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Oprea Y, Kody S, Shakshouk H, Greiling TM, Anstey KM, Ortega-Loayza AG. What can inherited immunodeficiencies reveal about pyoderma gangrenosum? Exp Dermatol 2024; 33:e14954. [PMID: 37846943 PMCID: PMC10841371 DOI: 10.1111/exd.14954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 09/14/2023] [Accepted: 10/05/2023] [Indexed: 10/18/2023]
Abstract
Pyoderma gangrenosum (PG) is a rare ulcerative neutrophilic dermatosis that is occasionally associated with primary immunodeficiency. Though contributions from dysregulation of the innate immune system, neutrophil dysfunction and genetic predisposition have been postulated, the precise pathogenesis of PG has not yet been elucidated. This article reviews reported cases of coexisting PG and primary immunodeficiency in order to gain insight into the complex pathophysiology of PG. Our findings suggest that variations in genes such as RAG1, ITGB2, IRF2BP2 and NFκB1 might play a role in genetically predisposing patients to develop PG. These studies support the feasibility of the role of somatic gene variation in the pathogenesis of PG which warrants further exploration to guide targeted therapeutics.
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Affiliation(s)
- Yasmine Oprea
- Albert Einstein College of Medicine, Bronx, New York, USA
| | - Shannon Kody
- Department of Dermatology, Oregon Health & Science University, Portland, Oregon, USA
| | - Hadir Shakshouk
- Department of Dermatology, Oregon Health & Science University, Portland, Oregon, USA
- Department of Dermatology and Andrology, Alexandria Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Teri M Greiling
- Department of Dermatology, Oregon Health & Science University, Portland, Oregon, USA
| | - Karen M Anstey
- Department of Medicine, Section of Allergy and Clinical Immunology, Oregon Health & Science University, Portland, Oregon, USA
| | - Alex G. Ortega-Loayza
- Department of Dermatology, Oregon Health & Science University, Portland, Oregon, USA
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Skin Manifestations in Patients with Selective Immunoglobulin E Deficiency. J Clin Med 2022; 11:jcm11226795. [PMID: 36431272 PMCID: PMC9694019 DOI: 10.3390/jcm11226795] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 11/08/2022] [Accepted: 11/12/2022] [Indexed: 11/19/2022] Open
Abstract
Selective immunoglobulin E deficiency (SIgED) is still an unrecognised primary immunodeficiency despite several observations supporting its existence. This study aimed to describe the skin manifestations associated with SIgED. We retrospectively assessed medical records of patients with SIgED, the diagnosis being based on serum IgE levels ≤2 Uk/L associated with normal serum levels of immunoglobulins G, M, and A. A total of 25 patients (24 female) with SIgED were included in the study. Eleven patients (44%) presented chronic spontaneous urticaria (CSU), five (20%) angioedema always associated with CSU, five erythema (20%), and six eczema (24%). Other, less frequent manifestations were lichen planus, anaphylactoid purpura, thrombocytopenic purpura, bullous pemphigoid, bullous pyoderma gangrenosum, and atypical skin lymphoproliferative infiltrate associated with reactive lymphadenopathy, chronic cholestasis, arthritis, and fibrosing mediastinitis. Fifteen patients (60%) had different types of associated autoimmune diseases, Hashimoto's thyroiditis being the most frequent (n = 5, 20%), followed by arthritis (n = 4, 16%), autoimmune hepatitis, neutropenia, vitiligo, and Sjögren's syndrome (n = 2, 8% each). Five malignancies were diagnosed in four patients (16%). An ultralow IgE serum level may be the only biomarker that reveals the presence of a dysregulated immune system in patients with a broad spectrum of skin manifestations.
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Demirel S, Shetty M, Patel M, Mahmood K. First presentation of pyoderma gangrenosum in a patient with partial immunoglobulin A deficiency. JRSM Open 2022; 13:20542704221086386. [PMID: 35464105 PMCID: PMC9019357 DOI: 10.1177/20542704221086386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
We describe the case of a 58-year-old female with an intensely painful and rapidly enlarging necrotic cutaneous ulcer to the right shin on a background of partial immunoglobulin A deficiency (IgAD). She was seen by various healthcare professionals and managed with upscaling antibiotics for cellulitis requiring an inpatient hospital stay. The dermatology team made a clinical diagnosis of ulcerative Pyoderma Gangrenosum (PG) on assessing the patient 13 days post-onset of symptoms. The patient responded dramatically to steroids and oral tetracycline. This case highlights the unusually described association between PG and IgAD as well as the diagnostic challenge seen in patients presenting with PG.
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Affiliation(s)
- S Demirel
- Department of Dermatology, NHS Tayside, Ninewells Hospital, James Arrott Drive Dundee, DD2 1SG
| | - M Shetty
- Department of Dermatology, London Northwest University Healthcare NHS trust, Ealing Hospital, Uxbridge Road, Southall, UB1 3HW
| | - M Patel
- Colchester General Hospital, Turner Rd, Mile End, Colchester, CO4 5JL
| | - K Mahmood
- Colchester General Hospital, Turner Rd, Mile End, Colchester, CO4 5JL
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Sun Q, Gehlhausen JR, Freudzon M, Kibbi N, Bale A, Choate K, Tomayko M, Odell I, Ramachandran S. A novel NFkB1 mutation linking pyoderma gangrenosum and common variable immunodeficiency. JAAD Case Rep 2021; 18:61-63. [PMID: 34825039 PMCID: PMC8605275 DOI: 10.1016/j.jdcr.2021.10.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Qisi Sun
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut
- Department of Internal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Correspondence to: Qisi Sun, MD, Department of Internal Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02120.
| | - Jeff R. Gehlhausen
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut
| | - Marianna Freudzon
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut
| | - Nour Kibbi
- Department of Dermatology, Stanford University School of Medicine, Stanford, California
| | - Allen Bale
- Department of Genetics, Yale University School of Medicine, New Haven, Connecticut
| | - Keith Choate
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut
| | - Mary Tomayko
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut
| | - Ian Odell
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut
| | - Sarika Ramachandran
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut
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Nanoudis S, Tsona A, Tsachouridou O, Morfesis P, Loli G, Georgiou A, Zebekakis P, Metallidis S. Pyoderma gangrenosum in a patient with chronic granulomatous disease: A case report. Medicine (Baltimore) 2017; 96:e7718. [PMID: 28767612 PMCID: PMC5626166 DOI: 10.1097/md.0000000000007718] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 07/04/2017] [Accepted: 07/06/2017] [Indexed: 12/27/2022] Open
Abstract
RATIONALE The simultaneous occurrence of pyoderma gangrenosum (PG) and chronic granulomatous disease (CGD) is uncommon and few cases have been reported worldwide. PATIENT CONCERNS PG is a rare, chronic, ulcerative, neutrophilic skin disease of unknown etiology that requires immunosuppressive treatment. CGD belongs to Primary Immune Deficiencies in which the main defect lies in an inability of the phagocytic cells to generate superoxide making patients susceptible to serious, potentially life-threatening bacterial and fungal infections. DIAGNOSES In this manuscript, we present a case of ulcerative pyoderma gangrenosum in a 28-year-old man with recent diagnosis of chronic granulomatous disease during hospitalization for resistant pulmonary tuberculosis complicated with Aspergillus infection. INTERVENTIONS Second-line therapy with dapsone and intravenous immunoglobulin was initially administered but eventually corticosteroids were added to treatment because of disease progression and further ulceration. OUTCOMES Patient's ulcers were gradually healed with no side effects. LESSONS Corticosteroids could be used under close monitoring for the treatment of PG in a patient with CGD, despite the increased risk for infections.
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Doll R, Johnson J, Tcheurekdjian H, Hostoffer R. Common variable immune deficiency associated with pemphigoid. Ann Allergy Asthma Immunol 2016; 118:122. [PMID: 27865716 DOI: 10.1016/j.anai.2016.10.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Accepted: 10/20/2016] [Indexed: 11/26/2022]
Affiliation(s)
- Rayna Doll
- Verde Valley Medical Center, Cottonwood, Arizona.
| | - John Johnson
- Conjoint Allergy/Immunology Fellowship, University Hospitals Regional Medical Centers, Cleveland, Ohio
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Tashtoush B, Memarpour R, Ramirez J, Bejarano P, Mehta J. Granulomatous-lymphocytic interstitial lung disease as the first manifestation of common variable immunodeficiency. CLINICAL RESPIRATORY JOURNAL 2016; 12:337-343. [PMID: 27243233 DOI: 10.1111/crj.12511] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 04/18/2016] [Accepted: 05/29/2016] [Indexed: 12/15/2022]
Abstract
Common variable immunodeficiency (CVID) is one of the most common primary immunodeficiencies, which is characterized by reduced serum immunoglobulin levels and B-lymphocyte dysfunction. There are many clinical manifestations of this disease, the most common of which are recurrent respiratory tract infections. Among the most recently recognized autoimmune manifestation of CVID is a disease described as granulomatous-lymphocytic interstitial lung disease (GLILD), where CVID coexists with a small airway lymphoproliferative disorder, mimicking follicular bronchiolitis, or lymphocytic interstitial pneumonitis (LIP) on histology specimens. We herein describe the clinical and radiological features of GLILD in a 55-year-old woman where the diagnosis of CVID was actively pursued and eventually confirmed after her lung biopsy showed characteristic features of GLILD. The patient had dramatic response to treatment with IVIG and corticosteroids for 3 months followed by Mycophenolate mofetil for maintenance therapy.
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Affiliation(s)
- Basheer Tashtoush
- Department of Pulmonary and Critical Care Medicine, Cleveland Clinic Florida, Weston, Florida
| | - Roya Memarpour
- Department of Pulmonary and Critical Care Medicine, Cleveland Clinic Florida, Weston, Florida
| | - Jose Ramirez
- Department of Pulmonary and Critical Care Medicine, Cleveland Clinic Florida, Weston, Florida
| | - Pablo Bejarano
- Department of Pathology, Cleveland Clinic Florida, Weston, Florida
| | - Jinesh Mehta
- Department of Pulmonary and Critical Care Medicine, Cleveland Clinic Florida, Weston, Florida
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Blattner CM, Gilliam AC, Murase JE. Thin yellow papules and plaques on the eyelids, cheeks, and neck. Int J Dermatol 2015; 54:1129-31. [PMID: 26148243 DOI: 10.1111/ijd.12818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2014] [Revised: 07/13/2014] [Accepted: 07/22/2014] [Indexed: 11/28/2022]
Affiliation(s)
- Collin M Blattner
- Department of Dermatology, Des Moines University, Des Moines, IA, USA
| | - Anita C Gilliam
- Department of Dermatology, Palo Alto Foundation Medical Group, Palo Alto, Mountain View, CA, USA
| | - Jenny E Murase
- Department of Dermatology, Palo Alto Foundation Medical Group, Palo Alto, Mountain View, CA, USA.,Department of Dermatology, University of California San Francisco, San Francisco, CA, USA
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Abraham T, Kim YM, Casselman J, Saad A, Wessell KR, Toller-Artis E, Tcheurekdjian H, Hostoffer R. Multiple necrotic deep wound infections associated with a subcutaneous immunoglobulin infusion. Ann Allergy Asthma Immunol 2015; 115:80-2. [PMID: 25963449 DOI: 10.1016/j.anai.2015.04.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Revised: 03/11/2015] [Accepted: 04/09/2015] [Indexed: 12/18/2022]
Affiliation(s)
- Tina Abraham
- Department of Internal Medicine, McLaren Oakland Hospital, Pontiac, Michigan.
| | - Yoon Mi Kim
- University Hospitals, Regional Medical Centers, Richmond Heights, Ohio
| | - Jason Casselman
- University Hospitals, Regional Medical Centers, Richmond Heights, Ohio
| | - Ali Saad
- Department of Internal Medicine, McLaren Oakland Hospital, Pontiac, Michigan; University Hospitals, Regional Medical Centers, Richmond Heights, Ohio
| | | | - Erin Toller-Artis
- University Hospitals, Regional Medical Centers, Richmond Heights, Ohio
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Pyoderma gangrenosum with monoclonal IgA gammopathy and pulmonary tuberculosis. Illustrative case and review. Postepy Dermatol Alergol 2015; 32:137-41. [PMID: 26015785 PMCID: PMC4436233 DOI: 10.5114/pdia.2014.40974] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2013] [Revised: 01/06/2014] [Accepted: 01/13/2014] [Indexed: 02/07/2023] Open
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Xiao X, Miao Q, Chang C, Gershwin ME, Ma X. Common variable immunodeficiency and autoimmunity--an inconvenient truth. Autoimmun Rev 2014; 13:858-64. [PMID: 24747700 DOI: 10.1016/j.autrev.2014.04.006] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Accepted: 04/08/2014] [Indexed: 11/19/2022]
Abstract
Coexisting morbidities in CVID include bronchiectasis, autoimmunity and malignancies. The incidence of autoimmune disease in CVID patients may approach 20% of cases. The most common autoimmune disease found in CVID patients is autoimmune cytopenia, but rheumatoid arthritis, lupus, and now primary biliary cirrhosis have also been reported. The coexistence of immunodeficiency and autoimmunity appears paradoxical, since one represents a hypoimmune state and the other a hyperimmune state. However, this paradox may not actually be all that implausible due to the complex nature of immune cells, signaling pathways and their interactions. The cellular alterations in combined variable immunodeficiency include a range of T and B cell abnormalities. Selective immune derangements found in CVID include a downregulation of regulatory T cells (Treg cells), accelerated T cell apoptosis, abnormal cytokine production secondary to cytokine gene polymorphisms and increased autoreactive B cell production. The impact of these abnormalities on T and B cell interaction may not only explain the immunodeficiency but also the development of autoimmunity in select groups of patients with CVID. The variability in the clinical manifestations of CVID as a result of this immune interaction suggests that CVID is not one disease but many. This is important because it follows that the treatment of CVID may not always be the same, but may need to be directed specifically towards each individual patient.
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Affiliation(s)
- Xiao Xiao
- State Key Laboratory of Oncogenes and Related Genes, Division of Gastroenterology and Hepatology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai Cancer Institute, Shanghai Institute of Digestive Disease, Shanghai, China
| | - Qi Miao
- State Key Laboratory of Oncogenes and Related Genes, Division of Gastroenterology and Hepatology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai Cancer Institute, Shanghai Institute of Digestive Disease, Shanghai, China
| | - Christopher Chang
- Division of Allergy and Immunology, Thomas Jefferson University, Nemours/A.I. duPont Hospital for Children, 1600 Rockland Road, Wilmington, DE 19810 USA.
| | - M Eric Gershwin
- Division of Rheumatology, Allergy and Clinical Immunology, University of California at Davis School of Medicine, 451 Health Sciences Drive, Suite 6510, Davis, CA 95616 USA.
| | - Xiong Ma
- State Key Laboratory of Oncogenes and Related Genes, Division of Gastroenterology and Hepatology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai Cancer Institute, Shanghai Institute of Digestive Disease, Shanghai, China.
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