Pemphigus. S2 Guideline for diagnosis and treatment--guided by the European Dermatology Forum (EDF) in cooperation with the European Academy of Dermatology and Venereology (EADV)

BACKGROUND Pemphigus encompasses a group of life-threatening autoimmune bullous diseases characterized by blisters and erosions of the mucous membranes and skin. Before the era of immunosuppressive treatment, the prognosis of pemphigus was almost fatal. Due to its rarity, only few prospective controlled therapeutic trials are available. OBJECTIVES For this reason, a group of European dermatologists with a long-standing interest and expertise in basic and clinical pemphigus research has sought to define diagnostic and therapeutic guidelines for the management of patients with pemphigus. RESULTS This group identified the statements of major agreement or disagreement regarding the diagnostic and therapeutic management of pemphigus. The revised final version of the pemphigus guideline was finally passed on to the European Dermatology Forum (EDF) for a final consensus with the European Academy of Dermatology and Venereology (EADV) and the European Union of Medical Specialists (UEMS).

Structural basis for major histocompatibility complex (MHC)-linked susceptibility to autoimmunity: charged residues of a single MHC binding pocket confer selective presentation of self-peptides in pemphigus vulgaris.

Human T-cell-mediated autoimmune diseases are genetically linked to particular alleles of MHC class II genes. Susceptibility to pemphigus vulgaris (PV), an autoimmune disease of the skin, is linked to a rare subtype of HLA-DR4 (DRB1*0402, 1 of 22 known DR4 subtypes). The PV-linked DR4 subtype differs from a rheumatoid arthritis-associated DR4 subtype (DRB1*0404) only at three residues (DR beta 67, 70, and 71). The disease is caused by autoantibodies against desmoglein 3 (DG), and T cells are thought to trigger the autoantibody production against this keratinocyte adhesion molecule. Based on the DRB1*0402 binding motif, seven candidate peptides of the DG autoantigen were identified. T cells from four PV patients with active disease responded to one of these DG peptides (residues 190-204); two patients also responded to DG-(206-220). T-cell clones specific for DG-(190-204) secreted high levels of interleukins 4 and 10, indicating that they may be important in triggering the production of DG-specific autoantibodies. The DG-(190-204) peptide was presented by the disease-linked DRB1*0402 molecule but not by other DR4 subtypes. Site-directed mutagenesis of DRB1*0402 demonstrated that selective presentation of DG-(190-204), which carries a positive charge at the P4 position, was due to the negatively charged residues of the P4 pocket (DR beta 70 and 71). DR beta 71 has a negative charge in DRB1*0402 but a positive charge in other DR4 subtypes, including the DR4 subtypes linked to rheumatoid arthritis. The charge of the P4 pocket in the DR4 peptide binding site therefore appears to be a critical determinant of MHC-linked susceptibility to PV and rheumatoid arthritis.

Correlation of peptide specificity and IgG subclass with pathogenic and nonpathogenic autoantibodies in pemphigus vulgaris: a model for autoimmunity.

Pemphigus vulgaris (PV) is a rare, potentially fatal, autoimmune disease that affects the skin and mucous membranes. The PV antigen (PVA) has been characterized as desmoglein 3. PV patients carry HLA-DR4- or HLA-DR6-bearing extended haplotypes. We recently demonstrated that patients with active disease have high titers of PV autoantibodies of the IgG1 and IgG4 subclasses. Patients in remission, healthy unaffected relatives, and some MHC-matched normal individuals have low levels of PV autoantibodies, which are IgG1 only. Furthermore, intraperitoneal injection of IgG from patients with active disease caused clinical disease in mice, but IgG from patients in remission, healthy relatives, or MHC-matched normal individuals did not. We prepared 12 peptides of 30 amino acids each (peptides Bos 1-12) spanning the extracellular domain of PVA. Patients with active disease recognize peptides Bos 1 and Bos 6 with high titers of IgG1 and IgG4 autoantibodies. Patients in remission have IgG1 autoantibodies to peptide Bos 1 only, in statistically significantly lower titers (P < 0.01). They no longer have IgG4 subclass autoantibodies to peptide Bos 6. Healthy relatives and normal unrelated individuals have low levels of only IgG1 autoantibodies that recognize only Bos 1. In vitro studies indicate that Bos 6-specific IgG and, to a lesser extent, Bos 1-specific IgG can cause acantholysis. Our data suggest that Bos 6-specific IgG4 is probably the main acantholytic autoantibody, while Bos 1-specific IgG4 may act as a facilitator or enhancer of the process. In this study we illustrate some of the paradigms that demonstrate the interactions between the MHC, subclass of autoantibodies, and peptide specificities of the autoantibodies in the autoimmune process. Thus, PV provides an important model to study the pathogenesis of autoimmunity.

Über einen seltenen Fall von Pemphigus : Inaugural-Abhandlung ... /

Tesis Univ. Tübingen.

An Insight into the Sialotranscriptome of Simulium nigrimanum, a Black Fly Associated with Fogo Selvagem in South America

Pemphigus foliaceus is a life threatening skin disease that is associated with autoimmunity to desmoglein, a skin protein involved in the adhesion of keratinocytes. This disease is endemic in certain areas of South America, suggesting the mediation of environmental factors triggering autoimmunity. Among the possible environmental factors, exposure to bites of black flies, in particular Simulittm nigrimanum has been suggested. In this work, we describe the sialotranscriptome of adult female S. nigrimanum flies. It reveals the complexity of the salivary potion of this insect, comprised by over 70 distinct genes within over 30 protein families, including several novel families, even when compared with the previously described sialotranscriptome of the autogenous black fly, S. vitiation. The uncovering of this sialotranscriptome provides a platform for testing pemphigus patient sera against recombinant salivary proteins from S. nigrimanum and for the discovery of novel pharmacologically active compounds.

Autoimmune bullous dermatoses

Autoimmune bullous dermatoses are diseases in which blisters and vesicles are the primary and fundamental types of skin lesion. Their classification is based on the location of the blister; intraepidermal and subepidermal. Patients produce autoantibodies against self-specific structures of the skin detectable by immunofluorescence techniques, immunoblotting and ELISA. Recent advances in molecular and cellular biology have brought to knowledge these self-antigens, against which patients are sensitized, and which are found in epidermis or in the dermo-epidermal junction. These are low incidence, but high morbidity diseases that may be fatal. The aim of this article is to review and describe the progress of four autoimmune vesiculobullous disorders; endemic pemphigus foliaccous (wild fire), pemphigus vulgaris, bullous pemphigoid and dermatitis herpetiformis.

Pênfigo Vulgar - Um Caso Pediátrico

O Pênfigo Vulgar é uma doença auto-imune rara na infância,com evolução crónica e mortalidade significativa. A doença manifesta-se por lesões vesiculares, semelhantes a infecções benignas, mas que são refractárias ao tratamento sintomático e persistem após a fase aguda. Apresenta-se o caso de uma criança de três anos com lesões muco-cutâneas orais, persistentes. A biópsia permitiu o diagnóstico de Pênfigo Vulgar, tendo sido iniciada terapia corticosteróide sistémica. A dificuldade no controlo da doença levou à introdução de outros fármacos imunossupressores, até se atingir a estabilidade clínica. Todas as opções de tratamento do Pênfigo apresentam efeitos iatrogénicos, sendo imprescindível um equilíbrio entre controlo da doença e qualidade de vida do doente.

Safety and efficacy of chronic therapy with captopril in hypertensive patients: an update

Captopril, an orally active angiotensin-converting enzyme inhibitor, has been administered to 81 patients with different types of clinical hypertension. Most of the patients had previously uncontrollable high blood pressure. In order to achieve a satisfactory blood pressure control during long-term captopril therapy, a concomitant decrease in total body sodium was required in more than half of the patients. During our first two years of clinical experience with this new antihypertensive agent, side effects developed in 46.9 per cent of the patients and necessitated the withdrawal of the drug in 23.4 per cent of all patients. Only a few side effects such as hypotensive or syncopal episodes and cold extremities appeared to be due to the chronic blockade of the renin-angiotensin system. The most frequent and the most serious adverse reactions such as skin rash, altered taste, pancytopenia, and pemphigus foliaceus seemed to be specifically drug related. The incidence of cutaneous and taste problems was markedly higher in patients with impaired renal function in whom retention of captopril has been previously demonstrated. This suggests that the occurrence of adverse reactions to captopril could be lowered in the future by using smaller daily doses and by titrating them according to the renal function.

Immunogenetics of drug-induced skin blistering disorders. Part II: Synthesis

The overall immunopathogenesis relevant to a large series of disorders caused by a drug or its associated hyperimmune condition is discussed based upon examining the genetics of severe drug-induced bullous skin problems (sporadic idiosyncratic adverse events including Stevens-Johnson syndrome and Toxic epidermal necrolysis). New results from an exemplar study on shared precipitating and perpetuating inner causes with other related disease phenotypes including aphtous stomatitis, Behcets, erythema multiforme, Hashimoto's thyroiditis, pemphigus, periodic fevers, Sweet's syndrome and drug-induced multisystem hypersensitivity are presented. A call for a collaborative, wider demographic profiling and deeper immunotyping in suggested future work is made.

Avaliação da angiogênese em lesões de líquen plano oral e pênfigo vulgar

Oral lichen planus and pemphigus vulgaris are chronic diseases mucous membrane immune of unknown aetiology that can be observed affecting to the oral mucous. A relevant as regards neoplasies the role angiogenesis in the inflammatory chronic disease pathogenesis as it provides a substancial interest can be considered as being an activity diseases marker; besides being through specialised research of this angiogenic process to improve of understanding pathogenic mechanism. This research proposes to assess angiogenic active through of antibody immunohistochemistry expression antiCD34 antibody in 26 OLP of reticular cases, 14 OLP erosives cases, 18 of PV cases and 15 specimens of normal oral mucosa. The result was submitted non-parametric tests of 5% significance level. It is not statistically significant correlacion was seen regarding between average vessels. However, only be effectively observed the median of OLP cases was larger than pemphigus vulgaris in fact proved average larger than oral normal mucosa (p=0,280). Regarding the microvascular count of CD34 concerning clinic form oral lichen planus (reticular and erosion) increased emphasis is more cross-border average for the form erosion clinic. Despite of the statistic tests could not be more effective (p=0,720). Even though, the results of the research is not sufficient to enable to consider of angiogenic process in the pathogenesis and lesions progression of oral lichen planus and pemphigus vulgaris, we suggest this process is present in both forms lesion, however, more studies must be made in the near future in order to prepare a well-founded proposal

Pênfigo foliáceo em eqüino: relato de caso

Diagnosticou-se pênfigo foliáceo em um eqüino macho, castrado, quatro anos de idade da raça Árabe apresentando dermatite generalizada caracterizada por placas escamo-crostosas e presença de dermatite pustular acantolítica subcorneal.

Incidência das dermatopatias auto-imunes em cães e gatos e estudo retrospectivo de 40 casos de lupus eritematoso discóide atendidos no serviço de dermatologia da Faculdade de Medicina Veterinária e Zootecnia da UNESP – Botucatu

The objectives of this study were to do a survey of the autoimmune skin diseases and update the records regarding the occurrence of discoid lupus erythematosus in canine and feline populations attended at the Dermatology Service of the College of Veterinary Medicine and Animal Science of UNESP - Botucatu, including species, gender, breed, age, location and characteristic of the lesions. Results have shown that the order of occurrence, regarding the number of cases of autoimmune skin diseases in the animals attended by the Dermatology Service in the period from 1988 to 2007 was: discoid lupus erythematosus, pemphigus folliaceus, uveo-dermatologic syndrome, pemphigus vulgaris, systemic lupus erythematosus, necrolytic migratory erythema, multiforme erythema and plasmacytic pododermatitis. All the animals with discoid lupus erythematosus were dogs and most of them were mongrel females. More frequently breeds affected by discoid lupus erythematosus were german shepherd and akita and the mean age was 56 months. Most lesions were located in nasal planum, narines and periocular area and were characterized by crusting, depigmentation and erythema.

Clinicopathological analysis of oral mucous autoimmune disease: A 27-year study

Objectives: The aim of the present study was to analyze the main clinical and histopathological features of autoimmune diseases with oral manifestations such as oral lichen planus (OLP); mucous membrane pemphigoid (MMP); pemphigus vulgaris (PV) and erythema multiforme (EM). Study design: Retrospective review of 5770 files from the Oral Pathology Laboratory of Sao Jose dos Campos Dental School, São Paulo State University (UNESP) comprising a 27- year period from 1974 to 2000.Results: The cases accounted for 64 (1.10%) of 5770 anatomopathological examinations performed over the study period. Among the autoimmune diseases diagnosed, 49 (76.56%) were OLP, 6 (9.37%) were MMP, 5 (7.82%) were em and 4 (6.25%) were PV. Descriptive statistical analysis was used.Conclusion: The initial manifestations of most autoimmune diseases occur in the oral mucosa. An earlier diagnosis and proper therapeutic protocol will delay the dissemination of the lesions, thus greatly contributing to a better prognosis and quality of life of the patient.

Evaluation of Staining Methods for Cytologic Diagnosis of Oral Lesions

ObjectiveTo compare the efficacy of Papanicolaou, hematoxylin-eosin (H-E), Leishman and periodic acid-Schiff (PAS) staining for Cytologic diagnosis of oral lesions.Study DesignPatients from the Discipline of Stomatology, Sao Jose dos Campos Dental School, from the wards of Hospital Heliopolis and from the dentistry outpatient clinic of the University Hospital, University of São Paulo Medical School, with the following diseases, were selected: erythematous candidiasis (n = 9), pseudomembranous candidiasis (n = 10), squamous cell carcinoma In = 19), herpes simplex (n = 8), paracoccidioidomycosis In = 8) and pemphigus vulgaris (n = 1).ResultsThe different staining methods were compared regarding the quality of definition of cytoplasmic and nuclear morphologic characteristics and the identification of bacteria, fungi, inflammatory cells and secretions. Papanicolaou and H-E staining were considered better methods. In cases of fungal infections, PAS staining is useful and should be applied as a complementary method.ConclusionWithin the limitations of this study, it can be concluded that the cytologic diagnosis of oral lesions along with different staining methods is a useful tool for oral diagnosis. (Acta Cytol 2008;52:697-701)

Caso para diagnóstico

Apresenta-se um caso de bullosis diabeticorum, doença rara associada ao diabetes mellitus crônico e complicações como a neuropatia ou nefropatia. As bolhas são tensas e grandes, com pouca inflamação circundante e localização acral, regredindo espontaneamente em cerca de três semanas. O exame histopatológico é inespecífico, e o diagnóstico diferencial deve ser feito com a epidermólise bolhosa, os pênfigos, o penfigóide bolhoso, queimaduras e erisipelas bolhosas.