Preliminary serological studies comparing immunofluorescence assay with radioimmunoassay

[Mucous membrane pemphigoid: IgG and IgA antibodies against the BP180 antigen]

INTRODUCTION

Mucous membrane pemphigoid is a group of autoimmune bullous diseases, mediated by autoantibodies directed against different proteins in the dermoepidermal junction, including the BP180 antigen.

PATIENTS, MATERIAL AND METHODS

We included five patients with MMP in this study. We studied the presence of circulating autoantibodies against the BP180 antigen and against recombinant extracellular fragments of this protein.

RESULTS

We detected the presence of circulating antibodies against BP180 in all of the patients. Indirect immunofluorescence (IIF) studies were positive in 2 patients (20 %), as well as in 2 patients via salt-split studies. We found reactivity to the extracellular fragment of BP180 (LAD-1) in 3 patients, 2 of them via IgA and 1 with IgG. The serum of only 2 patients recognized the NC16A fragment, and 4 of the 5 patients had antibodies against the carboxy-terminal domain BP180 4575.

CONCLUSIONS

Molecular biology techniques are very important to complement the diagnosis of MMP, especially when the results of hematoxylin-eosin or IF studies are not satisfactory for a diagnosis of MMP.

Ocular cicatricial pemphigoid: pathogenesis, diagnosis and treatment

Understanding of ocular cicatricial pemphigoid (OCP) has changed dramatically over the last three decades. Progress in basic science research in mucous membrane pemphigoid has been instrumental in outlining the key immune processes that participate in the autoimmune response. Immunomodulatory therapy has provided an avenue for preserving vision and preventing potentially fatal consequences of systemic pemphigoid. In this chapter we focus attention on the immunologic basis for disease and treatment strategies. We propose an algorithmic approach to diagnosis and management of OCP.

Bullous pemphigoid: interaction of interleukin 5, anti-basement membrane zone antibodies and eosinophils. A preliminary observation

Bullous pemphigoid (BP) is an autoimmune blistering skin disease characterized by the presence of autoantibodies to normal components of the hemidesmosome (BPAg1 and BPAg2). Histology of skin lesions demonstrate a subepidermal vesicle and a predominantly eosinophilic dermal cellular infiltrate. Interleukin 5 (IL-5) plays a major role in eosinophil recruitment and function. Using an ELISA, we investigated the levels of IL-5 in the sera and blister fluid of BP patients with active disease and those in prolonged clinical remission treated with intravenous immunoglobulin, and compared it to that in normal controls. Significantly increased levels of IL-5 were detected in the serum and particularly the blister fluid of patients with active disease (P=0.0043) when compared to levels in normal controls. There was no significant difference in IL-5 levels in patients in prolonged clinical remission compared to normal control serum. In an immunoblot assay, using bovine gingival lysate as substrate, we determined the presence of IgG and IgE autoantibodies specific to basement membrane zone proteins in blister fluid and serum of BP patients. IgG autoantibodies to BPAg1 and BPAg2 were detected in both blister fluid and serum of patients, whereas IgE autoantibodies, in much lower titers, were detected to only BPAg1. Elevated levels of blood and tissue eosinophilia were observed in these patients. Based on these data, we present a preliminary hypothesis for the initiation, progression and localization of blister formation in BP.

Cicatricial pemphigoid

Cicatricial pemphigoid (CP) is a heterogeneous group of rare, chronic, subepithelial blistering disorders of the mucous membranes and, occasionally, the skin, which can have serious and rarely fatal consequences. The most common clinical features are desquamative gingivitis, oral erosions, and conjunctival fibrosis. Skin lesions occur less frequently and may present as widespread vesicles and bullae, as in bullous pemphigoid (BP). In some patients, the scarring can be a source of significant morbidity because it can result in odynophagia, strictures of the upper aerodigestive tract, or corneal opacities leading to eventual blindness. This article is a comprehensive review and discusses clinical, pathologic, and pathophysiologic aspects of this group of disorders collectively known as CP. (J Am Acad Dermatol 2000;43:571-91.)

LEARNING OBJECTIVE

At the conclusion of this learning activity, participants should be familiar with the clinical spectrum of CP, the histopathologic and immunopathologic characteristics, the differential diagnosis, the treatment, and the natural history of the disease. Furthermore, this learning activity should facilitate early diagnosis of CP and should promote the idea that the involvement of other specialists, including ophthalmologists, otolaryngologists, gastroenterologists, and oral medicine specialists, as appropriate, will aid in providing these patients with the highest quality of care.

Intravenous immunoglobulin therapy for ocular cicatricial pemphigoid: a preliminary study

OBJECTIVE

To report the effects of intravenous immunoglobulin treatment of ten patients with progressive ocular cicatricial pemphigoid who did not respond to conventional immunomodulatory regimens.

DESIGN

Noncomparative, interventional case series.

PARTICIPANTS

Ten patients with biopsy-proven progressive cicatricial pemphigoid affecting the eyes who did not respond adequately to other local and systemic immunosuppressive treatment regimens.

INTERVENTION

Intravenous infusions of pooled human immunoglobulin, 2 to 3 g/kg body weight/cycle, divided over 3 days, and repeated every 2 to 6 weeks.

MAIN OUTCOME MEASURES

Reduction in conjunctival inflammation, prevention of progression of subepithelial conjunctival fibrosis, improvement in ocular symptoms (discomfort, photophobia), improved visual acuity, reduction in extraocular mucosal lesions.

RESULTS

Clinical deterioration was arrested and resolution of chronic conjunctivitis was documented in all ten patients. Maximum therapeutic effect was observed and maintained after a minimum of 4 cycles of therapy; three patients required 12 cycles before disease control. The duration of therapy in these ten patients has been 16 to 23 months (mean, 19.3 months) with no treatment-induced side effects. Extraocular mucosal lesion resolution has occurred in all but one patient, Visual acuity has stabilized or improved in all ten patients, and subjective complaints of discomfort and photophobia have decreased in all patients.

CONCLUSIONS

Intravenous immunoglobulin immunomodulatory therapy can be a safe and effective therapy for otherwise treatment-resistant ocular cicatricial pemphigoid.

Detection and partial characterization of ocular cicatricial pemphigoid antigens on COLO and SCaBER tumor cell lines

Ocular cicatricial pemphigoid (OCP) is a chronic autoimmune inflammatory disease which affects the conjunctiva and other squamous epithelial mucous membranes resulting in a scarring process. It is characterized by the deposition of an anti-basement membrane zone (BMZ) antibody in vivo. Sera from 11 patients with active OCP were studied. Using monkey esophagus and normal skin as substrate, weak staining of the BMZ was observed in conventional indirect immunofluorescence (IIF) assay. Using salt split human skin as substrate, the OCP sera demonstrated binding to the epidermal side of the split, in low titers with weak staining. Ten of the 11 sera were positive on an immunoblot assay using COLO and SCaBER tumor cell lysates demonstrating 230, 205, 160, and 85 kD proteins. Sera from six bullous pemphigoid (BP) patients, with only cutaneous involvement and high titer of anti-BMZ antibody, as detected by IIF, also bound to 230, 160, and 85 kD proteins on both lysates in comigration experiments. Serum from five normal individuals and two patients each with severe atopic conjunctival disease, erythema multiforme with chronic conjunctivitis and systemic lupus erythematosus (SLE), did not demonstrate those bands. When the two lysates were first absorbed with BP sera and then the same lysates were immunoblotted with OCP sera, in all ten OCP sera the 230, 160, and 85 kD bands were eliminated and only a single 205 kD band was uniformly present. These results indicate that OCP sera recognize peptide(s) present in 230, 205 and 160 kD proteins in lysates from COLO and SCaBER tumor cells. These proteins contain the immunodominant region of the BMZ molecule(s) in which the OCP antigen(s) reside. The OCP antigen(s) appears to be distinct from the BP antigen(s).