Pemphigus-Erkrankungen, die durch intraepidermale Blasenbildung und Autoantikörper gegen desmosomale Proteine wie Desmoglein (Dsg) 1, Dsg3 und Mitglieder der Plakin-Familie charakterisiert sind, sowie subepidermale BAIDs, die Pemphigoid-Erkrankungen und die Dermatitis herpetiformis umfassen. Bei der Dermatitis herpetiformis greifen die Autoantikörper die Transglutaminasen 2 und 3 an, während sie bei Pemphigoid-Erkrankungen gegen Strukturproteine der dermoepidermalen Junktionszone gerichtet sind. Die Analyse einer periläsionalen Biopsie mittels direkter Immunfluoreszenzmikroskopie (IF-Mikroskopie) stellt zwar nach wie vor den diagnostischen Goldstandard dar, mittlerweile sind jedoch verschiedene Tests allgemein verfügbar, die eine serologische Diagnosefindung für den Großteil der Patienten ermöglichen. Zur serologischen Standarddiagnostik gehört die indirekte IF auf Affenösophagus und NaCl-separierter Spalthaut. Die Spezifität der Autoantikörper kann mit ELISA-Systemen, die auf rekombinanten Formen der immundominanten Regionen der Zielantigene basieren, sowie indirekter IF-Mikroskopie anhand multivarianter Tests mit mehreren multivariate näher charakterisiert werden. Diese serologischen Tests werden durch verschiedene hauseigene Immunoblotting- und ELISA-Systeme ergänzt, die nur in spezialisierten Laboratorien verfügbar sind. In diesem Review geben wir einen Überblick über neue Entwicklungen bei der Diagnose von BAIDs und beschreiben moderne Diagnoseverfahren für diese Krankheitsgruppe.
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Affiliation(s)
- Nina van Beek
- Klinik für Dermatologie, Allergologie und Venerologie, Universität zu Lübeck
| | - Detlef Zillikens
- Klinik für Dermatologie, Allergologie und Venerologie, Universität zu Lübeck
| | - Enno Schmidt
- Klinik für Dermatologie, Allergologie und Venerologie, Universität zu Lübeck.,Lübecker Institut für Experimentelle Dermatologie (LIED), Universität zu Lübeck
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15
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Edwards G, Diercks GFH, Seelen MAJ, Horvath B, van Doorn MBA, Damman J. Complement Activation in Autoimmune Bullous Dermatoses: A Comprehensive Review. Front Immunol 2019; 10:1477. [PMID: 31293600 PMCID: PMC6606728 DOI: 10.3389/fimmu.2019.01477] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 06/13/2019] [Indexed: 12/14/2022] Open
Abstract
Autoimmune bullous dermatoses (AIBD) are characterized by circulating autoantibodies that are either directed against epidermal antigens or deposited as immune complexes in the basement membrane zone (BMZ). The complement system (CS) can be activated by autoantibodies, thereby triggering activation of specific complement pathways. Local complement activation induces a pathogenic inflammatory response that eventually results in the formation of a sub- or intraepidermal blister. Deposition of complement components is routinely used as a diagnostic marker for AIBD. Knowledge from different animal models mimicking AIBD and deposition of complement components in human skin biopsies provides more insight into the role of complement in the pathogenesis of the different AIBD. This review outlines the role of the CS in several AIBD including bullous pemphigoid, epidermolysis bullosa acquisita, mucous membrane pemphigoid (MMP), pemphigus, linear IgA-disease, and dermatitis herpetiformis. We also discuss potential therapeutic approaches targeting key complement components, pathways and pathogenic complement-mediated events.
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Affiliation(s)
- Gareth Edwards
- Department of Dermatology, University Medical Center Groningen, Groningen, Netherlands
| | - Gilles F H Diercks
- Department of Pathology, University Medical Center Groningen, Groningen, Netherlands
| | - Marc A J Seelen
- Department of Nephrology, University Medical Center Groningen, Groningen, Netherlands
| | - Barbara Horvath
- Department of Dermatology, University Medical Center Groningen, Groningen, Netherlands
| | | | - Jeffrey Damman
- Department of Pathology, Erasmus Medical Center Rotterdam, Rotterdam, Netherlands
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16
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Kamyab K, Abdolreza M, Ghanadan A, Mortazavi H, Nikoo A, Motavalli F, Nasimi M. C4d immunohistochemical stain of formalin‐fixed paraffin‐embedded tissue as a sensitive method in the diagnosis of bullous pemphigoid. J Cutan Pathol 2019; 46:723-728. [DOI: 10.1111/cup.13490] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Revised: 04/12/2019] [Accepted: 04/30/2019] [Indexed: 12/29/2022]
Affiliation(s)
- Kambiz Kamyab
- Department of DermatopathologyRazi Hospital, Tehran University of Medical Sciences Tehran Iran
| | - Mona Abdolreza
- Department of DermatopathologyRazi Hospital, Tehran University of Medical Sciences Tehran Iran
| | - Alireza Ghanadan
- Department of DermatopathologyRazi Hospital, Tehran University of Medical Sciences Tehran Iran
| | - Hossein Mortazavi
- Department of DermatologyRazi Hospital,Tehran University of Medical Sciences Tehran Iran
| | - Azita Nikoo
- Department of DermatopathologyRazi Hospital, Tehran University of Medical Sciences Tehran Iran
| | | | - Maryam Nasimi
- Department of DermatologyRazi Hospital,Tehran University of Medical Sciences Tehran Iran
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17
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Sun S, Zhong B, Li W, Jin X, Yao Y, Wang J, Liu J, Dan H, Chen Q, Zeng X. Immunological methods for the diagnosis of oral mucosal diseases. Br J Dermatol 2019; 181:23-36. [PMID: 30585301 DOI: 10.1111/bjd.17589] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2018] [Indexed: 02/05/2023]
Abstract
Immunological methods, which have been widely used in autoimmune blistering diseases (AIBDs) of the oral mucosa, can also be adopted as auxiliary diagnostic tools in oral lichen planus (OLP) and discoid lupus erythematosus (DLE). AIBDs, characterized by autoantibodies against structural proteins of keratinocytes or the basement membrane zone, clinically present as blisters and erosions of the oral mucosa. When atypical lesions occur, OLP or DLE may be confused with AIBDs. The improvement of diagnostic accuracy is necessary due to the significant differences in treatment and prognosis among these diseases. A variety of immunological methods are used for qualitative and quantitative detection of target antigens and autoantibodies. These methods can evaluate efficacy of treatment, monitor diseases and guide treatment decisions. In this review, we discuss the application of immunofluorescence, biochemical tests, and protein microarrays for AIBDs, OLP and DLE, as well as the differential diagnostic methods using immunological tests.
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Affiliation(s)
- S Sun
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Chinese Academy of Medical Sciences Research Unit of Oral Carcinogenesis and Management, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, 610041, China
| | - B Zhong
- Department of Otolaryngology, Head and Neck Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - W Li
- Department of Dermatovenereology, Rare Disease Center, West China Hospital, Sichuan University, Chengdu, China
| | - X Jin
- Chongqing Key Laboratory of Oral Diseases and Biomedical Sciences and College of Stomatology, Chongqing Medical University, Chongqing, China
| | - Y Yao
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Chinese Academy of Medical Sciences Research Unit of Oral Carcinogenesis and Management, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, 610041, China.,Department of Oral Medicine, Affiliated Hospital of Stomatology, Zunyi Medical University, Zunyi, China
| | - J Wang
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Chinese Academy of Medical Sciences Research Unit of Oral Carcinogenesis and Management, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, 610041, China
| | - J Liu
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Chinese Academy of Medical Sciences Research Unit of Oral Carcinogenesis and Management, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, 610041, China
| | - H Dan
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Chinese Academy of Medical Sciences Research Unit of Oral Carcinogenesis and Management, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, 610041, China
| | - Q Chen
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Chinese Academy of Medical Sciences Research Unit of Oral Carcinogenesis and Management, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, 610041, China
| | - X Zeng
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Chinese Academy of Medical Sciences Research Unit of Oral Carcinogenesis and Management, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, 610041, China
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18
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Shimanovich I, Nitz JM, Witte M, Zillikens D, Rose C. Immunohistochemical diagnosis of mucous membrane pemphigoid. J Oral Pathol Med 2018; 47:613-619. [DOI: 10.1111/jop.12732] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2018] [Indexed: 11/30/2022]
Affiliation(s)
| | | | - Mareike Witte
- Department of Dermatology; University of Lübeck; Lübeck Germany
| | | | - Christian Rose
- Department of Dermatology; University of Lübeck; Lübeck Germany
- Dermatohistopathology Laboratory Lübeck; Lübeck Germany
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19
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Giang J, Seelen MAJ, van Doorn MBA, Rissmann R, Prens EP, Damman J. Complement Activation in Inflammatory Skin Diseases. Front Immunol 2018; 9:639. [PMID: 29713318 PMCID: PMC5911619 DOI: 10.3389/fimmu.2018.00639] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 03/14/2018] [Indexed: 01/02/2023] Open
Abstract
The complement system is a fundamental part of the innate immune system, playing a crucial role in host defense against various pathogens, such as bacteria, viruses, and fungi. Activation of complement results in production of several molecules mediating chemotaxis, opsonization, and mast cell degranulation, which can contribute to the elimination of pathogenic organisms and inflammation. Furthermore, the complement system also has regulating properties in inflammatory and immune responses. Complement activity in diseases is rather complex and may involve both aberrant expression of complement and genetic deficiencies of complement components or regulators. The skin represents an active immune organ with complex interactions between cellular components and various mediators. Complement involvement has been associated with several skin diseases, such as psoriasis, lupus erythematosus, cutaneous vasculitis, urticaria, and bullous dermatoses. Several triggers including auto-antibodies and micro-organisms can activate complement, while on the other hand complement deficiencies can contribute to impaired immune complex clearance, leading to disease. This review provides an overview of the role of complement in inflammatory skin diseases and discusses complement factors as potential new targets for therapeutic intervention.
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Affiliation(s)
- Jenny Giang
- Department of Pathology, Erasmus Medical Center Rotterdam, Rotterdam, Netherlands
| | - Marc A J Seelen
- Department of Nephrology, University Medical Center Groningen, Groningen, Netherlands
| | | | | | - Errol P Prens
- Department of Dermatology, Erasmus Medical Center Rotterdam, Rotterdam, Netherlands
| | - Jeffrey Damman
- Department of Pathology, Erasmus Medical Center Rotterdam, Rotterdam, Netherlands
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20
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The Value of Direct Immunofluorescence on Proteinase-Digested Formalin-Fixed Paraffin-Embedded Skin Biopsies. Am J Dermatopathol 2018; 40:111-117. [DOI: 10.1097/dad.0000000000000934] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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21
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Al-Shenawy HAS. Can immunohistochemistry replace immunofluorescence in diagnosis of skin bullous diseases? APMIS 2017; 125:114-121. [PMID: 28052410 DOI: 10.1111/apm.12643] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 11/02/2016] [Indexed: 11/29/2022]
Abstract
Autoimmune bullous diseases are distressing and sometimes risky bullous dermatoses characterized by the presence of antibodies focused against disease-specific target antigens. Recognition of these antibodies using immunofluorescence is used to be the only sure diagnostic method after reviewing the routine histopathological section. Because of many causes that make the using of immunofluorescence difficult, we tried to evaluate the role of immunohistochemistry in diagnosis of these bullous skin diseases; 40 pemphigus cases (30 pemphigus vulgaris and 10 pemphigus foliaceus) and 37 non-pemphigus cases (35 vesiculobullous skin diseases and 2 normal skin). Skin biopsy was obtained for histopathological diagnosis, immunofluorescence study, and immune-histochemical studying for IgG4 and C3d expression. IgG4 was positive in almost all cases of pemphigus vulgaris and most of pemphigus foliaceus and bullous pemphigoides, while all other diseases were negative. C3d expression was positive in almost all bullous pemphigoides and pemphigus gestationis cases, while it was negative in almost all other cases. Sensitivity and specificity of both markers increase by using them in combination in diagnosis of such bullous diseases. IgG4 and C3d immunohistochemistry could replace DIF in almost all of our cases, so before doing DIF, reliable immunohistochemical detection of IgG4 and C3d on formalin-fixed tissue is advised to be done.
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22
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Application of C4d Immunohistochemistry on Routinely Processed Tissue Sections for the Diagnosis of Autoimmune Bullous Dermatoses. Am J Dermatopathol 2016; 38:186-8. [PMID: 25793311 DOI: 10.1097/dad.0000000000000333] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The diagnosis of autoimmune bullous dermatoses relies greatly on direct immunofluorescence (DIF) examination performed on frozen tissue sections, showing deposits of immunoglobulins and/or C3 on specific cutaneous structures. However, frozen material is not always available for DIF; therefore, alternative techniques are needed in the diagnostic procedure. We therefore tested the usefulness of C4d immunohistochemistry on formalin-fixed, paraffin-embedded tissue sections for the diagnosis of bullous pemphigoid (BP) and pemphigus (P). A retrospective immunohistochemical study was performed on biopsies of BP (n: 29) and P (n: 22, including 19 Pemphigus vulgaris and 3 paraneoplastic), submitted for routine histological examination and compared with DIF on the corresponding frozen sections. Twenty-five BP biopsies (86.2%) showed C4d deposits seen as a linear labeling along the dermal-epidermal junction and on the membrane of basal keratinocytes. Seventeen P biopsies (77.2%) showed C4d deposits in a classical "intercellular" pattern, predominating on the lower epidermal layers. The sensitivity, specificity, positive predictive value, and negative predictive value reached 86%, 98%, 96%, and 92% in BP, respectively and 77%, 98%, 94%, and 92% in P, respectively. Furthermore, in the cases where serological tests were available, the sensitivity of C4d detection was higher than that of enzyme-linked immunosorbent assay/indirect immunofluorescence in both BP (87% vs. 67%) and P (82% vs. 54.5%). We conclude that DIF on frozen sections still remains the gold standard for the immunopathological diagnosis of BP and P; however, in the absence of frozen material, C4d immunohistochemistry performed on routinely processed biopsy material can be of considerable help in confirming the diagnosis.
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23
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Glauser S, Rutz M, Cazzaniga S, Hegyi I, Borradori L, Beltraminelli H. Diagnostic value of immunohistochemistry on formalin-fixed, paraffin-embedded skin biopsy specimens for bullous pemphigoid. Br J Dermatol 2016; 175:988-993. [PMID: 27105821 DOI: 10.1111/bjd.14686] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/12/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Direct immunofluorescence microscopy (DIF) studies constitute the gold standard for diagnosis of bullous pemphigoid (BP) but depend on the availability of specialized laboratories and often on an additional skin biopsy specimen. OBJECTIVES To assess the value of immunohistochemical analyses (IHCA) in the diagnosis of BP using formalin-fixed, paraffin-embedded skin biopsy specimens as an alternative to DIF; and to study the correlation between the results of IHCA and the presence of histological subepidermal blister formation and of circulating autoantibodies by indirect immunofluorescence studies using split skin or by enzyme-linked immunosorbent assays. METHODS We included all patients newly diagnosed with BP evaluated between 2008 and 2010. There were 51 consecutive skin biopsy specimens obtained from 38 patients with BP with positive DIF. RESULTS By IHCA, deposits of immunoreactants were found in 45% of all tested cases. Deposits of C3d, IgG, IgM, IgE and IgA were found in 37%, 23%, 2%, 0% and 0% of cases, respectively. Deposits of C3d and/or IgG were found in 79% of the 24 cases with a blister and in 83% of the 12 cases with subepidermal blistering and positive immunoserological analyses, respectively. CONCLUSIONS In contrast to previous studies, our findings in an unselected patient cohort indicate that IHCA are not sufficiently sensitive to replace DIF studies for confirming the diagnosis of BP. IHCA sensitivity significantly increases in the presence of histological blistering and/or of circulating autoantibodies. IHCA represents a potential rescue diagnostic technique only if specialized laboratories and/or a second biopsy specimen for DIF are unavailable.
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Affiliation(s)
- S Glauser
- Department of Dermatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - M Rutz
- Department of Dermatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - S Cazzaniga
- Department of Dermatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Centro Studi GISED, Bergamo, Italy
| | - I Hegyi
- Department of Dermatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - L Borradori
- Department of Dermatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - H Beltraminelli
- Department of Dermatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
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24
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Mochel MC, Ming ME, Imadojemu S, Gangadhar TC, Schuchter LM, Elenitsas R, Payne AS, Chu EY. Cutaneous autoimmune effects in the setting of therapeutic immune checkpoint inhibition for metastatic melanoma. J Cutan Pathol 2016; 43:787-91. [PMID: 27161449 DOI: 10.1111/cup.12735] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 05/05/2016] [Accepted: 05/06/2016] [Indexed: 12/25/2022]
Abstract
Therapeutic immune checkpoint blockade for metastatic melanoma has been associated with vitiligo, pruritus and morbilliform eruptions. Reports of other autoimmune skin disease in this setting are rare. We sought to expand the spectrum of cutaneous immune-mediated effects related to immune checkpoint inhibitor therapy. In this report, we describe two unusual cutaneous reactions related to checkpoint inhibitor therapy, namely bullous pemphigoid (BP) and dermatitis herpetiformis. The development of BP and dermatitis herpetiformis in the context of checkpoint inhibitor therapy is consistent with previous investigations supporting the importance of effector and regulatory T cells in the pathogenesis of these diseases.
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Affiliation(s)
- Mark C Mochel
- Department of Dermatology, University of Pennsylvania, Philadelphia, PA, USA
| | - Michael E Ming
- Department of Dermatology, University of Pennsylvania, Philadelphia, PA, USA
| | - Sotonye Imadojemu
- Department of Dermatology, University of Pennsylvania, Philadelphia, PA, USA
| | - Tara C Gangadhar
- Division of Hematology/Oncology, Department of Medicine, Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Lynn M Schuchter
- Division of Hematology/Oncology, Department of Medicine, Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Rosalie Elenitsas
- Department of Dermatology, University of Pennsylvania, Philadelphia, PA, USA
| | - Aimee S Payne
- Department of Dermatology, University of Pennsylvania, Philadelphia, PA, USA
| | - Emily Y Chu
- Department of Dermatology, University of Pennsylvania, Philadelphia, PA, USA
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25
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26
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Hammers CM, Stanley JR. Mechanisms of Disease: Pemphigus and Bullous Pemphigoid. ANNUAL REVIEW OF PATHOLOGY-MECHANISMS OF DISEASE 2016; 11:175-97. [PMID: 26907530 DOI: 10.1146/annurev-pathol-012615-044313] [Citation(s) in RCA: 197] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Pemphigus and bullous pemphigoid are autoantibody-mediated blistering skin diseases. In pemphigus, keratinocytes in epidermis and mucous membranes lose cell-cell adhesion, and in pemphigoid, the basal keratinocytes lose adhesion to the basement membrane. Pemphigus lesions are mediated directly by the autoantibodies, whereas the autoantibodies in pemphigoid fix complement and mediate inflammation. In both diseases, the autoantigens have been cloned and characterized; pemphigus antigens are desmogleins (cell adhesion molecules in desmosomes), and pemphigoid antigens are found in hemidesmosomes (which mediate adhesion to the basement membrane). This knowledge has enabled diagnostic testing for these diseases by enzyme-linked immunosorbent assays and dissection of various pathophysiological mechanisms, including direct inhibition of cell adhesion, antibody-induced internalization of antigen, and cell signaling. Understanding these mechanisms of disease has led to rational targeted therapeutic strategies.
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Affiliation(s)
- Christoph M Hammers
- Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania 19104; .,Department of Dermatology, University of Luebeck, D-23562 Luebeck, Germany;
| | - John R Stanley
- Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania 19104;
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The utility of C4d immunohistochemistry on formalin-fixed paraffin-embedded tissue in the distinction of polymorphic eruption of pregnancy from pemphigoid gestationis. Am J Dermatopathol 2014; 35:787-91. [PMID: 24061402 DOI: 10.1097/dad.0b013e3182a6b6cc] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Polymorphic eruption of pregnancy (PEP), formerly known as pruritic urticarial papules and plaques of pregnancy, is a dermatosis of pregnancy that must be distinguished from pemphigoid gestationis (PG). Although this differential diagnosis may be possible on routine histology, an additional biopsy for direct immunofluorescence (DIF) is often needed. Recent studies have demonstrated the utility of anti-C4d or anti-C3d antibodies in the diagnosis of bullous pemphigoid (BP) in formalin-fixed paraffin-embedded tissue (FFPE). We investigated the utility of routine immunohistochemistry (IHC) for anti-C4d in FFPE tissue in the specific differential diagnosis of PEP versus PG in known, DIF-proven cases. We performed C4d IHC on PEP (n = 11), PG (n = 8), DIF-proven BP (n = 12), and other common dermatoses (n = 12) that are typically DIF negative. None of the PEP cases (0/11) or the other common dermatoses (0/12) demonstrated C4d positivity at the basement membrane zone. In comparison, 100% of PG cases (8/8) and 83.3% of BP cases (10/12) showed linear C4d immunoreactant deposition along the basement membrane zone. The results demonstrate the potential utility of C4d IHC in FFPE tissue for distinguishing PEP from PG, thus potentially obviating the need of a repeat biopsy for DIF, particularly in C4d-negative cases where there is a low suspicion of PG on both clinical and histological grounds. Also, patients with positive C4d-positive immunoreactivity may also potentially proceed directly to less invasive serological confirmatory testing, such as BP180 NC16a enzyme-linked immunoabsorbent assay.
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Zimmer V, Müller CS, Juengling B, Vogt T, Lammert F. Esophageal intramural pseudodiverticulosis in mucous membrane pemphigoid: potential diagnostic utility of C4d immunohistochemistry. Dig Endosc 2012; 24:487. [PMID: 23078456 DOI: 10.1111/j.1443-1661.2012.01360.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Vincent Zimmer
- Department of Medicine II; Saarland University Medical Center; Homburg; Germany
| | - Cornelia S Müller
- Department of Dermatology; Saarland University Medical Center; Homburg; Germany
| | - Bernhard Juengling
- Department of Medicine II; Saarland University Medical Center; Homburg; Germany
| | - Thomas Vogt
- Department of Dermatology; Saarland University Medical Center; Homburg; Germany
| | - Frank Lammert
- Department of Medicine II; Saarland University Medical Center; Homburg; Germany
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Schmidt E, della Torre R, Borradori L. Clinical features and practical diagnosis of bullous pemphigoid. Immunol Allergy Clin North Am 2012; 32:217-32, v. [PMID: 22560135 DOI: 10.1016/j.iac.2012.04.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Bullous pemphigoid (BP) represents the most common autoimmune subepidermal blistering disease. BP typically affects the elderly and is associated with significant morbidity. It has usually a chronic course with spontaneous exacerbations. The cutaneous manifestations of BP can be extremely protean. While diagnosis of BP in the bullous stage is straightforward, in the non-bullous stage or in atypical variants of BP signs and symptoms are frequently non-specific with eg, only itchy excoriated, eczematous, papular and/or urticarial lesions that may persist for several weeks or months. Diagnosis of BP critically relies on immunopathologic examinations including direct immunofluorescence microscopy and detection of serum autoantibodies by indirect immunofluorescence microscopy or BP180-ELISA.
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Affiliation(s)
- Enno Schmidt
- Department of Dermatology, University of Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany.
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van Beek N, Knuth-Rehr D, Altmeyer P, Assaf C, Babilas P, Bayerl C, Benoit S, Dippel E, Effendy I, Eming R, Fischer M, Glaenz T, Gläser R, Goebeler M, Gollnick H, Götze S, Gross G, Hadaschik E, Herbst R, Hermes B, Homey B, Hunzelmann N, Jünger M, Kapp A, Kern JS, Körber A, Luger T, Mechtel D, Megahed M, Moll I, Peters KP, Pfeiffer C, Ring J, Röcken M, Sárdy M, Seitz CS, Stadler R, Steinbrink K, Sticherling M, Szeimies RM, Tronnier M, Ulrich J, Vogt T, Wagner N, Welzel J, Wenzel J, Wozel G, Zouboulis CC, Zillikens D, Schmidt E. Diagnostics of autoimmune bullous diseases in German dermatology departments. J Dtsch Dermatol Ges 2012; 10:492-9. [PMID: 22304433 DOI: 10.1111/j.1610-0387.2011.07840.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND No consistent data are available on the currently employed diagnostic tools for autoimmune bullous diseases in Germany. The aim of this survey was to describe currently performed diagnostic methods for bullous autoimmune diseases in German dermatology departments. METHODS A standardized questionnaire evaluated the available diagnostic methods i. e. direct immunofluorescence microscopy (IFM), indirect IFM, commercial ELISA systems, and non-commercial serological tests as well as the number of samples per year in all 34 university and 39 non-university dermatology departments. RESULTS The overall return rate was 89 %, 100 % and 79 % for the university and non-university departments, respectively. Direct IFM was the most frequently used method and was applied in 98 % of the responding departments. In 74 % of the responding departments, indirect IFM was used mainly on monkey esophagus and human salt-split skin. Commercial ELISA systems were employed in 58 % of the clinics; all of them used anti-desmoglein ELISA, while anti-BP180 and anti-BP230 ELISA were established in 49 % and 48 % of departments, respectively. Non-commercial analytic methods were only performed in 22 % of the departments. CONCLUSIONS The high return rate of this survey allows a relatively precise description of the current diagnostic methods used in German dermatology departments. Standard diagnostic tests are available nationwide and in bullous pemphigoid and pemphigus, the antigen-specific detection of autoantibodies is routinely performed in half of the departments. Rare disorders may be diagnosed by cooperation with some specialized centers.
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Affiliation(s)
- Nina van Beek
- Department of Dermatology, Allergology and Venereology, University of Lübeck, Germany
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Abstract
Bullous pemphigoid (BP) constitutes the most frequent autoimmune subepidermal blistering disease. It is associated with autoantibodies directed against the BP antigens 180 (BP180, BPAG2) and BP230 (BPAG1-e). The pathogenicity of anti-BP180 antibodies has been convincingly demonstrated in animal models. The clinical features of BP are extremely polymorphous. The diagnosis of BP critically relies on immunopathologic findings. The recent development of novel enzyme-linked immunosorbent assays has allowed the detection of circulating autoantibodies with relatively high sensitivity and specificity. Although potent topical steroids have emerged in the past decade as first-line treatment of BP, management of the disease may be challenging.
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Affiliation(s)
- Giovanni Di Zenzo
- Molecular and Cell Biology Laboratory, Istituto Dermopatico dell'Immacolata, IDI-IRCCS, Rome, Italy.
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