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Moro F, Sinagra JLM, Salemme A, Fania L, Mariotti F, Pira A, Didona B, Di Zenzo G. Pemphigus: trigger and predisposing factors. Front Med (Lausanne) 2023; 10:1326359. [PMID: 38213911 PMCID: PMC10783816 DOI: 10.3389/fmed.2023.1326359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 11/29/2023] [Indexed: 01/13/2024] Open
Abstract
Pemphigus is a life-threatening autoimmune blistering disease affecting skin and mucous membranes. Despite its etiopathogenesis remains largely unknown, several trigger and predisposing factors have been reported. Pemphigus is caused by autoantibodies that target desmoglein 1 and desmoglein 3, impacting desmosome function. However, circulating autoantibodies are often the consequence of a precipitating factor that occurs in predisposed individuals. This review aims to describe and discuss almost all trigger and predisposing factors reported as possible or probable cause of the disease. Among the reported trigger factors that may induce or exacerbate pemphigus, we have found of particular interest: drug intake (especially thiol- and phenol-containing compounds), vaccines, infections, as well as some reports about pregnancy, radiations, emotional stress, pesticides and physical trauma. Moreover, we discuss the possible role of food intake in pemphigus onset and particular attention is given to dietary factors containing thiol, phenol and tannin compounds. A trigger factor is "the straw that breaks the camel's back," and often acts together with predisposing factors. Here we discuss how pemphigus onset may be influenced by genetic susceptibility and comorbidities like thyroid diseases, malignancies and other autoimmune disorders. To identify other hitherto unknown trigger and predisposing factors, well designed prospective studies are needed. In this context, future research should explore their connection with the aim to advance our understanding of pemphigus pathogenesis.
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Affiliation(s)
- Francesco Moro
- Molecular and Cell Biology Laboratory, Istituto Dermopatico dell’Immacolata (IDI)-IRCCS, Rome, Italy
- Dermatology Clinic, Istituto Dermopatico dell’Immacolata (IDI)-IRCCS, Rome, Italy
| | - Jo Linda Maria Sinagra
- Molecular and Cell Biology Laboratory, Istituto Dermopatico dell’Immacolata (IDI)-IRCCS, Rome, Italy
- Dermatology Clinic, Istituto Dermopatico dell’Immacolata (IDI)-IRCCS, Rome, Italy
| | - Adele Salemme
- Molecular and Cell Biology Laboratory, Istituto Dermopatico dell’Immacolata (IDI)-IRCCS, Rome, Italy
| | - Luca Fania
- Dermatology Clinic, Istituto Dermopatico dell’Immacolata (IDI)-IRCCS, Rome, Italy
| | - Feliciana Mariotti
- Molecular and Cell Biology Laboratory, Istituto Dermopatico dell’Immacolata (IDI)-IRCCS, Rome, Italy
| | - Anna Pira
- Molecular and Cell Biology Laboratory, Istituto Dermopatico dell’Immacolata (IDI)-IRCCS, Rome, Italy
| | - Biagio Didona
- Rare Diseases Unit, Istituto Dermopatico dell’Immacolata (IDI)-IRCCS, Rome, Italy
| | - Giovanni Di Zenzo
- Molecular and Cell Biology Laboratory, Istituto Dermopatico dell’Immacolata (IDI)-IRCCS, Rome, Italy
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2
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Ramachandran K, Kallabbe Shridhar R, Vaidya S, Heis L, Mee J. Immunobullous Transformation of Protracted Psoriasis: A Diagnostic Dilemma. Cureus 2023; 15:e37639. [PMID: 37200636 PMCID: PMC10188275 DOI: 10.7759/cureus.37639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2023] [Indexed: 05/20/2023] Open
Abstract
Pemphigus vulgaris is a rare autoimmune disorder, characterised by the development of blistering lesions in the skin and mucosal surfaces throughout the body. It is often misdiagnosed or missed completely in many patients, prolonging their suffering for many years, as it has the ability to mimic an array of other skin diseases. Many studies have concluded that there is a strong association between pemphigus vulgaris and psoriasis, though the exact mechanism is not clearly understood. We present the case of a 77-year-old gentleman on long-term treatment for psoriasis with ultraviolet B phototherapy, steroids, and many other topical treatments who eventually went on to develop pemphigus vulgaris.
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Affiliation(s)
| | | | - Shriram Vaidya
- Intensive Therapy Unit, King George Hospital, Ilford, GBR
| | - Leen Heis
- Dermatology, Queens Hospital Center, Romford, GBR
| | - John Mee
- Histopathology, St Thomas' Hospital, London, GBR
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3
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Adebiyi OT, Galloway DF, Augustin MS, Sinha AA. The multifactorial complexities of autoimmune development in Pemphigus vulgaris: Critical evaluation of the role of environmental and lifestyle "exposome" factors. Front Immunol 2023; 13:1058759. [PMID: 36703956 PMCID: PMC9871583 DOI: 10.3389/fimmu.2022.1058759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 12/19/2022] [Indexed: 01/11/2023] Open
Abstract
Pemphigus vulgaris (PV) is a potentially life-threatening blistering disorder characterized by autoantibodies directed against cell-cell adhesion molecules that serves as an excellent model to study human autoimmune development. Numerous studies have identified specific Human Leukocyte Antigen (HLA) genes, in particular DRB1*0402 and DQB1*0503, that confer disease risk. Although HLA is required, it is not sufficient for the initiation of disease. As with all autoimmune diseases, the etio-pathogenesis of PV is complex, meaning it is multifactorial. Susceptibility is polygenic, and the search for non-HLA disease-linked genes continues. Moreover, twin studies across autoimmune conditions indicate that non-genetic environmental and lifestyle factors, which can be collectively grouped under the term "exposome", are also major contributors to disease development. The literature presents evidence for the potential role of multiple triggers such as medications, infections, stress, diet, immunizations, and sleep to influence the etiology, pathophysiology, and prognosis of PV. However, a clear understanding of the degree to which specific factors impact PV is lacking. In this investigation, we comprehensively review the environmental elements listed above and consider the strength of evidence for these factors. The overall goals of this work are to provide greater insights into the factors that influence disease susceptibility, disease development and disease course and ultimately help to better guide clinicians and inform patients in the management of PV.
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Tariq U, Nasrullah A, Guha A, Mitre M. Oroesophageal Pemphigus vulgaris Secondary to Lisinopril Use: A New Side Effect. Cureus 2021; 13:e14333. [PMID: 33972894 PMCID: PMC8105187 DOI: 10.7759/cureus.14333] [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] [Indexed: 11/23/2022] Open
Abstract
Pemphigoid diseases are a group of blistering autoimmune pathologies including pemphigus vulgaris (PV) and pemphigus foliaceous, which affect mucocutaneous tissues. Non-steroidal anti-inflammatory drugs, penicillamine, and angiotensin-converting enzyme inhibitors such as captopril and enalapril are associated with drug-induced pemphigoid. We present a case of lisinopril-associated PV which has not been previously reported.
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Affiliation(s)
- Usman Tariq
- Internal Medicine, Allegheny Health Network, Pittsburgh, USA
| | - Adeel Nasrullah
- Internal Medicine, Allegheny Health Network, Pittsburgh, USA
| | - Aritra Guha
- Internal Medicine, Allegheny Health Network, Pittsburgh, USA
| | - Marcia Mitre
- Gastroenterology, Allegheny Health Network, Pittsburgh, USA
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Krammer S, Krammer C, Salzer S, Bağci IS, French LE, Hartmann D. Recurrence of Pemphigus Vulgaris Under Nivolumab Therapy. Front Med (Lausanne) 2019; 6:262. [PMID: 31781569 PMCID: PMC6861207 DOI: 10.3389/fmed.2019.00262] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 10/28/2019] [Indexed: 12/16/2022] Open
Abstract
For many types of cancer, immune checkpoint inhibitors have proven to be a highly effective treatment. The monoclonal anti-PD-1 antibody nivolumab stimulates the immune system and is one of the newest treatment options for non-small cell lung cancer. In doing so, immune checkpoint inhibitors can trigger many skin lesions that have not yet been completely investigated in their entirety. In this case report, pemphigus vulgaris is identified as a potential adverse event that occurs under the treatment with nivolumab. In addition to the standard methods, we examined our patient's samples with ex vivo confocal laser scanning microscopy. This is a new and innovative diagnostic method that uses vertical scanning to provide fast, high-resolution imaging of freshly excised tissue, even using fluorescently labeled antibodies.
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Affiliation(s)
- Sebastian Krammer
- Department of Dermatology and Allergology, University Hospital, LMU Munich, Munich, Germany
| | - Christian Krammer
- Department of Dermatology and Allergology, University Hospital, LMU Munich, Munich, Germany
| | - Suzanna Salzer
- Department of Dermatology, Municipal Hospital of Munich, Munich, Germany
| | - Işin Sinem Bağci
- Department of Dermatology and Allergology, University Hospital, LMU Munich, Munich, Germany
| | - Lars E French
- Department of Dermatology and Allergology, University Hospital, LMU Munich, Munich, Germany.,Department of Dermatology, Municipal Hospital of Munich, Munich, Germany
| | - Daniela Hartmann
- Department of Dermatology and Allergology, University Hospital, LMU Munich, Munich, Germany.,Department of Dermatology, Municipal Hospital of Munich, Munich, Germany
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Pietkiewicz P, Bowszyc-Dmochowska M, Gornowicz-Porowska J, Dmochowski M. Involvement of Nail Apparatus in Pemphigus Vulgaris in Ethnic Poles Is Infrequent. Front Med (Lausanne) 2018; 5:227. [PMID: 30155468 PMCID: PMC6102408 DOI: 10.3389/fmed.2018.00227] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 07/25/2018] [Indexed: 11/21/2022] Open
Abstract
Pemphigus vulgaris lesions have a tendency to localize around natural body orifices. The aim here was to analyze the involvement of nail apparatus in pemphigus vulgaris. Sixty seven ethnic Poles suffering from pemphigus vulgaris on photographic files archiving initial presentation were retrospectively evaluated. Pemphigus vulgaris was diagnosed using combination of clinical data, H+E histology, direct immunofluorescence of plucked scalp hair and/or perilesional tissue also for IgG1 and IgG4 deposits evaluation, indirect immunofluorescence on mosaic substrate and/or monkey esophagus, mono-analyte ELISA with desmoglein 1/3 or multi-analyte ELISA. The nail apparatus involvement was found in 9 of 67 patients (13.4%; 3 females and 6 males). Periungual fingernail lesions were found in 6 patients (2 females, 4 males), whereas periungual toenail lesions in just 3 patients (1 female, 2 males). Our patients nail apparatus changes included, by order of frequency, paronychia, nail discoloration, onychorrhexis, Beau lines, periungual hemorrhages, onychomadesis, cross-ridging, onycholysis, and trachyonychia. The average time between the onset, as recalled by patients, and the diagnosis of pemphigus vulgaris with direct immunofluorescence was not statistically different in PV patients with and without nail apparatus lesions. In this article the molecular and immunological rationale for of periungual involvement is discussed. Our single-center study suggests that nail apparatus involvement is infrequent in pemphigus vulgaris in ethnic Poles. Due to the fact that nail apparatus lesions in pemphigus vulgaris may clinically resemble onychomycosis, giving the proper diagnosis can be difficult particularly when other lesions are overlooked or misinterpreted.
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Affiliation(s)
- Pawel Pietkiewicz
- Department of Dermatology, Poznan University of Medical Sciences, Poznan, Poland
- Surgical Oncology and General Surgery Clinic I, Greater Poland Cancer Center, Poznan, Poland
| | | | | | - Marian Dmochowski
- Department of Dermatology, Poznan University of Medical Sciences, Poznan, Poland
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Chokoeva AA, Lozev I, Yungareva I, Wollina U, Lotti T, Maximov GK, Tchernev G. Seborrheic Pemphigus, Antigen Mimicry and the Subsequent-Wrong Diagnostic and Therapeutic Approach? Open Access Maced J Med Sci 2018; 6:128-131. [PMID: 29484008 PMCID: PMC5816282 DOI: 10.3889/oamjms.2018.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 08/20/2017] [Accepted: 08/21/2017] [Indexed: 11/06/2022] Open
Abstract
It is well-established that drugs could be leading cause of occurrence of numerous diseases, including pemphigus, being either inducer or triggering factor of the autoimmunity. Despite medications, it should be kept in mind that chronic or acute infections are also capable of being a trigger in various types of cutaneous eruptions, including pemphigus. The rapidly obtained and uncompleted history for accompanied medication leads to general mistakes in the subsequent treatment approach, as the first step in such cases is discontinuation of the drug-inductor. The absence of this information guaranties the fail of the treatment. On the other hand, the lack of performed screening for chronic or acute hepatitis and tuberculosis is not the only mistake, regarding the high dosage of immunosuppressors that have been planned as regiment and the possible fatal effect on the infection’s spread or exacerbation, but also because of the possible triggering ability of chronic or acute infection, which may play also a key role in the generation of antigen- or molecular- mimicry, as a potential source of antibodies reactive with various tissue antigens. It turns out that although the diagnosis of pemphigus in regular cases is usually not a challenge, the treatment occasionally could be, just because of a simple pitfall in anamnesis and screening, as in the presented case. Herein, we present a case of a patient with seborrheic pemphigus, which is strongly demonstrative for these statements, as we want to emphasise the importance of the first and the most powerful clinician’s weapons – the patient’s history and thorough examination.
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Affiliation(s)
| | - Ilia Lozev
- Medical Institute of Ministry of Interior Department of General, Vascular and Abdominal Surgery, Sofia, Bulgaria
| | - Irina Yungareva
- Medical Institute of Ministry of Interior (MVR-Sofia), Department of Dermatology, Venereology and Dermatologic Surgery, Sofia, Bulgaria
| | - Uwe Wollina
- Städtisches Klinikum Dresden - Department of Dermatology and Allergology, Dresden, Sachsen, Germany
| | - Torello Lotti
- University G. Marconi of Rome - Dermatology and Venereology, Rome, Italy
| | | | - Georgi Tchernev
- Medical Institute of Ministry of Interior (MVR-Sofia), Department of Dermatology, Venereology and Dermatologic Surgery, Sofia, Bulgaria.,"Onkoderma"- Policlinic for Dermatology and Dermatologic Surgery, Sofia, Bulgaria
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8
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Dew drops on spider web appearance: a newly named pattern of IgG4 deposition in pemphigus with direct immunofluorescence. Postepy Dermatol Alergol 2017; 34:295-298. [PMID: 28951702 PMCID: PMC5560175 DOI: 10.5114/ada.2017.69306] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 09/08/2016] [Indexed: 12/24/2022] Open
Abstract
Novel appearances in cutaneous pathology as well as mucocutaneous clinical signs are being described which indicate that this is still an attractive area for exploration. The H + E histology terms of “decorated tomb stoning” and “undecorated tomb stoning”, advocated by some pathologists, are misleading and as such should be avoided. Here, an appearance of IgG4 pemphigus deposits examined cost-effectively with direct immunofluorescence and suggested to be called “dew drops on spider web” is depicted in depth.
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9
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Reviewing putative industrial triggering in pemphigus: cluster of pemphigus in the area near the wastewater treatment plant. Postepy Dermatol Alergol 2017; 34:185-191. [PMID: 28670245 PMCID: PMC5471373 DOI: 10.5114/ada.2017.67840] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 07/01/2016] [Indexed: 01/14/2023] Open
Abstract
A range of pemphigus is relatively rare potentially fatal group of autoimmune blistering dermatoses. Usually, there is no apparent triggering, while in some predisposed patients there are alleged environmental/industrial inducing factors. In a short time period (4 years), we diagnosed 3 novel cases of pemphigus (1 pemphigus vulgaris, 1 pemphigus foliaceus and 1 shift from pemphigus foliaceus into pemphigus vulgaris) at a clinical and laboratory level (ELISA, immunofluorescence studies). We discuss a possible common inducing mechanism as these patients inhabit one estate of the Poznan suburbia (Kozieglowy, population < 12,000), Greater Poland district, Poland, and review literature data on alleged pemphigus triggers. To the best of our knowledge, this is the first report exploring the putative association between pemphigus diseases and wastewater treatment plant waterborne or volatile by-products in the vicinity of such a facility.
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10
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Accuracy of molecular diagnostics in pemphigus and bullous pemphigoid: comparison of commercial and modified mosaic indirect immunofluorescence tests as well as enzyme-linked immunosorbent assays. Postepy Dermatol Alergol 2017; 34:21-27. [PMID: 28261028 PMCID: PMC5329104 DOI: 10.5114/ada.2017.65617] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 11/29/2015] [Indexed: 12/24/2022] Open
Abstract
Introduction Pemphigus and bullous pemphigoid (BP) are identified by autoantibodies (abs) against desmoglein 1, 3 (DSG1/3) and BP180/BP230, respectively. A novel mosaic to indirect immunofluorescence (IIF) using purified BP180 recombinant proteins spotted on slide and transfected cells expressing BP230, DSG1, DSG3 is available. The commercial (IgG detection) and modified (IgG4 detection) mosaic for indirect immunofluorescence (IIFc – IIF commercial, IIFm – IIF modified) and IgG ELISAs were evaluated in pemphigus and bullous pemphigoid (BP) molecular diagnostics. Aim To compare diagnostic accuracy of commercial (IgG detection) and modified (IgG4 detection) mosaic IIF assay and to examine the diagnostic value of ELISAs in relation to mosaic IIF in routine laboratory diagnostics of pemphigus and BP. Material and methods Sera from 37 BP and 19 pemphigus patients were studied. Associations between tests were assessed using Fisher’s exact test. Results There are associations between the positive/negative samples detected by IIFc with desmoglein1 (DSG1)/desmoglein3 (DSG3)/BP230 transfected cells and ELISAs and no association between anti-BP180 IgG detection by IIFc and ELISA. IIFm with DSG1 and DSG3 showed both 100% sensitivity and 100% and 78% specificity, respectively, and 100% and 83% positive predictive value in relation to IIFc. IIFm with BP230 had 87% specificity, 55% sensitivity, whereas IIFm with BP180 had a 100% sensitivity and 13% specificity in relation to IIFc. Conclusions The IIFc with DSG1/DSG3/BP230 transfected cells, excluding BP180 spots, is an alternative method to ELISA in pemphigus/BP diagnostics. IgG4 antibodies, both pathogenically and diagnostically important, are inconsistently detectable with IIFm.
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Gornowicz-Porowska J, Dmochowski M, Pietkiewicz P, Bowszyc-Dmochowska M. Mucosal-dominant pemphigus vulgaris in a captopril-taking woman with angioedema. An Bras Dermatol 2016; 90:748-51. [PMID: 26560224 PMCID: PMC4631244 DOI: 10.1590/abd1806-4841.20153390] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Accepted: 03/17/2014] [Indexed: 11/22/2022] Open
Abstract
We describe a 39-year-old woman with an apparent captopril-induced, contact
mucosal-dominant pemphigus vulgaris and angioedema, who took captopril during a bout
of arterial hypertension. This exposure suggests that captopril and pathophysiology
of angioedema stimulated the development of pemphigus vulgaris, which was diagnosed
using the novel, indirect immunofluorescence BIOCHIP mosaic, with the modification to
detect serum IgG4 autoantibodies. We discuss the patient, who experienced a chain of
events leading to the active stage of pemphigus vulgaris, and review concepts of
pemphigus vulgaris inducible by drugs and pathological immunity.
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