Oropharyngeal pemphigus vulgaris and clinical remission: a long-term, longitudinal study

Oral Pemphigus Vulgaris Treatment with Corticosteroids and Azathioprine: A Long-Term Study in Shiraz, Iran

Background

Treating oral mucosal lesions of Pemphigus Vulgaris (PV) disease is usually challenging for clinicians. We studied the treatment outcomes of the oral PV patients referred to the Oral Medicine Department of Shiraz University of Medical Sciences from 2004 to 2018.

Methods

The medical records of 54 oral PV patients with histopathological confirmation who were treated by a single protocol were studied. The protocol consisted of initial treatment with 1 mg/kg/day of oral prednisolone for all patients. After 4-6 weeks, all patients were prescribed 40 mg of prednisolone. If lesion recovery was not observed or new lesions had developed, adjuvant therapy (maximum dose of 200 mg per day of Azathioprine (AZA)) was initiated anytime during the treatment. The oral prednisolone dosage was gradually tapered to 5 mg/alternate day in 9 months.

Results

47 patients were included in the study. 34.04% were male and 65.96% were female with a mean age of 41.83 ± 12.520. The mean follow-up period was 50.806 ± 44.417 months (over 4 years). The severity of oral involvement was mild in 21.27%, moderate in 36.17%, and severe in 42.6%. During treatment, all patients except one experienced complete remission. The mean time to achieve complete remission was 150.39 ± 224.075 days. Most of the patients experienced relapse due to self-discontinuation of treatment. 55% had complete remission and 43% were in partial remission at the last follow-up session. In 65.96% of patients, treatment-associated side effects were observed. The patients treated with prednisolone alone had significantly more side effects than those using AZA as an adjuvant (80% vs 50%, respectively; P=0.030). The mean duration of follow-ups was longer for patients with side effects (P < 0.01). Topical corticosteroids were used for all patients sometime during the treatment. No deaths were recorded.

Conclusion

Prescribing low-dose prednisolone and adding AZA in nonresponding cases has good clinical outcomes for the treatment of oral lesions of PV. Adjuvant therapy can avoid the increase in corticosteroid dosage and side effects. The treatment method described in this study can be a helpful guide for clinicians, especially when other immunosuppressive drugs are not available.

Immunocytometric Analysis of Oral Pemphigus vulgaris Patients after Treatment with Rituximab as Adjuvant

Background: B-cell depletion therapy was demonstrated to be a valid and safe alternative as an adjuvant in oral-pharyngeal pemphigus vulgaris (OPV) patients. We aimed to assess its effects on anti-desmoglein (Dsg) 1 and 3 and leukocytes subsets profile in these patients’ population. Methods and Materials: We evaluated the immunologic profile of 10 OPV patients treated with RTX as adjuvant by using the ELISA testing for anti-Dsg-1 and -3 titers and the immunophenotyping for B and T-cell lymphocyte subpopulations and compared them with the PDAI score for clinical remission. Results: A significant difference in medians between baseline, end of RTX therapy, and 6 months after RTX therapy was observed in Dsg-3 titer (p < 0.001), in the CD8 (p = 0.009), and CD20 counts (p < 0.001). Multiple comparisons after Bonferroni adjustment confirmed such significant differences mainly between baseline and the end of RTX therapy and baseline and 6 months after RTX therapy. Only the anti-Dsg-3 titer at the end of RTX therapy demonstrated a slight positive correlation with the PDAI score at baseline (p = 0.046, r = 0.652). Conclusions: B-cell depletion adjuvant therapy in OPV patients demonstrated a significant impact on anti-Dsg-3 titer and B and T-cell lymphocyte subpopulations profile.

Autoimmune mucocutaneous blistering diseases in the south of Italy: a 25-year retrospective study on 169 patients

BACKGROUND

Autoimmune mucocutaneous blistering diseases (AMBDs) represent a heterogeneous group of organ-specific and potentially life-threatening diseases. We sought to determine the relationship between clinical remission and therapeutic regimens with clinical type and phenotype of AMBDs, as well as clinical outcomes achieved based on different therapeutic regimens.

METHODS

A retrospective single-center study on 169 AMBDs patients, including pemphigus vulgaris (PV), mucous membrane pemphigoid (MMP), paraneoplastic autoimmune multiorgan syndrome (PAMS), and lichen planus pemphigoides (LPP), was performed from 1994 to 2019 in an oral medicine tertiary center, where we collected sociodemographic data, clinical type and phenotype, prescribed therapies, and related outcomes.

RESULTS

The mean age of AMBDs patients was 55.0 ± 16.4 years. They were followed for a mean of 8.4 ± 5.8 years. The majority of these patients (62.1%) were successfully managed with conventional immunosuppressive therapy (CIST) alone. However, 37.9% of patients required additional biological treatments, either because they were non-responders or developed severe side effects from CIST, or because of the rapid and severe progression of the disease. Overall, complete clinical remission was achieved in 92.3% of patients. A statistically significant difference was noted between the frequency distribution of AMBDs patients among different therapeutic regimens (P = .002), of different clinical phenotype and type of AMBDs patients and clinical remission (P = .012 and P = .005, respectively). No difference was reported regarding clinical outcomes and different therapeutic regimens.

CONCLUSIONS

AMBDs' management may be challenging, nonetheless CIST and biologic regimens introduced, when needed as reliable alternatives to CIST, result in a very high percentage of CCR.

Metoprolol-Induced Pemphigus-Like Reaction

INTRODUCTION

Pemphigus vulgaris (PV) is a relatively rare, potentially life-threatening autoimmune disease that, in most cases, has an unknown etiology. Medications for hypertension have been linked to the onset and exacerbation of PV-like symptoms. The diagnosis of medication-related PV can be challenging because it has an identical appearance to the clinical and histologic appearance of idiopathic PV and cases may not resolve after discontinuation of the drug.

CASE PRESENTATION

We present a case of an elderly patient with gingival and cutaneous erosions, who underwent several medical and dental consultations without an appropriate diagnosis. After biopsy and a thorough review of her medical history, metoprolol was suspected as the offending agent. After consulting with her cardiologist, metoprolol was discontinued, and a complete resolution of all lesions resulted.

CONCLUSIONS

To our knowledge, the current case is the first reported case of metoprolol-induced PV in the English-language literature. As such, it highlights the potential of medication involvement in some immune-mediated diseases. Because the oral mucosa is often the first site of involvement in PV, knowledge of drug-related PV is crucial in the diagnosis, treatment, and management of dental patients.

Identification of factors associated with treatment refractoriness of oral lesions in pemphigus vulgaris

BACKGROUND

The oral mucosal lesions of patients with pemphigus vulgaris are known to show more treatment refractoriness than skin lesions.

OBJECTIVES

To identify which clinical and laboratory parameters may indicate treatment refractoriness of oral lesions in pemphigus vulgaris.

METHODS

This was a prospective study of 50 adults with pemphigus vulgaris and oral lesions; patients were given treatment appropriate for overall disease severity. Treatment refractoriness was defined arbitrarily as less than 75% reduction in oral objective Autoimmune Bullous Skin Disorder Intensity Score (ABSIS) after treatment for 6 months.

RESULTS

Of 46 patients who completed the study, 17 (37%) were treatment refractory whereas 29 (63%) were treatment responsive. At baseline, the treatment refractory group had a significantly longer mean duration of disease (P = 0·02) and mean duration of oral lesions (P = 0·01), a higher percentage of lesions in the retromolar trigone (P = 0·05) and on the occlusion line along the buccal mucosa (P = 0·04), a higher percentage of deep/crateriform ulcers (P < 0·001) and erosions with a lichenoid hue (P < 0·001). Herpes simplex virus (HSV) DNA positivity, assessed by polymerase chain reaction in oral tissue scrapings (P = 0·02), was also significantly higher in the treatment refractory group. No other factors we tested for were statistically significant.

CONCLUSIONS

Treatment refractoriness of oral lesions was significantly associated with duration of disease/oral lesions; specific morphology and location of oral lesions; and the presence of HSV DNA in the oral cavity. These factors may forewarn the treating physician about a refractory course of oral lesions that may help with counselling patients.

A Comparative Effectiveness Research of Azathioprine and Cyclophosphamide on the Clinical and Serological Response in Pemphigus Vulgaris

CONTEXT

A prospective study was carried out to examine the efficacy of cyclophosphamide and azathioprine in pemphigus vulgaris.

AIMS

To compare the clinical and serological effect of azathioprine and cyclophosphamide in pemphigus patients.

MATERIALS AND METHODS

Prospective, institutional based study was conducted twenty-one patients of pemphigus vulgaris were initiated on either azathioprine (n = 9) or cyclophosphamide (n = 7) in addition to prednisolone and were evaluated clinically (mucosal and cutaneous severity) and serologically enzyme-linked immunosorbent assay (ELISA) at 0, 3 and 6 months.

RESULTS

Azathioprine had a slower onset of action with a statistically significant improvement seen by 6 months (P = 0.016). Cyclophosphamide had a faster onset of action (3 months) though there was no statistical difference in the efficacy between the two at the end of 6 months. The (RonT) was 33.3-44.4% for azathioprine and 28.8-42.9% for cyclophosphamide at 6 months. Though ELISA had a high sensitivity and specificity for diagnosis, as a tool for assessing therapeutic response a significant decrease was seen only till 3 months. This was restricted to Dsg1 for the azathioprine group and both Dsg3 and Dsg1 levels for the cyclophosphamide group. There were two deaths, both in the cyclophosphamide group.

CONCLUSIONS

Azathiorpine and cyclophosphamide are equally effective for mucosal and cutaneous disease in pemphigus after 6 months of therapy. Dsg ELISA is useful for diagnosis of pemphigus but is not a useful tool for monitoring response to therapy.

Desmosomes in disease: a guide for clinicians

The large number of diseases occurring when desmosome constituents are impaired provides striking evidence for the key role of desmosomes in maintaining tissue integrity. A detailed understanding of the molecular alterations causing desmosomal dysfunction has, in turn, underpinned the development of novel diagnostic tools. This has salient clinical implications for dentists and oral medicine practitioners because the majority of desmosomal diseases affect the oral cavity. In the present article, we review the autoimmune, infectious, genetic, and neoplastic diseases that target the desmosome, with particular emphasis on clinical manifestations, diagnostic pathways, and relevant laboratory investigations.

Urban legends: pemphigus vulgaris

Pemphigus vulgaris (PV) is the most common type of pemphigus. PV pathogenesis is still debated, and treatment remains challenging. We investigated five controversial topics: (1) What are the target antigens in PV? (2) Do desmogleins adequately address PV pathophysiology? (3) How does acantholysis occur in PV? (4) Is PV still a lethal disease? (5) What is the role of rituximab (RTX) in PV treatment? Results from extensive literature searches suggested the following: (1) Target antigens of PV include a variety of molecules and receptors that are not physically compartmentalized within the epidermis. (2) PV is caused by a variety of autoantibodies to keratinocyte self-antigens, which concur to cause blistering by acting synergistically. (3) The concept of apoptolysis distinguishes the unique mechanism of autoantibody-induced keratinocyte damage in PV from other known forms of cell death. (4) PV remains potentially life-threatening largely because of treatment side effects, but it is uncertain which therapies carry the highest likelihood of lethal risk. (5) RTX is a very promising treatment option in patients with widespread recalcitrant or life-threatening PV. RTX's cost is an issue, its long-term side effects are still unknown, and randomized controlled trials are needed to establish the optimal dosing regimen.