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Tekin B, Johnson EF, Wieland CN, Gibson LE, Camilleri MJ, Kalaaji AN, Comfere NI, Peters MS, Lehman JS. Histopathology of autoimmune bullous dermatoses: What's new? Hum Pathol 2022; 128:69-89. [PMID: 35764145 DOI: 10.1016/j.humpath.2022.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 06/19/2022] [Accepted: 06/21/2022] [Indexed: 11/25/2022]
Abstract
Autoimmune bullous dermatoses are characterized by the presence of tissue-bound and often circulating pathogenic autoantibodies targeting structural components of the skin and/or mucous membranes. The diagnostic workup for this heterogeneous group of disorders consists of a multi-step process, of which the light microscopic examination is a crucial component. This review is organized following a classification scheme that is based on two main histopathologic features, namely level of intraepithelial split and composition of the inflammatory infiltrate. Overall, we aim to place emphasis on the histopathologic clues that can assist pathologists in differential diagnosis and review the updates in the literature.
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Affiliation(s)
- Burak Tekin
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Emma F Johnson
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA; Department of Dermatology, Mayo Clinic, Rochester, MN, USA
| | - Carilyn N Wieland
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA; Department of Dermatology, Mayo Clinic, Rochester, MN, USA
| | - Lawrence E Gibson
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA; Department of Dermatology, Mayo Clinic, Rochester, MN, USA
| | - Michael J Camilleri
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA; Department of Dermatology, Mayo Clinic, Rochester, MN, USA
| | - Amer N Kalaaji
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA; Department of Dermatology, Mayo Clinic, Rochester, MN, USA
| | - Nneka I Comfere
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA; Department of Dermatology, Mayo Clinic, Rochester, MN, USA
| | - Margot S Peters
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA; Department of Dermatology, Mayo Clinic, Rochester, MN, USA
| | - Julia S Lehman
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA; Department of Dermatology, Mayo Clinic, Rochester, MN, USA.
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Kridin K, Schmidt E. Epidemiology of Pemphigus. JID INNOVATIONS 2021; 1:100004. [PMID: 34909708 PMCID: PMC8659392 DOI: 10.1016/j.xjidi.2021.100004] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 01/26/2021] [Accepted: 01/26/2021] [Indexed: 01/01/2023] Open
Abstract
Pemphigus is an epidemiologically heterogeneous group of autoimmune bullous diseases comprising pemphigus vulgaris (PV), pemphigus foliaceus, paraneoplastic pemphigus, IgA pemphigus, and pemphigus herpetiformis. Recently, our knowledge about the frequency of pemphigus, which is highly variable between different populations, has considerably expanded, and the first non-HLA genes associated with PV have been identified. In addition, a variety of comorbidities, including other autoimmune diseases, hematological malignancies, and psoriasis, have been described in this variant. Here, initial data about the impact of COVID-19 on this fragile patient population are discussed and perspectives for future epidemiological studies are outlined.
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Key Words
- ACE, angiotensin-converting enzyme
- AIBD, autoimmune bullous disease
- CAAR, chimeric autoantibody receptor
- CI, confidence interval
- DSG, desmoglein
- EADV, European Academy of Dermatology and Venereology
- EC, extracellular
- EMA, European Medicines Agency
- FS, fogo selvage
- HR, hazard ratio
- ICD, International Classification of Diseases
- PF, pemphigus foliaceus
- PNP, paraneoplastic pemphigus
- PV, pemphigus vulgaris
- SMR, standardized mortality ratio
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Affiliation(s)
- Khalaf Kridin
- Lűbeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - Enno Schmidt
- Lűbeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
- Department of Dermatology, University of Lübeck, Lübeck, Germany
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Amber KT, Valdebran M, Grando SA. Paraneoplastic autoimmune multiorgan syndrome (PAMS): Beyond the single phenotype of paraneoplastic pemphigus. Autoimmun Rev 2018; 17:1002-1010. [DOI: 10.1016/j.autrev.2018.04.008] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 04/15/2018] [Indexed: 12/20/2022]
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Monteiro A, Gomes T, Fitas D, Nadais G. Small lymphocytic lymphoma associated with extensive myelopathy: Case report and review of the literature. J Neurol Sci 2016; 369:283-285. [PMID: 27653909 DOI: 10.1016/j.jns.2016.08.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 08/15/2016] [Accepted: 08/17/2016] [Indexed: 11/19/2022]
Affiliation(s)
- Ana Monteiro
- Department of Neurology, Centro Hospitalar São João, Porto, Portugal; Department of Clinical Neurosciences and Mental Health, Faculty of Medicine University of Porto, Portugal.
| | - Tiago Gomes
- Department of Neurology, Centro Hospitalar São João, Porto, Portugal; Department of Clinical Neurosciences and Mental Health, Faculty of Medicine University of Porto, Portugal.
| | - Diogo Fitas
- Department of Neurology, Unidade Local de Saúde do Alto Minho, Viana do Castelo, Portugal.
| | - Goreti Nadais
- Department of Neurology, Centro Hospitalar São João, Porto, Portugal.
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Miest RY, Wetter DA, Drage LA, el-Azhary RA, Camilleri MJ. A mucocutaneous eruption. Int J Dermatol 2014; 53:1425-7. [PMID: 25310900 DOI: 10.1111/ijd.12591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Rachel Y Miest
- Department of Dermatology, Mayo Clinic, Rochester, MN, USA
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Porro AM, Caetano LDVN, Maehara LDSN, Enokihara MMDS. Non-classical forms of pemphigus: pemphigus herpetiformis, IgA pemphigus, paraneoplastic pemphigus and IgG/IgA pemphigus. An Bras Dermatol 2014; 89:96-106. [PMID: 24626654 PMCID: PMC3938360 DOI: 10.1590/abd1806-4841.20142459] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2013] [Accepted: 02/14/2013] [Indexed: 12/13/2022] Open
Abstract
The pemphigus group comprises the autoimmune intraepidermal blistering diseases
classically divided into two major types: pemphigus vulgaris and pemphigus
foliaceous. Pemphigus herpetiformis, IgA pemphigus, paraneoplastic pemphigus and
IgG/IgA pemphigus are rarer forms that present some clinical, histological and
immunopathological characteristics that are different from the classical types. These
are reviewed in this article. Future research may help definitively to locate the
position of these forms in the pemphigus group, especially with regard to pemphigus
herpetiformis and the IgG/ IgA pemphigus.
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Affiliation(s)
- Adriana Maria Porro
- Federal University of São Paulo, Paulista School of Medicine, Dermatology Department, São PauloSP, Brazil, Dermatologist. Masters Degree and PhD . Adjunct Professor and Coordinator of Bullous Dermatosis at the Dermatology Department, Paulista School of Medicine - Federal University of São Paulo (EPM-UNIFESP) - São Paulo (SP), Brazil
| | - Livia de Vasconcelos Nasser Caetano
- Federal University of São Paulo, Paulista School of Medicine, Dermatology Department, São PauloSP, Brazil, Dermatologist with specialization in Bullous Dermatosis at the Dermatology Department, Paulista School of Medicine - Federal University of São Paulo (EPM-UNIFESP) - São Paulo (SP), Brazil
| | - Laura de Sena Nogueira Maehara
- Federal University of São Paulo, Paulista School of Medicine, Dermatology Department, Dermatologist with specialization in Bullous Dermatosis and Pediatric Dermatology at the Dermatology Department, Paulista School of Medicine - Federal University of São Paulo (EPM-UNIFESP). PhD-candidate at UNIFESP (Translational Medicine) and the University of Groningen (Center for Blistering Diseases, Groningen University Medical Center, Netherlands)
| | - Milvia Maria dos Santos Enokihara
- Federal University of São Paulo, Paulista School of Medicine, Dermatology and Pathology Departments, São PauloSP, Brazil, Pathologist. Masters Degree and PhD. Dermatopathologist at the Dermatology and Pathology Departments, Paulista School of Medicine - Federal University of São Paulo (EPM-UNIFESP) - São Paulo (SP), Brazil
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DeVito N, Mui K, Jassam Y, Taylor L, Pilichowska M, Cossor F. Small Lymphocytic Lymphoma Presenting As a Paraneoplastic Syndrome With Acute Central Nervous System Demyelination. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2014; 14:e131-5. [DOI: 10.1016/j.clml.2014.02.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Revised: 01/30/2014] [Accepted: 02/11/2014] [Indexed: 12/19/2022]
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Lehman VT, Barrick BJ, Pittelkow MR, Peller PJ, Camilleri MJ, Lehman JS. Diagnostic imaging in paraneoplastic autoimmune multiorgan syndrome: retrospective single site study and literature review of 225 patients. Int J Dermatol 2014; 54:424-37. [DOI: 10.1111/ijd.12603] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Ammannagari N, Chikoti S, Bravin E. Hodgkin's lymphoma presenting as a complex paraneoplastic neurological syndrome: a case report. J Med Case Rep 2013; 7:96. [PMID: 23566362 PMCID: PMC3637286 DOI: 10.1186/1752-1947-7-96] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2012] [Accepted: 03/05/2013] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Paraneoplastic neuropathies are rare. They are often difficult to diagnose, especially when they precede the diagnosis of cancer. Hodgkin's lymphoma is associated with multiple paraneoplastic neurological syndromes, of which demyelinating polyneuropathies are very unusual. Association with chronic inflammatory demyelinating polyneuropathy is even more uncommon. CASE PRESENTATION We report the rare case of a 74-year-old Caucasian man who presented with a complex neurological syndrome and was eventually diagnosed with the nodular sclerosing variant of Hodgkin's lymphoma. With timely diagnosis and early institution of treatment of the underlying malignancy, our patient began to show gradual improvement of his symptoms. CONCLUSION Hodgkin's lymphoma is associated with several paraneoplastic neurological syndromes. Sometimes it can be the only presenting feature of an underlying Hodgkin's lymphoma, posing a diagnostic challenge. Prompt oncologic treatment and immunotherapy can be beneficial if instituted early in the course of the disease.
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Affiliation(s)
- Nischala Ammannagari
- Department of Internal Medicine, Bassett Medical Center, Cooperstown, NY 13326, USA
| | - Shailaja Chikoti
- Department of Internal Medicine, Bassett Medical Center, Cooperstown, NY 13326, USA
| | - Eric Bravin
- Division of Hematology and Oncology, Bassett Medical Center, Cooperstown, NY, 13326, USA
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Paraneoplastic pemphigus: a paraneoplastic autoimmune multiorgan syndrome or autoimmune multiorganopathy? Case Rep Dermatol Med 2012; 2012:207126. [PMID: 23316398 PMCID: PMC3535815 DOI: 10.1155/2012/207126] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Accepted: 12/03/2012] [Indexed: 12/13/2022] Open
Abstract
Paraneoplastic pemphigus (PNP), a clinically and immunopathologically distinct mucocutaneous blistering dermatosis, is a severe form of autoimmune multiorgan syndrome generally associated with poor therapeutic outcome and high mortality. This IgG-mediated disease is initiated by an obvious or occult lymphoproliferative disorder in most cases. Clinically severe mucositis, and polymorphic blistering skin eruptions, and histologically acantholysis, keratinocyte necrosis and interface dermatitis are its hallmark features. A 58-year-old female presented with recurrent, severe, recalcitrant stomatitis and widespread erosions/blistering lesions of one-year duration. Treatment with repeated courses of systemic corticosteroids at a peripheral center would provide temporary relief. She also had fever, productive cough, odynophagia and poor oral intake, herpes zoster ophthalmicus, pain in the abdomen, and watery diarrhea. An array of investigations revealed chronic lymphocytic leukemia (CLL), mediastinal and para-aortic lymphadenopathy, bronchiolitis obliterans, and vertebral osteoporosis/fractures. With the diagnosis of CLL-associated PNP she was managed with dexamethasone-cyclophosphamide pulse (DCP) therapy for 3 cycles initially, followed by COP regimen (cyclophosphamide, vincristine, and prednisolone) for 5 cycles. Remission is being maintained with chlorambucil and prednisolone pulse therapy once in 3 weeks with complete resolution of skin lesions and adequate control of CLL.
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Spectrum of neurologic complications in chronic lymphocytic leukemia. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2011; 12:164-79. [PMID: 22192500 DOI: 10.1016/j.clml.2011.10.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2011] [Revised: 10/19/2011] [Accepted: 10/27/2011] [Indexed: 12/21/2022]
Abstract
Neurologic disease is believed to be an unusual complication during the course of chronic lymphocytic leukemia. Nevertheless, it has already been proven in autopsy series that the incidence of occult nervous system infiltration is much higher than was previously expected. The advent of more potent drugs to treat this lymphoproliferative disorder has brought a new hope for a possible cure in the future. However, an appropriate systemic treatment for central nervous system infiltration of this disease is still lacking. Also, due to the potent immunosuppressive properties of the agents used in the up-front treatment, for example, the purine nucleoside analogues, we have witnessed an increase in the incidence of opportunistic infections, with progressive multifocal leukoencephalopathy being one of the most serious. The goal of this review is to summarize the spectrum of neurologic derangements linked to chronic lymphocytic leukemia and to raise clinicians' awareness to recognize the possibility of such associations.
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Czernik A, Camilleri M, Pittelkow MR, Grando SA. Paraneoplastic autoimmune multiorgan syndrome: 20 years after. Int J Dermatol 2011; 50:905-14. [DOI: 10.1111/j.1365-4632.2011.04868.x] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Fatal paraneoplastic systemic leukocytoclastic vasculitis as a presenting feature of chronic lymphocytic leukemia. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2011; 11 Suppl 1:S14-6. [PMID: 22035741 DOI: 10.1016/j.clml.2011.03.030] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2011] [Revised: 03/15/2011] [Accepted: 03/15/2011] [Indexed: 12/19/2022]
Abstract
BACKGROUND The most common paraneoplastic vasculitis is leukocytoclastic vasculitis (LCV),(1) 75% of which are caused by hematological malignancies. Chronic lymphocytic leukemia (CLL) is associated with a multitude of auto-immune paraneoplastic syndromes. Data on LCV in association with CLL is restricted to isolated case reports,(3,4) none of which had systemic LCV. We present a unique case of fatal paraneoplastic, systemic LCV as an initial presentation of CLL in an elderly male with multiple co-morbidities. CASE A 71-year-old man presented with a palpable, symmetric, purpuric rash on the lower extremities and an absolute lymphocytosis (white blood cell count 26.9; 23% lymphocytes). His co-morbidities included coronary artery disease, congestive heart failure, and new critical aortic stenosis. Flow cytometry of peripheral blood demonstrated an abnormal population of B-cells, positive for CD5, CD19, and CD23, consistent with CLL. The skin biopsy specimen revealed neutrophilic inflammation in vessel walls indicative of LCV. Acute renal failure (creatinine 2 mg/dL), urinary red cell casts, and hypocomplementemia were concerning for a systemic vasculitis. The antinuclear antibody, cryoglobulin titer, antineutrophil cytoplasmic antibody, serum protein electrophoresis, viral serologies were negative. On hospital day 6, he developed acute hepatocellular injury and acute respiratory failure. Continuous veno-venous hemodialysis was begun for worsening acidemia and hyperkalemia. Two days later he became obtunded on hospital day 8 and had an elevated lactic acid level with generalized abdominal tenderness worrisome for bowel ischemia. The same day he needed intubation with cardiopulmonary resuscitation for a brief episode of asystole. Despite aggressive treatment with high-dose steroids and plasmapheresis, he suffered worsening renal failure and shock. His family sought withdrawal of care on hospital day 11. Autopsy revealed diffuse LCV of the stomach, distal ileum, integument and alveoli with petechial hemorrhages, fibrin thrombi, and gangrenous patchy necrosis. CONCLUSION Paraneoplastic LCV is a rare syndrome and seldom occurs in association with CLL. This is the first reported case of fatal systemic paraneoplastic LCV from B-cell CLL. Dermatologic involvement is universal with LCV, and may portend systemic disease. More data on its pathogenesis in CLL is warranted.
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Abstract
Since its approval in 1997 by the US Food and Drug Administration, rituximab has been approved for use in certain B-cell lymphomas and treatment-resistant rheumatoid arthritis. Over the past 10 years, many published reports have suggested rituximab's efficacy in several inflammatory conditions in dermatology. This article includes a review of the mechanism of action, dosing, side-effect profile, and the current literature for various off-label uses of this CD20+ B-cell antagonist, rituximab.
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Affiliation(s)
- David R Carr
- Department of Dermatology, Wright State University, One Elizabeth Place, Suite 200, Dayton, OH 45408, USA
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Sands J, Tuscano JM. Geoepidemiology and autoimmune manifestations of lymphoproliferative disorders. Autoimmun Rev 2009; 9:A335-41. [PMID: 19914405 DOI: 10.1016/j.autrev.2009.11.009] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The pathogenesis of lymphoproliferative disorders represents an underlying dysfunction in lymphocyte development and homeostasis. This typically manifests with the accumulation of lymphocytes in the bone marrow, peripheral blood or lymph nodes and spleen. It has been hypothesized that the mechanism for elimination of dysfunctional and autoreactive lymphocytes is defective and contributes to the pathogenesis of these disorders. Based on this hypothesis, it would not be surprising to find an increased incidence of autoimmune manifestations that are associated with these disorders. Autoimmune paraneoplastic syndromes (PNS) are often the result of a dysfunctional immune response, which is related to an underlying malignant process. While all the PNS that are associated with lymphoproliferative disorders do not have an autoimmune basis, many do. Here we review the literature of PNS associated with lymphoproliferative disorders. A concise overview of each syndrome is provided with a focus on clinical manifestations, diagnostics, pathophysiology, and treatment. While the treatment is typically directed at managing the underlying lymphoproliferative process, and can be assumed to be case throughout this review, there are exceptions that are described within the context of each disorder.
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Affiliation(s)
- Jacob Sands
- Department of Internal Medicine, University of California, Davis, Sacramento, CA 95817, USA
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