Severe multi-resistant pemphigus vulgaris: prolonged remission with a single cycle of rituximab

Dexamethasone-cyclophosphamide pulse therapy outcomes comparing pemphigus vulgaris and pemphigus foliaceus groups in a Brazilian cohort study

BACKGROUND

Dexamethasone-cyclophosphamide pulse (DCP) and dexamethasone pulse (DP) have been successfully used to treat pemphigus, but DCP/DP outcomes comparing pemphigus vulgaris (PV) and pemphigus foliaceus (PF) are scarce.

OBJECTIVE

To compare DCP/DP outcomes in a Brazilian cohort of PV and PF patients according to demographic and clinical data.

METHODS

Retrospective analytical cohort study, reviewing medical charts of PV and PF patients (for DCP/DP Phases I‒IV consult Pasricha et al.16‒18).

RESULTS

37 PV and 41 PF patients non responsive to usual treatments were included similarly for DCP or DP therapy. Disease duration was longer among PF before DCP/DP prescription (p < 0.001); PF required a higher number of monthly pulses to acquire remission in Phase I (median 10 and 6 pulses, respectively; p = 0.005). DCP/DP outcomes were similar in both groups: remission in 37.8% of PV and 34.1% of PF after completed DCP/DP cycles following a median of 13 months (1-56 months follow-up); failure occurred in 13.5% of PV and 14.6% of PF in Phase I; relapse in 13.5% of PV and 12.2% of PF, and dropout in 27% of PV and 24.4% of PF in Phases II to IV. Mild side effects were documented.

STUDY LIMITATIONS

The severity of PV and PF disease was not assessed by score indexes.

CONCLUSIONS

PV and PF patients presented similar DCP/DP outcomes. DCP/DP should be initiated earlier in PF patients due to the longer duration of their disease in order to decrease the number of pulses and the duration of Phase I to acquire remission.

Kaposi Varicelliform Eruption in a Patient with Pemphigus Vulgaris: A Case Report and Review of the Literature

Haemorrhagic crusted lesions over pre-existing pemphigus vulgaris erosions should arouse suspicion of Kaposi varicelliform eruption (KVE). Immediate treatment with antivirals helps to prevent mortality and morbidities. Here, we report a case of a 67-year-old male who developed haemorrhagic crusted lesions on pre-existing pemphigus lesions during his hospital stay and obtained almost 90% resolution of cutaneous lesions of Pemphigus vulgaris as well as Kaposi varicelliform eruption within 2 weeks of acyclovir treatment along with the continuation of systemic steroids. We also highlight the review of the literature of other reported cases with its management.

Vesiculobullous autoimmune diseases with oral mucosa manifestations: retrospective and follow-up study

ABSTRACT Objective: To conduct a retrospective study on a series of cases of PV and BMMP with manifestations in the oral cavity in order to ascertain prevalence, sociodemographic characteristics, diagnostic maneuvers, treatment and follow-up. Methods: This is a retrospective, descriptive study in which clinical data were collected from the medical records of all cases of PV and BMMP registered and diagnosed, between 1995 and 2015, in the Oral Diagnostic Service of the UFRN Department of Dentistry. Results: The mean age of the total sample (n = 36) was 41.64, with females the most frequent (n = 26; 72.22%) and the cheek mucosa being the site most affected (n = 20; 27.40%). Eight patients (22.22%), including 5 cases of PV and 3 BMMP, were clinically reevaluated. All patients exhibited lesions at the time of follow-up. Prednisone (n=7; 87.5%) and clobetasol propionate (n=8, 100%) were the most widely used drugs in the systemic and topical treatment, respectively. The follow-up period ranged from 5 months to 5 years. Conclusion: The clinical profile of patients in this study was similar to that evidenced in the literature. However, it was found that the oral lesions were more resistant to the treatment used on the patients evaluated.

Rituximab therapy improves recalcitrant Pemphigus vulgaris

Pemphigus is a severe life-threatening blistering disease associated with autoantibodies against cell adhesion proteins desmogleins 1 and 3. Patients with severe pemphigus commonly show high rates of relapse after conventional immunosuppressive therapy. The newly developed drug Rituximab showed impressing promises in the treatment of refractory pemphigus vulgaris (PV). In the present study the efficacy of a single course rituximab therapy in the treatment of PV was investigated. Eighteen patients with severe recalcitrant PV were recruited to this study. Pemphigus disease activity index (PDAI), anti-desmoglein 1 and anti-desmoglein 3 antibody titers, and percent of CD20 positive cells were measured at baseline, 10 ± 1, and 22 ± 2 weeks after rituximab therapy. Rituximab was given intravenously at dose 375 mg/m(2) once weekly for 4 weeks. Rituximab therapy caused a dramatic reduction in the PDAI, accompanied by decreases in anti-desmoglein 1 and anti-desmoglein 3 antibody titers over the follow-up course. The B-cell population decreased at the first follow-up, but returned to its baseline levels at the second follow-up. Rituximab therapy decreased the dose of immunosuppressive drugs required to control the disease. It seems that the rituximab may be effective and safe for treatment of refractory PV.

The emerging role of rituximab in autoimmune blistering diseases

Rituximab is a chimeric monoclonal antibody that selectively binds to the CD20 molecule on B cells, resulting in their lysis. In autoimmune blistering diseases, the auto-antibody-producing B cells are destroyed and auto-antibody levels are reduced or eliminated. In the majority of patients, rituximab produces rapid clinical response and early resolution. In part, this accounts for the increased use of rituximab. Rituximab does not distinguish normal from pathologic B cells. Hence, shortly after its use, B-cell levels are zero and remain so for several months. In most patients, the use of systemic corticosteroids and immunosuppressive agents are continued after rituximab therapy, while their dosages are significantly decreased. In the majority of patients rituximab is used according to the protocol used in treating lymphoma patients or patients with rheumatoid arthritis. Approximately 50% of patients experience a relapse, requiring additional therapy. Serious adverse events and fatal outcomes have been reported, although their incidence is less than that observed with conventional therapy. Nonetheless, the causes, i.e. infections and septicemia, are similar. Several gaps exist in our understanding of how to optimally benefit from the use of this valuable biological agent. Future studies need to be targeted in designing and implanting protocols that maximize the benefit of rituximab and result in producing sustained prolonged remissions with minimal adverse events and a high quality of life.

Rituximab therapy improves recalcitrant Pemphigus vulgaris

Pemphigus is a severe life-threatening blistering disease associated with autoantibodies against cell adhesion proteins desmogleins 1 and 3. Patients with severe pemphigus commonly show high rates of relapse after conventional immunosuppressive therapy. The newly developed drug Rituximab showed impressing promises in the treatment of refractory pemphigus vulgaris (PV). In the present study the efficacy of a single course rituximab therapy in the treatment of PV was investigated. Eighteen patients with severe recalcitrant PV were recruited to this study. Pemphigus disease activity index (PDAI), anti-desmoglein 1 and anti-desmoglein 3 antibody titers, and percent of CD20 positive cells were measured at baseline, 10 ± 1, and 22 ± 2 weeks after rituximab therapy. Rituximab was given intravenously at dose 375 mg/m(2) once weekly for 4 weeks. Rituximab therapy caused a dramatic reduction in the PDAI, accompanied by decreases in anti-desmoglein 1 and anti-desmoglein 3 antibody titers over the follow-up course. The B-cell population decreased at the first follow-up, but returned to its baseline levels at the second follow-up. Rituximab therapy decreased the dose of immunosuppressive drugs required to control the disease. It seems that the rituximab may be effective and safe for treatment of refractory PV.