1
|
Huang S, Anderson HJ, Lee JB. Paraneoplastic pemphigus/paraneoplastic autoimmune multiorgan syndrome: Part II. Diagnosis and management. J Am Acad Dermatol 2024; 91:13-22. [PMID: 37714216 DOI: 10.1016/j.jaad.2023.08.084] [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: 03/24/2023] [Revised: 08/09/2023] [Accepted: 08/11/2023] [Indexed: 09/17/2023]
Abstract
In the second part of this Continuing Medical Education article on paraneoplastic pemphigus/paraneoplastic autoimmune multiorgan syndrome (PNP/PAMS), its diagnostic criteria, investigative work-up, and management are reviewed. PNP/PAMS is a rare autoimmune blistering disorder associated with high morbidity and mortality. Recognizing PNP/PAMS's key features and its diagnostic criteria is critical in initiating appropriate work-up. Evaluating PNP/PAMS requires knowledge of its findings on histopathology, direct immunofluorescence, indirect immunofluorescence, and enzyme-linked immunosorbent assay. Lastly, treatments for PNP/PAMS are reviewed with suggestions based on case reports and expert opinions in the literature.
Collapse
Affiliation(s)
- Simo Huang
- Department of Dermatology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Hannah J Anderson
- Department of Dermatology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Jason B Lee
- Department of Dermatology, Thomas Jefferson University, Philadelphia, Pennsylvania.
| |
Collapse
|
2
|
Saowaluksakul W, Seree-aphinan C, Rutnin S, Boonyawat K, Chanprapaph K. Coexistence of Discoid Lupus Erythematosus and Paraneoplastic Pemphigus: A Case Report and Literature Review. Clin Cosmet Investig Dermatol 2022; 15:2477-2486. [DOI: 10.2147/ccid.s389341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 11/08/2022] [Indexed: 11/16/2022]
|
3
|
Chu KY, Yu HS, Yu S. Current and Innovated Managements for Autoimmune Bullous Skin Disorders: An Overview. J Clin Med 2022; 11:3528. [PMID: 35743598 PMCID: PMC9224787 DOI: 10.3390/jcm11123528] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 06/13/2022] [Accepted: 06/17/2022] [Indexed: 11/16/2022] Open
Abstract
Autoimmune bullous skin disorders are a group of disorders characterized by the formation of numerous blisters and erosions on the skin and/or the mucosal membrane, arising from autoantibodies against the intercellular adhesion molecules and the structural proteins. They can be classified into intraepithelial or subepithelial autoimmune bullous dermatoses based on the location of the targeted antigens. These dermatoses are extremely debilitating and fatal in certain cases, depending on the degree of cutaneous and mucosal involvement. Effective treatments should be implemented promptly. Glucocorticoids serve as the first-line approach due to their rapid onset of therapeutic effects and remission of the acute phase. Nonetheless, long-term applications may lead to major adverse effects that outweigh the benefits. Hence, other adjuvant therapies are mandatory to minimize the potential harm and ameliorate the quality of life. Herein, we summarize the current therapeutic strategies and introduce promising therapies for intractable autoimmune bullous diseases.
Collapse
Affiliation(s)
- Kuan-Yu Chu
- Department of Dermatology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807378, Taiwan;
| | - Hsin-Su Yu
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807378, Taiwan
| | - Sebastian Yu
- Department of Dermatology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807378, Taiwan;
- Department of Dermatology, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807378, Taiwan
- Neuroscience Research Center, Kaohsiung Medical University, Kaohsiung 807378, Taiwan
| |
Collapse
|
4
|
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.
Collapse
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
| |
Collapse
|
5
|
Malik AM, Tupchong S, Huang S, Are A, Hsu S, Motaparthi K. An Updated Review of Pemphigus Diseases. Medicina (B Aires) 2021; 57:medicina57101080. [PMID: 34684117 PMCID: PMC8540565 DOI: 10.3390/medicina57101080] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 09/26/2021] [Accepted: 09/28/2021] [Indexed: 01/19/2023] Open
Abstract
Clinicians may encounter a variety of skin conditions that present with vesiculobullous lesions in their everyday practice. Pemphigus vulgaris, pemphigus foliaceus, IgA pemphigus, and paraneoplastic pemphigus represent the spectrum of autoimmune bullous dermatoses of the pemphigus family. The pemphigus family of diseases is characterized by significant morbidity and mortality. Considering the risks associated with a delayed diagnosis or misdiagnosis and the potential for overlap in clinical features and treatment, evaluation for suspected pemphigus disease often requires thorough clinical assessment and laboratory testing. Diagnosis is focused on individual biopsies for histopathology and direct immunofluorescence. Additional laboratory methods used for diagnosis include indirect immunofluorescence and enzyme-linked immunosorbent assay. Recent advancements, including anti-CD20 therapy, have improved the efficacy and reduced the morbidity of pemphigus treatment. This contribution presents updates on the pathophysiology, clinical features, diagnostic work-up, and medical management of pemphigus. Improved strategies for diagnosis and clinical assessment are reviewed, and newer treatment options are discussed.
Collapse
Affiliation(s)
- Ali M. Malik
- College of Medicine, University of Florida, Gainesville, FL 32606, USA; (A.M.M.); (A.A.)
| | - Sarah Tupchong
- Lewis Katz School of Medicine, Temple University, Philadelphia, PA 19140, USA;
| | - Simo Huang
- Department of Dermatology, Lewis Katz School of Medicine, Temple University, Philadelphia, PA 19140, USA; (S.H.); (S.H.)
| | - Abhirup Are
- College of Medicine, University of Florida, Gainesville, FL 32606, USA; (A.M.M.); (A.A.)
| | - Sylvia Hsu
- Department of Dermatology, Lewis Katz School of Medicine, Temple University, Philadelphia, PA 19140, USA; (S.H.); (S.H.)
| | - Kiran Motaparthi
- Department of Dermatology, College of Medicine, University of Florida, Gainesville, FL 32606, USA
- Correspondence:
| |
Collapse
|
6
|
Intraepithelial autoimmune bullous dermatoses disease activity assessment and therapy. J Am Acad Dermatol 2021; 84:1523-1537. [PMID: 33684497 DOI: 10.1016/j.jaad.2021.02.073] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 02/19/2021] [Accepted: 02/21/2021] [Indexed: 12/30/2022]
Abstract
Intraepithelial autoimmune blistering dermatoses are a rare group of skin disorders characterized by disruptions of inter-keratinocyte connections within the epidermis through the action of autoantibodies. The second article in this continuing medical education series presents validated disease activity scoring systems, serologic parameters of disease, treatments, and clinical trials for pemphigus and its subtypes.
Collapse
|
7
|
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.
Collapse
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
| |
Collapse
|
8
|
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.
Collapse
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
| |
Collapse
|
9
|
Autoimmune bullous skin diseases, pemphigus and pemphigoid. J Allergy Clin Immunol 2020; 145:1031-1047. [DOI: 10.1016/j.jaci.2020.02.013] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 02/19/2020] [Accepted: 02/20/2020] [Indexed: 02/07/2023]
|
10
|
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.
Collapse
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
| |
Collapse
|
11
|
Kim JH, Kim SC. Paraneoplastic Pemphigus: Paraneoplastic Autoimmune Disease of the Skin and Mucosa. Front Immunol 2019; 10:1259. [PMID: 31214197 PMCID: PMC6558011 DOI: 10.3389/fimmu.2019.01259] [Citation(s) in RCA: 74] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 05/17/2019] [Indexed: 12/25/2022] Open
Abstract
Paraneoplastic pemphigus (PNP) is a rare but life-threatening mucocutaneous disease mediated by paraneoplastic autoimmunity. Various neoplasms are associated with PNP. Intractable stomatitis and polymorphous cutaneous eruptions, including blisters and lichenoid dermatitis, are characteristic clinical features caused by humoral and cell-mediated autoimmune reactions. Autoreactive T cells and IgG autoantibodies against heterogeneous antigens, including plakin family proteins and desmosomal cadherins, contribute to the pathogenesis of PNP. Several mechanisms of autoimmunity may be at play in this disease on the type of neoplasm present. Diagnosis can be made based on clinical and histopathological features, the presence of anti-plakin autoantibodies, and underlying neoplasms. Immunosuppressive agents and biologics including rituximab have been used for the treatment of PNP; however, the prognosis is poor due to underlying malignancies, severe infections during immunosuppressive treatment, and bronchiolitis obliterans mediated by autoimmunity. In this review, we overview the characteristics of PNP and focus on the immunopathology and the potential pathomechanisms of this disease.
Collapse
Affiliation(s)
- Jong Hoon Kim
- Department of Dermatology and Cutaneous Biology Research Institute, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Soo-Chan Kim
- Department of Dermatology and Cutaneous Biology Research Institute, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| |
Collapse
|
12
|
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]
|
13
|
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
|
14
|
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
|
15
|
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.
Collapse
|
16
|
Ransohoff JD, Kwong BY. Cutaneous Adverse Events of Targeted Therapies for Hematolymphoid Malignancies. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2017; 17:834-851. [PMID: 28918995 DOI: 10.1016/j.clml.2017.07.005] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 07/10/2017] [Indexed: 12/11/2022]
Abstract
The identification of oncogenic drivers of liquid tumors has led to the rapid development of targeted agents with distinct cutaneous adverse event (AE) profiles. The diagnosis and management of these skin toxicities has motivated a novel partnership between dermatologists and oncologists in developing supportive oncodermatology clinics. In this article we review the current state of knowledge of clinical presentation, mechanisms, and management of the most common and significant cutaneous AEs observed during treatment with targeted therapies for hematologic and lymphoid malignancies. We systematically review according to drug-targeting pathway the cutaneous AE profiles of these drugs, and offer insight when possible into whether pharmacologic target versus immunologic modulation primarily underlie presentation. We include discussion of tyrosine kinase inhibitors (imatinib, dasatinib, nilotinib, bosutinib, ponatinib), blinatumomab, ibrutinib, idelalisib, anti-B cell antibodies (rituximab, ibritumomab, obinutuzumab, ofatumumab, tositumomab), immune checkpoint inhibitors (nivolumab, pembrolizumab), alemtuzumab, brentuximab, and proteasome inhibitors (bortezomib, carfilzomib, ixazomib). We highlight skin reactions seen with antiliquid but not solid tumor agents, draw attention to serious cutaneous AEs that might require therapy modification or cessation, and offer management strategies to permit treatment tolerability. We emphasize the importance of early diagnosis and treatment to minimize disruptions to care, optimize prognosis and quality of life, and promptly address life-threatening skin or infectious events. This evolving partnership between oncologists and dermatologists in the iterative characterization and management of skin toxicities will contribute to a better understanding of these drugs' cutaneous targets and improved patient care.
Collapse
Affiliation(s)
- Julia D Ransohoff
- Department of Dermatology, Stanford University School of Medicine, Stanford, CA
| | - Bernice Y Kwong
- Department of Dermatology, Stanford University School of Medicine, Stanford, CA.
| |
Collapse
|
17
|
Abstract
RATIONALE Paraneoplastic pemphigus (PNP) is an autoimmune syndrome associated with neoplasms. The treatment approach principally includes suppressing the immunity, but its therapeutic effect is not satisfying. PATIENT CONCERNS We report a case of paraneoplastic pemphigus linked to chronic lymphocytic leukemia in a 63-year-old man. DIAGNOSES At first, the patient was diagnosed with pityriasis rose caused by a viral infection. Biopsies for histology and immunofluorescence showed PNP, was treated with immunosuppressive and antiinfective therapy. INTERVENTIONS Immunosuppressive and antiinfective therapy were performed. OUTCOMES The skin lesions of PNP were alleviated. However, the infections were aggravated and the disease progressed. The patient died of respiratory failure. LESSONS Treatment for PNP should be adapted to disease severity as early as possible. Antiinfection treatment should be timely and effective because infections are the most common complication that can lead to death.
Collapse
MESH Headings
- Diagnosis, Differential
- Fatal Outcome
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/complications
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Male
- Middle Aged
- Paraneoplastic Syndromes/diagnosis
- Paraneoplastic Syndromes/drug therapy
- Paraneoplastic Syndromes/etiology
- Paraneoplastic Syndromes/pathology
- Pemphigus/diagnosis
- Pemphigus/drug therapy
- Pemphigus/etiology
- Pemphigus/pathology
- Respiratory Insufficiency/etiology
Collapse
|
18
|
Kim M, Borradori L, Murrell DF. Autoimmune Blistering Diseases in the Elderly: Clinical Presentations and Management. Drugs Aging 2016; 33:711-723. [DOI: 10.1007/s40266-016-0402-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
19
|
Lehman VT, Barrick BJ, Pittelkow MR, Peller PJ, Camilleri MJ, Lehman JS. Diagnostic imaging in paraneoplastic autoimmune multiorgan syndrome: retrospective single site study and literature review of 225 patients. Int J Dermatol 2014; 54:424-37. [DOI: 10.1111/ijd.12603] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
|
20
|
Bech R, Baumgartner-Nielsen J, Peterslund NA, Steiniche T, Deleuran M, d'Amore F. Alemtuzumab is effective against severe chronic lymphocytic leukaemia-associated paraneoplastic pemphigus. Br J Dermatol 2014; 169:469-72. [PMID: 23517368 DOI: 10.1111/bjd.12324] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/13/2013] [Indexed: 12/01/2022]
Abstract
Alemtuzumab (ALZ) is a monoclonal antibody used in the treatment of a variety of lymphoproliferative diseases, primarily chronic lymphocytic leukaemia (CLL). Paraneoplastic pemphigus (PNP) is a severe mucocutaneous disease, which can occur in association with B-cell malignancies. A correct diagnosis of PNP relies on distinct clinical and histopathological features, and the demonstration, by direct immunofluorescence, of intercellular and basement membrane IgG deposits in the affected tissue. PNP is often refractory to immunosuppressive drugs and frequently has a fatal outcome. We report three cases where sustained remissions of both PNP and CLL were induced by ALZ. In one of these cases, ALZ was able to reinduce a sustained remission of PNP at the reappearance of the disorder years after the primary treatment. In all cases, the PNP diagnosis was confirmed by immunofluorescence. In conclusion, ALZ should be considered as a treatment option in severe CLL-associated PNP. Patients should be carefully selected and receive appropriate infectious prophylaxis before, during and after ALZ treatment, due to the risk of opportunistic infections secondary to combined disease- and drug-induced immunosuppression.
Collapse
Affiliation(s)
- R Bech
- Department of Haematology, Aarhus University Hospital, Aarhus, Denmark.
| | | | | | | | | | | |
Collapse
|
21
|
Vezzoli P, Berti E, Marzano AV. Rationale and efficacy for the use of rituximab in paraneoplastic pemphigus. Expert Rev Clin Immunol 2014; 4:351-63. [DOI: 10.1586/1744666x.4.3.351] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
22
|
Gatt ME, Ben-Yehuda D, Izraeli S. Lymphoid leukemias. Clin Immunol 2013. [DOI: 10.1016/b978-0-7234-3691-1.00092-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
|
23
|
Abstract
Paraneoplastic pemphigus (PNP) is a distinct autoimmune blistering disease that can affect multiple organs other than the skin. It occurs in association with certain neoplasms, among which lymphoproliferative diseases are most commonly associated. The clinical presentation of PNP consists typically of painful, severe oral erosions that may be accompanied by a generalised cutaneous eruption and systemic involvement. The eruption may be of different morphology, consisting of lesions that resemble pemphigus, pemphigoid, erythema multiforme or graft versus host disease, as well as lesions resembling lichen planus. Similarly, the histological findings also show considerable variability. PNP is characterised by the presence of autoantibodies against various antigens: desmoplakin I (250 kd), bullous pemphigoid antigen I (230 kd), desmoplakin II (210 kd), envoplakin (210 kd), periplakin (190 kd), plectin (500 kd) and a 170-kd protein. This 170-kd protein has recently been identified as alpha-2-macroglobulin-like-1, a broad range protease inhibitor expressed in stratified epithelia and other tissue damaged in PNP. The prognosis of PNP is poor and the disease is often fatal. Immunosuppressive agents are often required to decrease blistering, and treating the underlying malignancy with chemotherapy may control autoantibody production. The prognosis is better when PNP is associated with benign tumours and these should be surgically excised when possible.
Collapse
|
24
|
Paraneoplastic pemphigus associated with chronic lymphocytic leukaemia: treatment with alemtuzumab. Leuk Res 2012; 36:e190-1. [PMID: 22579369 DOI: 10.1016/j.leukres.2012.04.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2011] [Revised: 04/15/2012] [Accepted: 04/16/2012] [Indexed: 11/20/2022]
|
25
|
Frew JW, Murrell DF. Current management strategies in paraneoplastic pemphigus (paraneoplastic autoimmune multiorgan syndrome). Dermatol Clin 2011; 29:607-12. [PMID: 21925005 DOI: 10.1016/j.det.2011.06.016] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Paraneoplastic pemphigus (PNP) or paraneoplastic autoimmune multiorgan syndrome (PAMS) is a life-threatening autoimmune blistering disease commonly associated with lymphoproliferative neoplasms. This article focuses on current management strategies in PNP/PAMS, and reported instances of their treatment successes and failures. Due to the rarity of the condition and the high rates of treatment failure, no randomized control trials exist to guide the evidence-based treatment of this condition; all evidence to date on the efficacy of therapeutic modalities has been gained from individual case reports, small case series, and expert recommendations.
Collapse
Affiliation(s)
- John W Frew
- St George Hospital, Gray Street, Kogarah, Sydney, NSW 2217, Australia
| | | |
Collapse
|
26
|
Czernik A, Camilleri M, Pittelkow MR, Grando SA. Paraneoplastic autoimmune multiorgan syndrome: 20 years after. Int J Dermatol 2011; 50:905-14. [DOI: 10.1111/j.1365-4632.2011.04868.x] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
27
|
Ehst BD, Minzer-Conzetti K, Swerdlin A, Devere TS. Cutaneous manifestations of internal malignancy. Curr Probl Surg 2010; 47:384-445. [PMID: 20363406 DOI: 10.1067/j.cpsurg.2010.01.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
|
28
|
|
29
|
Sands J, Tuscano JM. Geoepidemiology and autoimmune manifestations of lymphoproliferative disorders. Autoimmun Rev 2009; 9:A335-41. [PMID: 19914405 DOI: 10.1016/j.autrev.2009.11.009] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The pathogenesis of lymphoproliferative disorders represents an underlying dysfunction in lymphocyte development and homeostasis. This typically manifests with the accumulation of lymphocytes in the bone marrow, peripheral blood or lymph nodes and spleen. It has been hypothesized that the mechanism for elimination of dysfunctional and autoreactive lymphocytes is defective and contributes to the pathogenesis of these disorders. Based on this hypothesis, it would not be surprising to find an increased incidence of autoimmune manifestations that are associated with these disorders. Autoimmune paraneoplastic syndromes (PNS) are often the result of a dysfunctional immune response, which is related to an underlying malignant process. While all the PNS that are associated with lymphoproliferative disorders do not have an autoimmune basis, many do. Here we review the literature of PNS associated with lymphoproliferative disorders. A concise overview of each syndrome is provided with a focus on clinical manifestations, diagnostics, pathophysiology, and treatment. While the treatment is typically directed at managing the underlying lymphoproliferative process, and can be assumed to be case throughout this review, there are exceptions that are described within the context of each disorder.
Collapse
Affiliation(s)
- Jacob Sands
- Department of Internal Medicine, University of California, Davis, Sacramento, CA 95817, USA
| | | |
Collapse
|
30
|
Billet SE, Grando SA, Pittelkow MR. Paraneoplastic autoimmune multiorgan syndrome: Review of the literature and support for a cytotoxic role in pathogenesis. Autoimmunity 2009; 39:617-30. [PMID: 17101506 DOI: 10.1080/08916930600972099] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Paraneoplastic autoimmune multiorgan syndrome (PAMS), first described as paraneoplastic pemphigus in 1990, is an autoimmune blistering disease associated with neoplasia. Patients with this rare disorder have severe blistering and painful erosions of the oral cavity and various other cutaneous findings ranging from classic pemphigus vulgaris-like erosions to targetoid lesions resembling erythema multiforme and papular to more confluent lichenoid eruptions. This syndrome involves multiple organ systems, and its high rate of mortality often stems from constrictive bronchiolitis obliterans. The histologic findings are as diverse as the clinical presentation, often making diagnosis difficult initially. Immunodermatologic and serologic laboratory findings typically establish the diagnosis. These results can be confirmed with immunoprecipitation profiling of specific molecular weight protein markers. The proposed pathogenesis of PAMS continues to evolve, and recent reports implicate the involvement of cell-mediated, cytotoxic immunity, in addition to humoral autoantibodies. This review characterizes and summarizes the clinical, pathologic, and immunohistologic features of PAMS and outlines the possible role of cytotoxic T lymphocytes in the pathogenesis of this syndrome.
Collapse
Affiliation(s)
- Sara E Billet
- Department of Dermatology, Mayo Clinic, Rochester, MN 55905, USA
| | | | | |
Collapse
|
31
|
Abstract
Cutaneous lesions occur in up to 25% of patients with chronic lymphocytic leukemia (CLL). These can be caused by either cutaneous seeding by leukemic cells (leukemia cutis, LC) and other malignant diseases or nonmalignant disorders. Skin infiltration with B-lymphocyte CLL manifests as solitary, grouped, or generalized papules, plaques, nodules, or large tumors. Prognosis in CLL patients with LC is rather good and many authors claim that it does not significantly affect patients' survival. However, prognosis is poor in patients in whom LC shows blastic transformation (Richter's syndrome) and when leukemic infiltrations in the skin appear after the diagnosis of CLL. Secondary cutaneous malignancies are also frequent complications in patients with CLL. A higher risk was seen in skin cancer, for which eightfold higher occurrence has been stated. There are some suggestions that alkylating agents and purine analogs may be associated with an increased incidence of secondary malignancies in CLL. Nonspecific, secondary cutaneous lesions are frequently observed in CLL patients. The most common secondary cutaneous changes seen in CLL are those of infectious or hemorrhagic origin. Other secondary lesions present as vasculitis, purpura, generalized pruritus, exfoliative erythroderma, and paraneoplastic pemphigus. An exaggerated reaction to an insect bite and insect bite-like reactions have been also observed.
Collapse
MESH Headings
- Diagnosis, Differential
- Female
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/complications
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemic Infiltration
- Male
- Neoplasms, Second Primary/diagnosis
- Neoplasms, Second Primary/pathology
- Pemphigoid, Bullous/diagnosis
- Pemphigus/diagnosis
- Prognosis
- Skin/pathology
- Skin Diseases/diagnosis
- Skin Diseases/metabolism
- Skin Diseases/microbiology
- Skin Neoplasms/complications
- Skin Neoplasms/diagnosis
- Skin Neoplasms/secondary
- Syndrome
Collapse
Affiliation(s)
- Ewa Robak
- Department of Dermatology and Venereology, Medical University of Lodz, Poland
| | | |
Collapse
|
32
|
|
33
|
Gatt ME, Ben-Yehuda D, Izraeli S. Lymphoid leukemias. Clin Immunol 2008. [DOI: 10.1016/b978-0-323-04404-2.10076-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
34
|
Espandar L, O'Brien S, Thirkill C, Lubecki LA, Esmaeli B. Successful treatment of cancer-associated retinopathy with alemtuzumab. J Neurooncol 2007; 83:295-302. [PMID: 17252185 DOI: 10.1007/s11060-006-9326-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2006] [Accepted: 12/29/2006] [Indexed: 10/23/2022]
Abstract
We herein report a patient with cancer-associated retinopathy who experienced multiple bouts of paraneoplastic retinopathy and optic neuropathy but responded to treatments with alemtuzumab and was able to maintain useful vision over the course of 8 years of follow-up.
Collapse
Affiliation(s)
- Ladan Espandar
- Section of Ophthalmology, Unit 441, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | | | | | | | | |
Collapse
|
35
|
Cummins DL, Mimouni D, Tzu J, Owens N, Anhalt GJ, Meyerle JH. Lichenoid paraneoplastic pemphigus in the absence of detectable antibodies. J Am Acad Dermatol 2007; 56:153-9. [PMID: 17097371 DOI: 10.1016/j.jaad.2006.06.007] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2006] [Revised: 05/20/2006] [Accepted: 06/04/2006] [Indexed: 11/20/2022]
Abstract
Paraneoplastic pemphigus (PNP) has been described as an antibody-mediated mucocutaneous disease occurring almost exclusively in patients with lymphocytic neoplasms. We describe 4 patients with the clinical features of the lichenoid variant of PNP in the absence of detectable autoantibodies. On the basis of these findings, we conclude that the spectrum of PNP likely includes patients with disease predominantly or exclusively mediated by cytotoxic T cells rather than autoantibodies. The pathophysiology and range of PNP disease are likely more complex than was initially believed.
Collapse
MESH Headings
- Aged
- Antibodies, Monoclonal/administration & dosage
- Antibodies, Monoclonal/pharmacology
- Antibodies, Monoclonal/therapeutic use
- Antibodies, Monoclonal, Murine-Derived
- Antibody Formation/drug effects
- Antineoplastic Combined Chemotherapy Protocols/administration & dosage
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Autoantibodies/blood
- B-Lymphocytes/drug effects
- Combined Modality Therapy
- Cyclophosphamide/administration & dosage
- Doxorubicin/administration & dosage
- Esophageal Diseases/diagnosis
- Esophageal Diseases/etiology
- Esophageal Diseases/immunology
- Etoposide/administration & dosage
- Female
- Hematopoietic Stem Cell Transplantation
- Humans
- Immunity, Cellular
- Interleukin-2/administration & dosage
- Leukemia, Lymphocytic, Chronic, B-Cell/complications
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/radiotherapy
- Leukemia, Lymphocytic, Chronic, B-Cell/surgery
- Lichenoid Eruptions/diagnosis
- Lichenoid Eruptions/etiology
- Lichenoid Eruptions/immunology
- Lymphoma, Follicular/complications
- Lymphoma, Follicular/drug therapy
- Lymphoma, Follicular/radiotherapy
- Lymphoma, Non-Hodgkin/complications
- Lymphoma, Non-Hodgkin/drug therapy
- Lymphoma, Non-Hodgkin/radiotherapy
- Male
- Middle Aged
- Mucositis/complications
- Paraneoplastic Syndromes/etiology
- Paraneoplastic Syndromes/immunology
- Pemphigus/diagnosis
- Pemphigus/etiology
- Pemphigus/immunology
- Prednisone/administration & dosage
- Recurrence
- Rituximab
- T-Lymphocytes/immunology
- Vidarabine/administration & dosage
- Vidarabine/analogs & derivatives
- Vincristine/administration & dosage
Collapse
Affiliation(s)
- Deborah L Cummins
- Department of Dermatology, Johns Hopkins Hospital, Baltimore, MD 21205, USA
| | | | | | | | | | | |
Collapse
|
36
|
&NA;. Ocular manifestations of autoimmune bullous disease have the potential for sight-threatening complications, but are often difficult to treat. DRUGS & THERAPY PERSPECTIVES 2006. [DOI: 10.2165/00042310-200622090-00005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
|
37
|
Laforest C, Huilgol SC, Casson R, Selva D, Leibovitch I. Autoimmune bullous diseases: ocular manifestations and management. Drugs 2005; 65:1767-79. [PMID: 16114976 DOI: 10.2165/00003495-200565130-00003] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The ocular manifestations of autoimmune bullous diseases are common and potentially sight-threatening. Major ophthalmic involvement is most commonly seen in mucous membrane pemphigoid (cicatricial pemphigoid), epidermolysis bullosa acquisita, linear IgA bullous disease, pemphigus vulgaris and paraneoplastic pemphigus. The main pathological process is related to autoimmune-induced conjunctival inflammation with consequent lid and corneal pathology, which may eventually result in permanent visual loss. Ocular involvement can be asymptomatic. Early detection is aided by careful attention to symptoms and signs of early ophthalmic disease. Ocular disease can be difficult to treat and management usually involves systemic therapy with immunomodulators to control inflammation and prevent progression to irreversible blindness, as well as surgical intervention in advanced disease. Recent advances in treatment, including methotrexate, mycophenolate mofetil, monoclonal antibodies and topical tacrolimus therapies, have led to promising results.
Collapse
Affiliation(s)
- Caroline Laforest
- Oculoplastic & Orbital Unit, Department of Ophthalmology, Royal Adelaide Hospital, University of Adelaide, Adelaide, South Australia, Australia.
| | | | | | | | | |
Collapse
|