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Caux F, Patsatsi A, Karakioulaki M, Antiga E, Baselga E, Borradori L, Caproni M, Cardones AR, Chandran NS, Dräger S, Drenovska K, Goebeler M, Günther C, Hofmann SC, Ioannides D, Joly P, Marinović B, Mariotti EB, Marzano AV, Morel KD, Murrell DF, Prost C, Sárdy M, Setterfield J, Skiljevic D, Uzun S, Vassileva S, Zambruno G, Schmidt E. S2k guidelines on diagnosis and treatment of linear IgA dermatosis initiated by the European Academy of Dermatology and Venereology. J Eur Acad Dermatol Venereol 2024; 38:1006-1023. [PMID: 38421060 DOI: 10.1111/jdv.19880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 01/19/2024] [Indexed: 03/02/2024]
Abstract
INTRODUCTION Linear IgA dermatosis (LAD) is a rare subepidermal autoimmune bullous disease (AIBD) defined by predominant or exclusive immune deposits of immunoglobulin A at the basement membrane zone of skin or mucous membranes. This disorder is a rare, clinically and immunologically heterogeneous disease occurring both in children and in adults. The aim of this project is to present the main clinical features of LAD, to propose a diagnostic algorithm and provide management guidelines based primarily on experts' opinion because of the lack of large methodologically sound clinical studies. METHODS These guidelines were initiated by the European Academy of Dermatology and Venereology (EADV) Task Force Autoimmune Bullous Diseases (AIBD). To achieve a broad consensus for these S2k consensus-based guidelines, a total of 29 experts from different countries, both European and non-European, including dermatologists, paediatric dermatologists and paediatricians were invited. All members of the guidelines committee agreed to develop consensus-based (S2k) guidelines. Prior to a first virtual consensus meeting, each of the invited authors elaborated a section of the present guidelines focusing on a selected topic, based on the relevant literature. All drafts were circulated among members of the writing group, and recommendations were discussed and voted during two hybrid consensus meetings. RESULTS The guidelines summarizes evidence-based and expert opinion-based recommendations (S2 level) on the diagnosis and treatment of LAD. CONCLUSION These guidelines will support dermatologists to improve their knowledge on the diagnosis and management of LAD.
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Affiliation(s)
- Frédéric Caux
- Department of Dermatology and Referral Center for Autoimmune Bullous Diseases, Groupe Hospitalier Paris Seine-Saint-Denis, AP-HP and University Paris 13, Bobigny, France
| | - Aikaterini Patsatsi
- Autoimmune Bullous Diseases Unit, 2nd Department of Dermatology, Aristotle University School of Medicine, Papageorgiou General Hospital, Thessaloniki, Greece
| | - Meropi Karakioulaki
- Department of Dermatology and Venereology, Medical Center, University Hospital Freiburg, Freiburg, Germany
| | - Emiliano Antiga
- Department of Health Sciences, Section of Dermatology, Azienda USL Toscana Centro, Rare Diseases Unit, European Reference Network-Skin Member, University of Florence, Florence, Italy
| | - Eulalia Baselga
- Department of Dermatology, Hospital Sant Joan de Deu, Barcelona, Spain
| | - Luca Borradori
- Department of Dermatology, University of Bern, Inselspital, Berne, Switzerland
| | - Marzia Caproni
- Department of Health Sciences, Section of Dermatology, Azienda USL Toscana Centro, Rare Diseases Unit, European Reference Network-Skin Member, University of Florence, Florence, Italy
| | - Adela R Cardones
- Division of Dermatology, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Nisha Suyien Chandran
- Division of Dermatology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Sören Dräger
- Department of Dermatology, Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Kossara Drenovska
- Department of Dermatology and Venereology, University Hospital "Alexandrovska", Medical University-Sofia, Sofia, Bulgaria
| | - Matthias Goebeler
- Department of Dermatology, Venereology and Allergology, University Hospital Würzburg, Würzburg, Germany
| | - Claudia Günther
- Department of Dermatology, University Hospital, Technical University Dresden, Dresden, Germany
| | - Silke C Hofmann
- Department of Dermatology, Allergy and Dermatosurgery, Helios University Hospital Wuppertal, University Witten-Herdecke, Wuppertal, Germany
| | - Dimitrios Ioannides
- 1st Department of Dermatology, Aristotle University School of Medicine, Hospital of Skin and Venereal Diseases, Thessaloniki, Greece
| | - Pascal Joly
- Department of Dermatology, Rouen University Hospital, INSERM 1234, Normandie University, Rouen, France
| | - Branka Marinović
- Department of Dermatology and Venereology, University Hospital Centre Zagreb, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Elena Biancamaria Mariotti
- Department of Health Sciences, Section of Dermatology, Azienda USL Toscana Centro, Rare Diseases Unit, European Reference Network-Skin Member, University of Florence, Florence, Italy
| | - Angelo Valerio Marzano
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Kimberly D Morel
- Departments of Dermatology and Pediatrics at Columbia University Medical Center, Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Dedee F Murrell
- Department of Dermatology, St George Hospital, University of New South Wales, Sydney, New South Wales, Australia
| | - Catherine Prost
- Department of Dermatology and Referral Center for Autoimmune Bullous Diseases, Groupe Hospitalier Paris Seine-Saint-Denis, AP-HP and University Paris 13, Bobigny, France
| | - Miklós Sárdy
- Department of Dermatology, Venereology and Dermatooncology, Semmelweis University, Budapest, Hungary
- Department of Dermatology and Allergy, University Hospital, LMU, Munich, Germany
| | - Jane Setterfield
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Centre for Host-Microbiome Interactions, King's College London Faculty of Dentistry, Oral & Craniofacial Sciences, London, UK
| | - Dusan Skiljevic
- Department of Dermatovenereology, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Soner Uzun
- Department of Dermatology, Akdeniz University Faculty of Medicine, Antalya, Turkey
| | - Snejina Vassileva
- Department of Dermatology and Venereology, University Hospital "Alexandrovska", Medical University-Sofia, Sofia, Bulgaria
| | - Giovanna Zambruno
- Genodermatosis Unit, Translational Pediatrics and Clinical Genetics Research Division, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Enno Schmidt
- Department of Dermatology, Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
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Burmann SN, Oellig F, Wehry UP, Matull J, Kreuter A. [Blisters in a "cluster of jewels"-like pattern in a child with chronic hepatitis B infection]. DERMATOLOGIE (HEIDELBERG, GERMANY) 2024; 75:176-178. [PMID: 38092978 DOI: 10.1007/s00105-023-05270-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/20/2023] [Indexed: 01/30/2024]
Affiliation(s)
- Sven-Niklas Burmann
- Klinik für Dermatologie, Venerologie und Allergologie, Helios St. Elisabeth Klinik Oberhausen, Universität Witten/Herdecke, Oberhausen, Deutschland
| | - Frank Oellig
- Pathologie Rhein-Ruhr, Mülheim an der Ruhr, Deutschland
| | - Ulrich Peter Wehry
- Klinik für Dermatologie, Venerologie und Allergologie, Helios St. Elisabeth Klinik Oberhausen, Universität Witten/Herdecke, Oberhausen, Deutschland
| | - Johanna Matull
- Klinik für Dermatologie, Venerologie und Allergologie, Helios St. Elisabeth Klinik Oberhausen, Universität Witten/Herdecke, Oberhausen, Deutschland
| | - Alexander Kreuter
- Klinik für Dermatologie, Venerologie und Allergologie, Helios St. Elisabeth Klinik Oberhausen, Universität Witten/Herdecke, Oberhausen, Deutschland.
- Klinik für Dermatologie, Venerologie und Allergologie, Helios St. Johannes Klinik Duisburg, Universität Witten/Herdecke, Duisburg, Deutschland.
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3
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Marín-Piñero D, Mascaró JM, Perandones-González H, Vicente-Villa MA. A preterm infant with acral congenital erosions. Pediatr Dermatol 2024; 41:121-123. [PMID: 37288943 DOI: 10.1111/pde.15375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 05/19/2023] [Indexed: 06/09/2023]
Affiliation(s)
| | - José M Mascaró
- Department of Dermatology, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
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4
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Vičić M, Marinović B. Autoimmune bullous diseases in pregnancy: an overview of pathogenesis, clinical presentations, diagnostics and available therapies. Ital J Dermatol Venerol 2023; 158:99-109. [PMID: 37153944 DOI: 10.23736/s2784-8671.23.07553-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
Autoimmune bullous diseases (AIBDs) are rare organ-specific diseases characterized by the appearance of blisters and erosions on the skin and mucous membranes. These dermatoses are marked by the development of autoantibodies targeting the autoantigens located in intercellular junctions, i.e., between keratinocytes or in the basement membrane area. Therefore, the fundamental division of AIBDs into the pemphigus and pemphigoid groups exists. Although AIBDs are uncommon in the general population, their overall incidence is somewhat higher in women of all ages, for which a pregnant women can be likely affected too. While the pemphigoid gestationis is exclusive bullous dermatosis of pregnancy, the other AIBDs can also start or worsen during this period. The appearance of AIBDs in childbearing women is a particularly sensitive situation requiring exceptional clinicians' caution due to the possibility of pregnancy complications with adverse effects and risks to the mother and the child. Also, there are numerous management difficulties in the period of pregnancy and lactation related to the drugs' choice and safety. This paper aimed to outline the pathophysiologic mechanisms, clinical manifestations, diagnostic approach and therapy of the most commonly recognized AIBDs in pregnancy.
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Affiliation(s)
- Marijana Vičić
- Department of Dermatovenereology, Faculty of Medicine, Clinical Hospital Centre of Rijeka, University of Rijeka, Rijeka, Croatia
| | - Branka Marinović
- Department of Dermatovenereology, Faculty of Medicine, University Hospital Centre of Zagreb, University of Zagreb, Zagreb, Croatia -
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Machado Morais J, Meneses M, Freitas C, Oliveira H, Leite I. Linear Immunoglobulin A Dermatosis: A Rare Case Illustrating Successful Treatment With Dapsone. Cureus 2023; 15:e35569. [PMID: 37007367 PMCID: PMC10061548 DOI: 10.7759/cureus.35569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2023] [Indexed: 03/06/2023] Open
Abstract
This is the case report of a previously healthy four-year-old girl with a history of upper airway infection that was treated with a β-lactam antibiotic. She was seen in the emergency department one month later with vesiculobullous lesions with clear content that were isolated or grouped in rosettes. Direct immunofluorescence showed baseline linear positivity for immunoglobulin A (IgA) (+) and fibrinogen-positive bullous content with absent remaining immunosera expression. The observed results were compatible with linear IgA bullous dermatosis. After confirming the diagnosis and excluding glucose-6-phosphate dehydrogenase (G6PD) deficiency, dapsone was added to the initial treatment with systemic and topical corticosteroids. This case report is a reminder of the importance of a high index of clinical suspicion for this condition to reach a timely diagnosis.
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Rekik M, Regaieg C, Sellami K, Khanfir H, Kolsi N, Baklouti M, Amouri M, Masmoudi A, Ben Thabet A, Gargouri A, Turki H. Acral blisters in neonates: Three rare and benign diseases. Clin Case Rep 2022; 10:e06420. [PMID: 36245441 PMCID: PMC9552545 DOI: 10.1002/ccr3.6420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 08/30/2022] [Accepted: 09/20/2022] [Indexed: 11/07/2022] Open
Abstract
Exclusive acral involvement in neonatal pemphigus is unusual. Blisters in neonatal bullous pemphigoid, affecting 2%–3% of newborns of mothers with gestational pemphigoid, can be located in the trunk, limbs and acral areas. Unlike neonatal bullous pemphigoid, which can appear up to 5 days after birth, neonatal pemphigus is often revealed at birth. They are benign diseases in newborns. There is no correlation between the disease severity in babies and mothers. Neonatal risk is dominated by the side effects of corticosteroid therapy.
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Affiliation(s)
- Mariem Rekik
- Dermatology departementHedi Chaker HospitalSfaxTunisia
| | | | | | | | - Nadia Kolsi
- Neonatology departementHedi Chaker HospitalSfaxTunisia
| | | | - Mariem Amouri
- Dermatology departementHedi Chaker HospitalSfaxTunisia
| | | | | | | | - Hamida Turki
- Dermatology departementHedi Chaker HospitalSfaxTunisia
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7
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Afra TP, Daroach M, Mahajan R, De D, Handa S. Pustular lesions in the neonate: Focused diagnostic approach based on clinical clues. Indian J Dermatol Venereol Leprol 2022; 88:708-716. [DOI: 10.25259/ijdvl_209_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 04/01/2022] [Indexed: 11/04/2022]
Abstract
Pustules in a neonate can be due to various causes. Though the majority of conditions causing pustules in a neonate are benign, it is essential to clearly differentiate these from serious ones. A systematic approach based on detailed history and clinical examination of the neonate along with basic laboratory evaluation narrows down diagnostic possibilities and aids in the correct diagnosis. This review outlines a step-by-step approach so as to avoid clinical dilemmas and unnecessary intervention.
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Affiliation(s)
| | - Manju Daroach
- Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Rahul Mahajan
- Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Dipankar De
- Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Sanjeev Handa
- Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
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8
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Mori F, Saretta F, Liotti L, Giovannini M, Castagnoli R, Arasi S, Barni S, Mastrorilli C, Pecoraro L, Caminiti L, Marseglia GL, Barbaud A, Novembre E. Linear Immunoglobulin a Bullous Dermatosis in Children. Front Pediatr 2022; 10:937528. [PMID: 35874598 PMCID: PMC9304959 DOI: 10.3389/fped.2022.937528] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 06/20/2022] [Indexed: 02/03/2023] Open
Abstract
Linear Immunoglobulin A Bullous Disease (LABD) is a rare dermatosis whose pathomechanisms are not yet completely understood. LABD has different features characterizing adults and children in terms of potential triggers, clinical manifestations, and prognosis. The aim of the present study is to review all neonatal and pediatric cases of LABD and summarize the major characteristics. Childhood LABD is mainly idiopathic with a benign prognosis. Neonatal cases are difficult to differentiate from infectious diseases and usually have a poor prognosis. Drugs are one of the possible triggers that can activate autoimmune responses through antigen mimicry and epitope spreading as well as different stimuli (e.g., infections, inflammatory diseases, trauma). The gold standard for the diagnosis is based on direct immunofluorescence. Prognosis is generally favorable but often depends on the prompt dermatological diagnosis, treatment and follow-up guaranteed by a multidisciplinary team, including pediatricians for this group of age.
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Affiliation(s)
- Francesca Mori
- Allergy Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
| | - Francesca Saretta
- Pediatric Department, Latisana-Palmanova Hospital, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Lucia Liotti
- Department of Pediatrics, Salesi Children's Hospital, AOU Ospedali Riuniti Ancona, Ancona, Italy
| | - Mattia Giovannini
- Allergy Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
| | - Riccardo Castagnoli
- Pediatric Clinic, Department of Pediatrics, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Stefania Arasi
- Translational Research in Pediatric Specialties Area, Division of Allergy, Bambino Gesù Children's Hospital (IRCCS), Rome, Italy
| | - Simona Barni
- Allergy Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
| | - Carla Mastrorilli
- Pediatric Unit and Emergency, University Hospital Consortium Corporation Polyclinic of Bari, Pediatric Hospital Giovanni XXIII, Bari, Italy
| | - Luca Pecoraro
- Pediatric Unit, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy
| | - Lucia Caminiti
- Department of Human Pathology in Adult and Development Age “Gaetano Barresi”, Allergy Unit, Department of Pediatrics, AOU Policlinico Gaetano Martino, Messina, Italy
| | - Gian Luigi Marseglia
- Pediatric Clinic, Department of Pediatrics, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Annick Barbaud
- Sorbonne Universités, Service de Dermatologie et d'Allergologie, Hôpital Tenon, Paris HUEP, APHP, Paris, France
| | - Elio Novembre
- Allergy Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
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Migliarino V, Di Mascio A, Berti I, Taddio A, Barbi E. A bullous rash. Arch Dis Child Educ Pract Ed 2022; 107:194-195. [PMID: 33214238 DOI: 10.1136/archdischild-2020-319179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 10/07/2020] [Indexed: 11/03/2022]
Abstract
A 3-year-old boy presented with a 5-day history of bullous skin lesions localised mainly in the upper and lower limbs and in the genital region (figure 1). Lesions were not pruritic nor painful and showed a central crust. There was no family history of skin disorders or autoimmune diseases. The child never had fever and his physical examination was otherwise unremarkable.
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Affiliation(s)
| | | | - Irene Berti
- Pediatric Department, Institute of Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
| | - Andrea Taddio
- Pediatric Department, University of Trieste, Trieste, Italy
- Pediatric Department, Institute of Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
| | - Egidio Barbi
- Pediatric Department, University of Trieste, Trieste, Italy
- Pediatric Department, Institute of Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
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10
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Lim YL, Bohelay G, Hanakawa S, Musette P, Janela B. Autoimmune Pemphigus: Latest Advances and Emerging Therapies. Front Mol Biosci 2022; 8:808536. [PMID: 35187073 PMCID: PMC8855930 DOI: 10.3389/fmolb.2021.808536] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 12/20/2021] [Indexed: 12/31/2022] Open
Abstract
Pemphigus represents a group of rare and severe autoimmune intra-epidermal blistering diseases affecting the skin and mucous membranes. These painful and debilitating diseases are driven by the production of autoantibodies that are mainly directed against the desmosomal adhesion proteins, desmoglein 3 (Dsg3) and desmoglein 1 (Dsg1). The search to define underlying triggers for anti-Dsg-antibody production has revealed genetic, environmental, and possible vaccine-driven factors, but our knowledge of the processes underlying disease initiation and pathology remains incomplete. Recent studies point to an important role of T cells in supporting auto-antibody production; yet the involvement of the myeloid compartment remains unexplored. Clinical management of pemphigus is beginning to move away from broad-spectrum immunosuppression and towards B-cell-targeted therapies, which reduce many patients’ symptoms but can have significant side effects. Here, we review the latest developments in our understanding of the predisposing factors/conditions of pemphigus, the underlying pathogenic mechanisms, and new and emerging therapies to treat these devastating diseases.
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Affiliation(s)
- Yen Loo Lim
- Department of Dermatology, National Skin Centre, Singapore
| | - Gerome Bohelay
- Department of Dermatology and INSERM U1125, Avicenne Hospital, Bobigny, France
| | - Sho Hanakawa
- A*STAR Skin Research Labs (ASRL), Agency for Science, Technology and Research (A*STAR), Singapore
| | - Philippe Musette
- Department of Dermatology and INSERM U1125, Avicenne Hospital, Bobigny, France
| | - Baptiste Janela
- A*STAR Skin Research Labs (ASRL), Agency for Science, Technology and Research (A*STAR), Singapore
- Skin Research Institute of Singapore (SRIS), Agency for Science, Technology and Research (A*STAR), Singapore
- A*STAR Infectious Diseases Labs, Agency for Science, Technology and Research (A*STAR), Singapore
- Singapore Immunology network, Agency for Science, Technology and Research (A*STAR), Singapore
- *Correspondence: Baptiste Janela,
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Jimenez A, Blain K, Khalighi M, Clarke JT, Snook J, Cipriano SD. Neonatal pemphigoid gestationis: An atypical presentation of a rare disease. Pediatr Dermatol 2021; 38:1575-1576. [PMID: 34713489 DOI: 10.1111/pde.14849] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Bullous pemphigoid (BP) is an autoimmune blistering disease characterized by urticarial plaques and/or vesicles and tense bullae. A unique presentation of BP can occur during pregnancy, the postpartum period after delivery, or with the initiation of contraception, in which case it is referred to as pemphigoid gestationis (PG). In rare instances, newborns born to mothers with PG may also present with blisters due to transplacental passage of maternal anti-bullous pemphigoid 180 (BP180) or 230 (BP230) immunoglobulin G (IgG). In this report, we present an unusual case of neonatal PG in an infant born to an asymptomatic mother without a previous diagnosis of PG.
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Affiliation(s)
- Amber Jimenez
- School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Kimberly Blain
- Department of Dermatology, University of Utah, Salt Lake City, Utah, USA
| | - Mazdak Khalighi
- Department of Dermatology, University of Utah, Salt Lake City, Utah, USA
| | - Jennie T Clarke
- Department of Dermatology, University of Utah, Salt Lake City, Utah, USA
| | - Jeremy Snook
- Department of Dermatology, University of Utah, Salt Lake City, Utah, USA
| | - Sarah D Cipriano
- Department of Dermatology, University of Utah, Salt Lake City, Utah, USA
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Egami S, Suzuki C, Kurihara Y, Yamagami J, Kubo A, Funakoshi T, Nishie W, Matsumura K, Matsushima T, Kawaida M, Sakamoto M, Amagai M. Neonatal Linear IgA Bullous Dermatosis Mediated by Breast Milk-Borne Maternal IgA. JAMA Dermatol 2021; 157:1107-1111. [PMID: 34259802 DOI: 10.1001/jamadermatol.2021.2392] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Neonatal linear immunoglobulin A (IgA) bullous dermatosis (LABD) is a rare disease that can be fatal when associated with respiratory failure. All previously reported cases of neonatal LABD have been in newborns with healthy asymptomatic mothers, and the pathogenic IgA was of unknown origin. Objective To clarify the origin of IgA associated with LABD in neonates born of healthy asymptomatic mothers. Design, Setting, and Participants This case study analyzed the laboratory findings of a single breast-fed newborn male with neonatal LABD admitted to the Keio University Hospital in Tokyo and his healthy asymptomatic mother. The healthy newborn developed life-threatening blisters and erosions of the skin and mucous membranes on day 4 after birth. Blood serum, skin, and maternal breast milk were examined for IgA autoantibodies. Main Outcomes and Measures Histopathologic and immunofluorescence analyses of specimens (serum, skin, and breast milk) from the patient and his mother. Results Histopathologic evaluation of the newborn's skin revealed subepidermal blisters with neutrophil infiltrates, and immunofluorescence testing showed linear IgA deposition along the basement membrane zone (BMZ), which lead to the diagnosis of neonatal LABD. Indirect immunofluorescence using normal human skin after treatment with 1-mol/L sodium chloride showed the patient to have circulating IgA binding to the dermal side of BMZ. Immunohistochemical staining proved the deposition of secretory IgA in the neonatal skin by demonstrating the presence of J chain-not been seen in other LABD cases-indicating that the autoantibodies producing the blisters were derived from the maternal breast milk. Although no circulating IgA against the skin was detected in mother's sera, the breast milk contained IgA that reacted with the dermal side of the BMZ. No new blister formation was observed after cessation of breastfeeding. Conclusions and Relevance The results of this case study suggest a passive transfer of pathogenic IgA to a newborn from an asymptomatic mother via breast milk. In prior reports, no serum from asymptomatic mothers of newborns with LABD had IgA autoantibodies binding to skin components; however, in this case, we found that the maternal breast milk contained IgA autoantibodies associated with neonatal LABD. In neonatal LABD, maternal breast milk should be examined for IgA autoantibodies and breast milk feeding should be discontinued as soon as neonatal LABD is suspected.
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Affiliation(s)
- Shohei Egami
- Department of Dermatology, Keio University School of Medicine, Tokyo, Japan
| | - Chihiro Suzuki
- Department of Dermatology, Keio University School of Medicine, Tokyo, Japan
| | - Yuichi Kurihara
- Department of Dermatology, Keio University School of Medicine, Tokyo, Japan
| | - Jun Yamagami
- Department of Dermatology, Keio University School of Medicine, Tokyo, Japan
| | - Akiharu Kubo
- Department of Dermatology, Keio University School of Medicine, Tokyo, Japan
| | - Takeru Funakoshi
- Department of Dermatology, Keio University School of Medicine, Tokyo, Japan
| | - Wataru Nishie
- Department of Dermatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Kazuya Matsumura
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Takahiro Matsushima
- Department of General Pediatrics, Tokyo Metropolitan Children's Medical Center, Fuchu, Japan
| | - Miho Kawaida
- Department of Pathology, Keio University School of Medicine, Tokyo, Japan
| | - Michiie Sakamoto
- Department of Pathology, Keio University School of Medicine, Tokyo, Japan
| | - Masayuki Amagai
- Department of Dermatology, Keio University School of Medicine, Tokyo, Japan
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How to Deal with Skin Biopsy in an Infant with Blisters? Dermatopathology (Basel) 2021; 8:159-175. [PMID: 34199848 PMCID: PMC8293140 DOI: 10.3390/dermatopathology8020022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 05/31/2021] [Accepted: 06/01/2021] [Indexed: 01/22/2023] Open
Abstract
The onset of blisters in a neonate or an infant is often a source of great concern for both parents and physicians. A blistering rash can reveal a wide range of diseases with various backgrounds (infectious, genetic, autoimmune, drug-related, traumatic, etc.), so the challenge for the dermatologist and the pediatrician is to quickly determine the etiology, between benign causes and life-threatening disorders, for a better management of the patient. Clinical presentation can provide orientation for the diagnosis, but skin biopsy is often necessary in determining the cause of blister formations. In this article, we will provide information on the skin biopsy technique and discuss the clinical orientation in the case of a neonate or infant with a blistering eruption, with a focus on the histology for each etiology.
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14
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Juratli HA, Avci P, Horváth B. Clinicians' pearls and myths in pemphigus. Ital J Dermatol Venerol 2021; 156:142-146. [PMID: 33960749 DOI: 10.23736/s2784-8671.21.06810-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Pemphigus comprises a heterogeneous group of autoimmune blistering diseases, which can affect both skin and mucous membranes, especially oral mucosa. This group of diseases shows usually a chronic-relapsing course. Since pemphigus is a rare disease, the diagnosis is often delayed, because it is based upon the recognition of consistent clinical, histologic, and direct immunofluorescence findings, as well as indirect immunofluorescence, and/or enzyme-linked immunosorbent assay. Usually the patients are treated for multiple other conditions before starting the correct therapy, leading to a critical reduction of the patients' quality of life. This review is a succinct compilation of pearls gathered from clinical experience in pemphigus and the myths that may have influenced everyday practice but have been proven false. This review provided a selection of such dilemmas and controversies, focusing on myths and pearls that can help young dermatologist in the clinic, while also dispelling them.
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Affiliation(s)
- Hazem A Juratli
- Department of Dermatology and Allergology, Philipps University, Marburg, Germany -
| | - Pinar Avci
- Department of Dermatology and Allergology, Philipps University, Marburg, Germany
| | - Barbara Horváth
- Department of Dermatology, Center for Blistering Diseases, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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15
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Genovese G, Derlino F, Berti E, Marzano AV. Treatment of Autoimmune Bullous Diseases During Pregnancy and Lactation: A Review Focusing on Pemphigus and Pemphigoid Gestationis. Front Pharmacol 2020; 11:583354. [PMID: 33117178 PMCID: PMC7566587 DOI: 10.3389/fphar.2020.583354] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 09/15/2020] [Indexed: 12/16/2022] Open
Abstract
Pregnancy may induce the onset or exacerbation of autoimmune bullous diseases such as pemphigus or pemphigoid gestationis. A shift toward T helper (Th) 2 immune response and the influence of hormonal changes have been evoked as possible triggering factors. Therapeutic management of this setting of patients may represent a challenge, mainly due to safety concerns of some immunosuppressive drugs during pregnancy and lactation. In this narrative review, we provided a comprehensive overview of the therapeutic management of autoimmune bullous diseases in pregnant and breastfeeding women, focusing on pemphigus and pemphigoid gestationis.
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Affiliation(s)
- Giovanni Genovese
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | | | - Emilio Berti
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Angelo Valerio Marzano
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
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16
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Raiber S, Sezin T, Sadik CD, Bergman R, Avitan-Hersh E. Neonatal Autoimmune Subepidermal IgG/IgA Blistering Disease With Severe Laryngeal and Esophageal Involvement: A Report of a Case and Review of the Literature. Am J Dermatopathol 2020; 42:783-786. [PMID: 32568839 DOI: 10.1097/dad.0000000000001700] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Neonatal autoimmune subepidermal blistering disease is rare. Mucosal involvement is more common in neonatal linear immunoglobulin A (IgA) bullous dermatosis. We describe a neonate with subepidermal cutaneous blistering disease with severe laryngeal and esophageal involvement leading to acute respiratory distress. Histopathology demonstrated a subepidermal blister with neutrophils and eosinophils at the dermal base. Collagen IV was detected at the dermal floor, and direct immunofluorescence showed linear IgG, IgA, and C3 deposits at the basement membrane zone. The patient demonstrated markedly increased serum levels of anti-BP180 NC16A and anti-BP230 IgG antibodies (Abs) but failed to show anti-LAD-1 IgA Abs. His healthy mother showed serum anti-LAD-1 IgA Abs but did not show anti-BP180 and anti-BP230 Abs. The neonate responded promptly to systemic corticosteroid therapy. A review of the literature detected 11 cases of neonatal subepidermal blistering disease with linear IgA deposits. Nine of these cases demonstrated coexisting linear IgG deposits, often with C3. Respiratory compromise was present in most of the cases. Neutrophils and eosinophils were commonly present in the inflammatory cell infiltrates. Besides our case, 2 cases of neonatal IgG/IgA subepidermal blistering disease with esophageal involvement were previously described. IgA Abs were present in the sera of both cases. Anti-LAD-1 IgA Abs were detected in the mother's serum of our case alone, but IgA Abs do not cross the placenta. Our case was consistent with neonatal IgG/IgA pemphigoid. Neonatal IgG/IgA subepidermal blistering disease may be associated with severe laryngeal and esophageal involvement leading to respiratory compromise. Expedited diagnosis and prompt treatment are warranted.
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Affiliation(s)
- Sofia Raiber
- Department of Dermatology, Rambam Health Care Campus, Haifa, Israel
| | - Tanya Sezin
- Department of Dermatology, Allergy, and Venereology, University of Lübeck, Lübeck, Germany
| | - Christian D Sadik
- Department of Dermatology, Allergy, and Venereology, University of Lübeck, Lübeck, Germany
- Center for Research on Inflammation of the Skin (CRIS), University of Lübeck, Lübeck, Germany; and
| | - Reuven Bergman
- Department of Dermatology, Rambam Health Care Campus, Haifa, Israel
- Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Emily Avitan-Hersh
- Department of Dermatology, Rambam Health Care Campus, Haifa, Israel
- Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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17
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McAndrew R, Massey PR, Diaz LZ, Levy ML. Visual Diagnosis: Eosinophilia as a Clue to the Diagnosis of Infantile Bullous Pemphigoid. Pediatr Rev 2020; 41:e34-e36. [PMID: 32873568 DOI: 10.1542/pir.2018-0115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
| | | | - Lucia Z Diaz
- Department of Internal Medicine (Dermatology) and.,Department of Pediatrics, University of Texas at Austin Dell Medical School, Austin, TX.,Department of Pediatric/Adolescent Dermatology, Dell Children's Medical Center of Central Texas, Austin, TX
| | - Moise L Levy
- Department of Internal Medicine (Dermatology) and.,Department of Pediatrics, University of Texas at Austin Dell Medical School, Austin, TX.,Department of Pediatric/Adolescent Dermatology, Dell Children's Medical Center of Central Texas, Austin, TX
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18
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Koneczny I. Update on IgG4-mediated autoimmune diseases: New insights and new family members. Autoimmun Rev 2020; 19:102646. [PMID: 32801046 DOI: 10.1016/j.autrev.2020.102646] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Accepted: 03/08/2020] [Indexed: 12/23/2022]
Abstract
Antibodies of IgG4 subclass are exceptional players of the immune system, as they are considered to be immunologically inert and functionally monovalent, and as such may be part of classical tolerance mechanisms. IgG4 antibodies are found in a range of different diseases, including IgG4-related diseases, allergy, cancer, rheumatoid arthritis, helminth infection and IgG4 autoimmune diseases, where they may be pathogenic or protective. IgG4 autoimmune diseases are an emerging new group of diseases that are characterized by pathogenic, antigen-specific autoantibodies of IgG4 subclass, such as MuSK myasthenia gravis, pemphigus vulgaris and thrombotic thrombocytopenic purpura. The list of IgG4 autoantigens is rapidly growing and to date contains 29 candidate antigens. Interestingly, IgG4 autoimmune diseases are restricted to four distinct organs: 1) the central and peripheral nervous system, 2) the kidney, 3) the skin and mucous membranes and 4) the vascular system and soluble antigens in the blood circulation. The pathogenicity of IgG4 can be validated using our classification system, and is usually excerted by functional blocking of protein-protein interaction.
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Affiliation(s)
- Inga Koneczny
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Währingergürtel 18-20, 1090 Vienna, Austria.
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19
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Ciobanu AM, Dumitru AE, Gica N, Botezatu R, Peltecu G, Panaitescu AM. Benefits and Risks of IgG Transplacental Transfer. Diagnostics (Basel) 2020; 10:E583. [PMID: 32806663 PMCID: PMC7459488 DOI: 10.3390/diagnostics10080583] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 08/07/2020] [Accepted: 08/10/2020] [Indexed: 12/13/2022] Open
Abstract
Maternal passage of immunoglobulin G (IgG) is an important passive mechanism for protecting the infant while the neonatal immune system is still immature and ineffective. IgG is the only antibody class capable of crossing the histological layers of the placenta by attaching to the neonatal Fc receptor expressed at the level of syncytiotrophoblasts, and it offers protection against neonatal infectious pathogens. In pregnant women with autoimmune or alloimmune disorders, or in those requiring certain types of biological therapy, transplacental passage of abnormal antibodies may cause fetal or neonatal harm. In this review, we will discuss the physiological mechanisms and benefits of transplacental transfer of maternal antibodies as well as pathological maternal situations where this system is hijacked, potentially leading to adverse neonatal outcomes.
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Affiliation(s)
- Anca Marina Ciobanu
- Carol Davila University of Medicine and Pharmacy, Bucharest 020021, Romania; (A.M.C.); (N.G.); (R.B.); (G.P.)
- Filantropia Clinical Hospital, Bucharest 11171, Romania;
| | | | - Nicolae Gica
- Carol Davila University of Medicine and Pharmacy, Bucharest 020021, Romania; (A.M.C.); (N.G.); (R.B.); (G.P.)
- Filantropia Clinical Hospital, Bucharest 11171, Romania;
| | - Radu Botezatu
- Carol Davila University of Medicine and Pharmacy, Bucharest 020021, Romania; (A.M.C.); (N.G.); (R.B.); (G.P.)
- Filantropia Clinical Hospital, Bucharest 11171, Romania;
| | - Gheorghe Peltecu
- Carol Davila University of Medicine and Pharmacy, Bucharest 020021, Romania; (A.M.C.); (N.G.); (R.B.); (G.P.)
- Filantropia Clinical Hospital, Bucharest 11171, Romania;
| | - Anca Maria Panaitescu
- Carol Davila University of Medicine and Pharmacy, Bucharest 020021, Romania; (A.M.C.); (N.G.); (R.B.); (G.P.)
- Filantropia Clinical Hospital, Bucharest 11171, Romania;
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20
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Neonatal Pemphigus Vulgaris: A Case Report. ARCHIVES OF PEDIATRIC INFECTIOUS DISEASES 2020. [DOI: 10.5812/pedinfect.101153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
: Pemphigus vulgaris (PV) is an autoimmune blistering disorder of the skin and mucous membranes. The transplacental passage of maternal immunoglobulin G (IgG) autoantibodies to desmoglein-3 (a transmembrane glycoprotein component in the skin) from the mother’s blood to the fetus can cause transient PV in the neonatal period. The duration of PV is short in the neonatal period, and the disease is improved with no prolonged sequelae. The similarity of skin lesions in PV to other skin conditions, such as infectious diseases caused by bacterial, viral, and fungal pathogens, or inherited bullous disorders, such as epidermolysis bullosa and incontinentia pigmenti, leads to misdiagnosis, inappropriate hospital admission, and poor antimicrobial treatment of patients. On the other hand, the maternal history of PV, besides laboratory examination, confirms the exact diagnosis. In this case report, we present a male term neonate with multiple pustules and blisters on the skin, developed within the first hours of life. The patient was admitted to the neonatal ward of our hospital for a sepsis workup and antibiotic treatment. Regarding the positive maternal history of PV in the second trimester of pregnancy and neonatal examinations skin biopsy confirmed the diagnosis of this disease.
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21
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Fenner J, Min MS, Liu S, Silverberg N. A case of neonatal pemphigus vulgaris with co-existing BP180 autoantibodies. Pediatr Dermatol 2020; 37:241-243. [PMID: 31774569 DOI: 10.1111/pde.14059] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
A male neonate was born with blisters on the trunk to a 37-year-old primigravid woman with a past medical history of recurrent, painful, topical steroid-responsive oral blisters. The diagnosis of neonatal pemphigus was made after the neonate and mother were found to have elevated desmoglein 3 (Dsg3) antibodies in conjunction with histopathologic features of pemphigus vulgaris. Interestingly, both neonate and mother also had elevated levels of BP180 antibodies, classically seen in bullous pemphigoid. This case is unique in that it portrays neonatal pemphigus, an already rare condition, complicated by the presence of BP180 antibodies.
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Affiliation(s)
- Justine Fenner
- Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Michelle S Min
- Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Stephanie Liu
- Department of Dermatopathology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Nanette Silverberg
- Departments of Dermatology and Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York
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22
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Abstract
Bullous diseases are uncommon in children; however, as they have the potential to affect quality of life, occasionally have long-term side effects in the setting of scarring processes, and carry a rare risk of underlying malignancy [e.g., with paraneoplastic pemphigus (PNP)], knowledge of their clinical presentation and treatment options is essential. Given the rarity of these conditions, our current state of knowledge is largely derived from case reports and case series, with a paucity of evidence-based recommendations. In this review, we discuss the clinical presentation of and treatment options for linear immunoglobulin A disease, dermatitis herpetiformis, pemphigus vulgaris, pemphigus foliaceus, PNP, bullous pemphigoid, mucus membrane pemphigoid, epidermolysis bullosa acquisita, and inherited epidermolysis bullosa. In general, when these conditions, except for PNP, occur in childhood, they have a better prognosis than when they occur in adults. Clinical, histopathological, and immunologic features frequently overlap, but distinct differences have also been reported, most commonly in clinical presentation. Treatment is often similar to that in adults, although specific considerations are necessary for a pediatric population.
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Affiliation(s)
- Brittney Schultz
- Department of Dermatology, University of Minnesota, 240 Phillips-Wangensteen Building, 516 Delaware Street Southeast, Minneapolis, MN, 55455, USA.,Department of Internal Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Kristen Hook
- Department of Dermatology, University of Minnesota, 240 Phillips-Wangensteen Building, 516 Delaware Street Southeast, Minneapolis, MN, 55455, USA. .,Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA.
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23
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Abstract
Pemphigus consists of a group of rare and severe autoimmune blistering diseases mediated by pathogenic autoantibodies mainly directed against two desmosomal adhesion proteins, desmoglein (Dsg)1 and Dsg3 (also known as DG1 and DG3), which are present in the skin and surface-close mucosae. The binding of autoantibodies to Dsg proteins induces a separation of neighbouring keratinocytes, in a process known as acantholysis. The two main pemphigus variants are pemphigus vulgaris, which often originates with painful oral erosions, and pemphigus foliaceus, which is characterised by exclusive skin lesions. Pemphigus is diagnosed on the basis of either IgG or complement component 3 deposits (or both) at the keratinocyte cell membrane, detected by direct immunofluorescence microscopy of a perilesional biopsy, with serum anti-Dsg1 or anti-Dsg3 antibodies (or both) detected by ELISA. Corticosteroids are the therapeutic mainstay, which have recently been complemented by the anti-CD20 antibody rituximab in moderate and severe disease. Rituximab induces complete remission off therapy in 90% of patients, despite rapid tapering of corticosteroids, thus allowing for a major corticosteroid-sparing effect and a halved number of adverse events related to corticosteroids.
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Affiliation(s)
- Enno Schmidt
- Department of Dermatology, University of Lübeck, Lübeck, Germany; Lübeck Institute for Experimental Dermatology, University of Lübeck, Lübeck, Germany.
| | - Michael Kasperkiewicz
- Department of Dermatology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Pascal Joly
- Department of Dermatology, Rouen University Hospital, Rouen, France; INSERM Unit 2345, French Reference Center for Autoimmune Bullous Diseases, Normandy University, Rouen, France
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24
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Krain RL, Chen KL, Werth VP. Management of autoimmune blistering diseases in pregnancy and the neonate. GIORN ITAL DERMAT V 2019; 154:539-549. [PMID: 31195784 DOI: 10.23736/s0392-0488.19.06375-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The management of autoimmune blistering diseases (AIBD) is therapeutically challenging, particularly in patients who plan to conceive, or are pregnant or breastfeeding. Not only is a patient's immune system altered by pregnancy-associated hormonal changes, but several medications used for AIBD treatment are not recommended for use in pregnancy or lactation. The data acquired regarding the safety and efficacy of these therapeutic interventions are gathered from studies or case reports from other diseases, as the treatment modalities are similar and randomized controlled trials are typically not performed in the setting of pregnancy. Although some medications for AIBD treatment are considered unsafe for use in pregnancy, many effective and tolerable therapies are able to provide benefit to these patients. In fact, most first-line agents may be used in pregnancy, to a given extent. This article discusses the medications used to treat AIBD prior to conception, during pregnancy, and while breastfeeding, as well as highlights those that are contraindicated. The preferred approach to management in these patients is also discussed. Additionally, we present the available information regarding neonates of mothers with a diagnosis of AIBD, including the likelihood, identification, and management of neonatal blistering and the effects from medication exposure in utero.
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Affiliation(s)
- Rebecca L Krain
- Department of Dermatology, Corporal Michael J. Crescenz VAMC, Philadelphia, PA, USA.,Department of Dermatology, University of Pennsylvania, Philadelphia, PA, USA
| | - Kristen L Chen
- Department of Dermatology, Corporal Michael J. Crescenz VAMC, Philadelphia, PA, USA.,Department of Dermatology, University of Pennsylvania, Philadelphia, PA, USA
| | - Victoria P Werth
- Department of Dermatology, Corporal Michael J. Crescenz VAMC, Philadelphia, PA, USA - .,Department of Dermatology, University of Pennsylvania, Philadelphia, PA, USA
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25
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Porro AM, Hans Filho G, Santi CG. Consensus on the treatment of autoimmune bullous dermatoses: pemphigus vulgaris and pemphigus foliaceus - Brazilian Society of Dermatology. An Bras Dermatol 2019; 94:20-32. [PMID: 31166407 PMCID: PMC6544031 DOI: 10.1590/abd1806-4841.2019940206] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 01/30/2019] [Indexed: 02/08/2023] Open
Abstract
Pemphigus are intraepidermal autoimmune bullous dermatoses that occur with
lesions on the skin and / or mucous membranes. The most frequent types are
pemphigus vulgaris and pemphigus foliaceus (classic and endemic). This consensus
aims to present a complete and updated review of the treatment of these two more
frequent forms of pemphigus, based on the literature and the personal experience
of the authors. In moderate and severe cases of pemphigus vulgaris and
foliaceus, systemic corticosteroid therapy (prednisone or prednisolone) is the
treatment of choice. Adjuvant drugs, usually immunosuppressive drugs
(azathioprine, mycophenolate mofetil, methotrexate, cyclophosphamide) may be
prescribed as corticosteroid sparers in refractory cases or with
contraindications to corticosteroids to minimize side effects. In severe and
nonresponsive cases, corticosteroids in the form of intravenous pulse therapy,
immunoglobulin and plasmapheresis / immunoadsorption can be administered.
Immunobiological drugs, particularly rituximab, appear as a promising
alternative. For milder cases, smaller doses of oral corticosteroid, dapsone and
topical corticosteroids are options. At the end flowcharts are presented as
suggestions for a therapeutic approach for patients with pemphigus vulgaris and
pemphigus foliaceus.
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Affiliation(s)
- Adriana Maria Porro
- Department of Dermatology, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Günter Hans Filho
- Dermatology Service, Hospital Universitário Maria Aparecida Pedrossian, Universidade Federal de Mato Grosso do Sul, Campo Grande, MS, Brazil
| | - Claudia Giuli Santi
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
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26
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Dewan AK, Braue J, Danford B, Stack LB, Boyd AS, Fine JD, Albers SE. In utero development of epidermolysis bullosa acquisita. Pediatr Dermatol 2019; 36:e46-e47. [PMID: 30338555 DOI: 10.1111/pde.13704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
We report the case of an infant born with perioral vesicles that rapidly spread to involve his mouth and the majority of his body. Histopathology, immunofluorescence, and enzyme-linked immunohistochemistry assays confirmed a diagnosis of epidermolysis bullosa acquisita (EBA). His mother had no history of EBA, and serum indirect immunofluorescence was negative. The patient improved rapidly with local wound care and oral dapsone.
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Affiliation(s)
- Anna K Dewan
- Department of Dermatology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jonathan Braue
- Department of Dermatology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Brandon Danford
- Department of Dermatology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Lawrence B Stack
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Alan S Boyd
- Department of Dermatology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jo-David Fine
- Department of Dermatology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sharon E Albers
- Department of Dermatology, Vanderbilt University Medical Center, Nashville, Tennessee
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27
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Feliciani C, Genovese G, D'astolto R, Pontini P, Marzano AV. Autoimmune bullous diseases during pregnancy: insight into pathogenetic mechanisms and clinical features. GIORN ITAL DERMAT V 2018; 154:256-262. [PMID: 30375213 DOI: 10.23736/s0392-0488.18.06153-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Pemphigoid gestationis (PG), also known as herpes gestationis, is the prototypic pregnancy-associated autoimmune bullous disease (AIBD), but also the other AIBDs, notably pemphigus vulgaris, may begin or exacerbate during pregnancy. Although the increase in concentration of T and B regulatory cells makes pregnancy a state of increased immunologic tolerance toward the semiallogeneic fetal antigens, a prevalent T helper (Th) 2 profile, that is reported to be associated with pregnancy, may cause exacerbation of pemphigus and AIBDs in general during this period. Active disease may lead to stillbirth, spontaneous abortion, preterm pregnancy, low birthweight, and neonatal pemphigus. PG is a rare AIBD usually starting during the third trimester of pregnancy and healing in the postpartum. It is due to the formation of autoantibodies directed against different epitopes of bullous pemphigoid (BP) 180 as a consequence of the aberrant expression of BP180 in the placental tissue of genetically predisposed women. PG is characterized by vesicles with herpetiform distribution, blisters and urticarial elements typically involving the periumbilical area and the distal portion of the upper limbs. Diagnosis is based on: 1) physical examination; 2) histopathological pattern consisting of a dermal inflammatory infiltrate rich in eosinophils; 3) direct immunofluorescence test demonstrating linear deposits of complement fraction 3 and immunoglobulin G along the basement membrane zone; 4) detection of circulating autoantibodies by means of indirect immunofluorescence or enzyme linked immunosorbent assay. Here, we provide an updated overview on the pathophysiologic mechanisms of pregnancy-associated or pregnancy-exacerbated AIBDs, focusing also on peculiar clinical features of these disorders.
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Affiliation(s)
- Claudio Feliciani
- Section of Dermatology, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Giovanni Genovese
- Unit of Dermatology, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy.,Department of Physiopathology and Transplantation, University of Milan, Milan, Italy
| | - Roberto D'astolto
- Section of Dermatology, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Paolo Pontini
- Unit of Dermatology, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy.,Department of Physiopathology and Transplantation, University of Milan, Milan, Italy
| | - Angelo V Marzano
- Unit of Dermatology, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy - .,Department of Physiopathology and Transplantation, University of Milan, Milan, Italy
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28
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Abstract
IgG4 autoimmune diseases are characterized by the presence of antigen-specific autoantibodies of the IgG4 subclass and contain well-characterized diseases such as muscle-specific kinase myasthenia gravis, pemphigus, and thrombotic thrombocytopenic purpura. In recent years, several new diseases were identified, and by now 14 antigens targeted by IgG4 autoantibodies have been described. The IgG4 subclass is considered immunologically inert and functionally monovalent due to structural differences compared to other IgG subclasses. IgG4 usually arises after chronic exposure to antigen and competes with other antibody species, thus "blocking" their pathogenic effector mechanisms. Accordingly, in the context of IgG4 autoimmunity, the pathogenicity of IgG4 is associated with blocking of enzymatic activity or protein-protein interactions of the target antigen. Pathogenicity of IgG4 autoantibodies has not yet been systematically analyzed in IgG4 autoimmune diseases. Here, we establish a modified classification system based on Witebsky's postulates to determine IgG4 pathogenicity in IgG4 autoimmune diseases, review characteristics and pathogenic mechanisms of IgG4 in these disorders, and also investigate the contribution of other antibody entities to pathophysiology by additional mechanisms. As a result, three classes of IgG4 autoimmune diseases emerge: class I where IgG4 pathogenicity is validated by the use of subclass-specific autoantibodies in animal models and/or in vitro models of pathogenicity; class II where IgG4 pathogenicity is highly suspected but lack validation by the use of subclass specific antibodies in in vitro models of pathogenicity or animal models; and class III with insufficient data or a pathogenic mechanism associated with multivalent antigen binding. Five out of the 14 IgG4 antigens were validated as class I, five as class II, and four as class III. Antibodies of other IgG subclasses or immunoglobulin classes were present in several diseases and could contribute additional pathogenic mechanisms.
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Affiliation(s)
- Inga Koneczny
- Institute of Neurology, Medical University of Vienna, Vienna, Austria
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Vanoni F, Lava SAG, Fossali EF, Cavalli R, Simonetti GD, Bianchetti MG, Bozzini MA, Agostoni C, Milani GP. Neonatal Systemic Lupus Erythematosus Syndrome: a Comprehensive Review. Clin Rev Allergy Immunol 2017; 53:469-476. [DOI: 10.1007/s12016-017-8653-0] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Abstract
Pemphigus is a group of IgG-mediated autoimmune diseases of stratified squamous epithelia, such as the skin and oral mucosa, in which acantholysis (the loss of cell adhesion) causes blisters and erosions. Pemphigus has three major subtypes: pemphigus vulgaris, pemphigus foliaceus and paraneoplastic pemphigus. IgG autoantibodies are characteristically raised against desmoglein 1 and desmoglein 3, which are cell-cell adhesion molecules found in desmosomes. The sites of blister formation can be physiologically explained by the anti-desmoglein autoantibody profile and tissue-specific expression pattern of desmoglein isoforms. The pathophysiological roles of T cells and B cells have been characterized in mouse models of pemphigus and patients, revealing insights into the mechanisms of autoimmunity. Diagnosis is based on clinical manifestations and confirmed with histological and immunochemical testing. The current first-line treatment is systemic corticosteroids and adjuvant therapies, including immunosuppressive agents, intravenous immunoglobulin and plasmapheresis. Rituximab, a monoclonal antibody against CD20+ B cells, is a promising therapeutic option that may soon become first-line therapy. Pemphigus is one of the best-characterized human autoimmune diseases and provides an ideal paradigm for both basic and clinical research, especially towards the development of antigen-specific immune suppression treatments for autoimmune diseases.
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