Phenytoin-induced linear IgA bullous disease

Ocular Manifestations and Management of Autoimmune Bullous Diseases

Autoimmune bullous diseases with ocular involvement consist of a group of systemic entities that are characterized by formation of autoantibodies against the proteins of the epithelial basement membrane zone of the conjunctiva. Mostly, the elderly are affected by these diseases. The characteristic patterns of mucocutaneous involvement and the specific tissue components targeted by these autoantibodies are differentiating features of these diseases. Ocular pemphigus vulgaris exhibits intraepithelial activity, whereas the autoimmune activity in linear immunoglobulin A disease, mucous membrane pemphigoid, and epidermolysis bullosa acquisita occurs at a subepithelial location. Given the increased risk for blindness with delays in diagnosis and management, early detection of ocular manifestations in these diseases is vital. The precise diagnosis of these autoimmune blistering diseases, which is essential for proper treatment, is based on clinical, histological, and immunological evaluation. Management usually includes anti-inflammatory and immunosuppressive medications. Inappropriate treatment results in high morbidity and even potential mortality.

Linear IgA bullous dermatosis: comparison between the drug-induced and spontaneous forms

BACKGROUND

Linear IgA bullous dermatosis (LABD) is a rare autoimmune blistering skin disorder characterized by linear deposits of IgA along the dermoepidermal junction, visualized by direct immunofluorescence (DIF). It is usually spontaneous and drug induced.

OBJECTIVES

To compare the clinical and histological forms of LABD.

METHODS

This retrospective single-centre cohort study concerned 28 patients diagnosed with LABD between 1 January 1995 and 31 December 2010. Imputability, determined according to the French imputability method (modified Bégaud score) and Naranjo score, enabled classification into drug-induced and spontaneous LABD groups. Clinical and histological features were compared by blinded analysis of images and histological patterns.

RESULTS

Sixteen patients had spontaneous LABD and 12 had drug-induced LABD. Nikolsky sign and large erosions were significantly more frequent in drug-induced than spontaneous LABD (P = 0.003 and P = 0.03, respectively), with no between-group differences for erythematous plaques, target or target-like lesions, string of pearls, location, mucosal involvement or histological features.

CONCLUSIONS

Drug-induced LABD was more severe than the spontaneous form, with lesions mimicking toxic epidermal necrolysis. Because LABD may be polymorphic and sometimes life threatening, DIF assay is recommended for all patients with Nikolsky sign and large erosions.

Diagnosis and classification of drug-induced autoimmunity (DIA)

Since sulfadiazine associated lupus-like symptoms were first described in 1945, certain drugs have been reported to interfere with the immune system and induce a series of autoimmune diseases (named drug-induced autoimmunity, DIA), exemplified by systemic lupus erythematosus (SLE). Among the drugs, procainamide and hydralazine are considered to be associated with the highest risk for developing lupus, while quinidine has a moderate risk, and all other drugs have low or very low risk. More recently, drug-induced lupus has been associated with the use of newer biological modulators, such as tumor necrosis factor (TNF)-alpha inhibitors and cytokines. In addition to lupus, other major autoimmune diseases, including vasculitis and arthritis, have also been associated with drugs. Because resolution of symptoms generally occurs after cessation of the offending drugs, early diagnosis is crucial for treatment strategy and improvement of prognosis. Unfortunately, it is difficult to establish standardized criteria for DIA diagnosis. Diagnosis of DIA requires identification of a temporal relationship between drug administration and the onset of symptoms, but the relative risk with respect to dose and duration for each drug has rarely been determined. DIA is affected by multiple genetic and environmental factors, leading to difficulties in establishing a list of global clinical features that are characteristic of most or all DIA patients. Moreover, the distinction between authentic DIA and unmasking of a latent autoimmune disease also poses challenges. In this review, we summarize the highly variable clinical features and laboratory findings of DIA, with an emphasis on the diagnostic criteria.

Molecular diagnosis in autoimmune skin blistering conditions

Blister formation in skin and mucous membranes results from a loss of cell-cell or cell-matrix adhesion and is a common outcome of pathological events in a variety of conditions, including autoimmune and genetic diseases, viral and bacterial infections, or injury by physical and chemical factors. Autoantibodies against structural components maintaining cell-cell and cell-matrix adhesion induce tissue damage in autoimmune blistering diseases. Detection of these autoantibodies either tissue-bound or circulating in serum is essential to diagnose the autoimmune nature of disease. Various immunofluorescence methods as well as molecular immunoassays, including enzyme-linked immunosorbent assay and immunoblotting, belong to the modern diagnostic algorithms for these disorders. There is still a considerable need to increase awareness of the rare autoimmune blistering diseases, which often show a severe, chronic-relapsing course, among physicians and the public. This review article describes the immunopathological features of autoimmune bullous diseases and the molecular immunoassays currently available for their diagnosis and monitoring.

Childhood linear IgA bullous disease induced by trimethoprim-sulfamethoxazole

BACKGROUND

Linear IgA bullous disease (LABD) is a rare mucocutaneous autoimmune subepidermal blistering disease that can affect children mostly of pre-school age. As many as two-thirds of LABD are related to drug ingestion, particularly certain antibiotics, non-steroidal anti-inflammatory drugs and diuretics.

MAIN OBSERVATION

We describe a 3-year-old boy who presented a CMV infection followed by LABD induced by trimtheporim-sulfametoxazole. To our knowledge, this is the first reported case of trimethoprim-sulfamethoxazole that was confirmed by a rechallenge.

CONCLUSIONS

Most cases of drug-induced LABD are patients being treated with multiple systemic drugs that could induce the LABD. In the lack of suitable alternative treatment, the identification of the causative drug can be achieved by a rechallenge under close medical surveillance.

About linear igA/igG bullous dermatosis

A case study of linear IgA/IgG bullous dermatosis has been described, and issues related to classification as well as clinical, histological and immunopathological signs of the disease have been discussed.

Bullous skin eruption in an HIV patient during antiretroviral drugs therapy

Dermo-epidermal blistering is an uncommon presentation of adverse drug reactions. Several drugs are associated to such eruptions, but review of current knowledge does not list antiretroviral drugs. A 37-year-old Caucasian HIV-positive woman presented with a 6-week history of diffuse annular blistering affecting the trunk and limbs. Lesions appeared both on erythematous and normal-appearing skin. The patient was in treatment with antiretroviral (lamivudine + didanosine + nelfinavir) for 2 years. A history of previous adverse reactions to betalactams, nonsteroidal anti-inflammatory drugs, and a nevirapine-induced hepatitis was also referred. Histopathology showed a dermo-epidermal blister; direct immunofluorescence was positive for IgG, C3c at the basement membrane zone; enzyme-linked immunosorbent assay was positive for BP180 antigen. Oral prednisone 1 mg/kg daily for 20 days led to poor improvement. Discontinuation of the antiretrovirals was followed by a rapid healing. Blisters reappeared at first re-introduction essay 1 month later. Awareness of iatrogenic dermo-epidermal blistering is necessary to suspect the diagnosis and avoid long-term immunosuppressant treatment. Complete spontaneous recovery after withdrawal of the responsible drug and relapse at rechallenge are the main criteria for the diagnosis. Factors related to the state of the HIV infection, and/or immunodeficiency may have contributed in precipitating the reaction in the present authors' case.

Ocular manifestations of blistering diseases

Ocular manifestations are a comorbidity of a group of chronic autoimmune blistering diseases that includes mucous membrane pemphigoid, linear immunoglobulin A disease, epidermolysis bullosa acquisita, and ocular pemphigus vulgaris. Various diagnostic measures differentiate between the diseases and allow for appropriate treatment including a specific selection of immunomodulatory medications. New treatment modalities offer alternatives that may minimize disease severity and residual tissue damage and may reduce treatment-related complications.

Childhood linear IgA bullous disease triggered by amoxicillin-clavulanic acid

Linear immunoglobulin A bullous disease is an autoimmune subepidermal blistering disease that has been described in both children and adults. Reports have shown that as many as two-thirds of occurrences may be drug-induced. The offending drugs include antibiotics, predominantly vancomycin, nonsteroidal anti-inflammatory agents and diuretics. We report childhood linear immunoglobulin A bullous dermatosis developing following amoxicillin-clavulanic acid administration. The patient presented with characteristic blisters in an annular fashion, likened to a ''crown of jewels.'' The diagnosis was confirmed by the presence of a linear band of immunoglobulin A at the dermoepidermal junction on direct immunofluorescence. The lesions resolved with withdrawal of the drug, and systemic therapy was not required. We review the current literature and concepts of drug-induced linear immunoglobulin A bullous disease.

Phenytoin-induced linear IgA dermatosis mimicking toxic epidermal necrolysis

A 60-year-old woman developed a severe widespread blistering eruption that also involved the palms and soles, but spared the mucosae, approximately 7 days after starting phenytoin. Phenytoin was commenced postoperatively after a craniotomy resection of a glioblastoma multiforme. The clinical features resembled that seen in toxic epidermal necrolysis. However, the patient was systemically well and the histology and immunofluorescence revealed linear IgA dermatosis. The skin lesions began to slowly heal 2 weeks after discontinuation of the phenytoin.

UV light–induced linear IgA dermatosis

Various exogenous factors (eg, drugs, dietary antigens, trauma, infections, radiographs, and UV radiation) are known to induce or aggravate skin diseases. UV radiation in particular is known to induce or aggravate the autoimmune bullous diseases of pemphigus foliaceus, pemphigus vulgaris, and bullous pemphigoid. Its role in linear IgA dermatosis, however, is not well recognized. We report the second case of linear IgA dermatosis induced by intense sun exposure in which blistering was induced by UVA radiation. Furthermore, a review of the literature on photoinduced autoimmune bullous diseases and the wavelengths responsible for the induction of blistering is presented and several proposed mechanisms of action for the blister induction, including release or unmasking of antigens, promotion of antibody fixation by UV radiation, and launching of an inflammatory process, are discussed. We conclude that linear IgA dermatosis should be added to the list of autoimmune bullous diseases induced and/or aggravated by UV radiation.

Progress in the understanding of the pathology and pathogenesis of cutaneous drug eruptions : implications for management

Cutaneous drug eruptions are among the most common adverse reactions to drug therapy. The etiology may reflect immunologic or nonimmunologic mechanisms, the former encompassing all of the classic Gell and Combs immune mechanisms. Cumulative and synergistic effects of drugs include those interactions of pharmacokinetic and pharmacodynamic factors reflecting the alteration by one drug of the effective serum concentration of another and the functions of drugs and their metabolites that interact to evoke cutaneous and systemic adverse reactions. Recent observations include the role of concurrent infection with lymphotropic viruses and drug effects that, through the enhancement of lymphoid blast transformation and/or lymphocyte survival and the contribution of intercurrent systemic connective tissue disease syndromes, promote enhanced lymphocyte longevity and the acquisition of progressively broadening autoantibody specificities. The latter are particularly opposite to drug-induced lupus erythematosus and to drug reactions in the setting of HIV infection. Specific common types of cutaneous drug eruptions will be discussed in this review. Successful management of cutaneous drug eruptions relies upon the prompt discontinuation of the causative medication; most drug eruptions have a good prognosis after this is accomplished. Oral or topical corticosteroids can be administered to aid in the resolution of some types of eruptions. Antihistamines or anti-inflammatory agents may also be administered for some eruptions.

Linear IgA dermatosis induced by a new angiotensin-converting enzyme inhibitor

A 68-year-old female patient treated with benazepril for arterial hypertension developed oral and cutaneous blistering. Biopsy of the oral and cutaneous lesions showed neutrophilic microabscesses in the mesenchymal papillae, with epitheliomesenchymal separation. Direct immunofluorescence revealed linear immunoglobulin deposits at the epithelial basement membrane zone, consisting predominantly of IgA. The histologic results supported the clinical diagnosis of drug-induced linear IgA disease. The substitution of benazepril with a beta blocker resulted in complete resolution of all mucocutaneous lesions.

Spectrum of subepidermal immunobullous disorders seen at the National Skin Centre, Singapore: a 2-year review

BACKGROUND

The subepidermal immunobullous disorders (SEIBDs) comprise bullous pemphigoid (BP), cicatricial pemphigoid (CP), epidermolysis bullosa acquisita (EBA), linear IgA disease (LAD), dermatitis herpetiformis (DH), pemphigoid gestationis (PG) and bullous systemic lupus erythematosus (BSLE). They are thought to be rarer in the Far East than in western Europe.

OBJECTIVE

This 2-year retrospective study investigates the spectrum seen at our centre and the minimum estimated incidence of each.

PATIENTS AND METHODS

A total of 67 patients seen at the National Skin Centre (NSC), Singapore between January 1998 and December 1999 were diagnosed as having an SEIBD. Fifty-nine (88%) had BP, four (6%) had EBA, two (3%) LAD and two (3%) BSLE. There were no cases of CP, DH or PG diagnosed during this period. The minimum estimated incidence in our local population was 7.6, 0.5, 0.26 and 0.26 per million population per year, respectively. The mean age of onset was 77, 68, 65 and 31 years, respectively.

RESULTS

BP is the commonest SEIBD seen locally, with an incidence at least equal to that in western Europe. It is diagnosed at our centre three times more frequently than pemphigus. There is a predilection for ethnic Chinese but not Indian. EBA is twice as common as in western Europe and shows a predilection for ethnic Indians. LAD is rare here compared to China, despite the predominant Chinese population. BSLE is also rare. In contrast to western Europe, CP, DH and PG are very rare in Singapore.

CONCLUSIONS

This is the first study from this region to show that certain SEIBDs are not rarer in the Far East, as previously thought.

Linear IgA disease in a patient with Castleman's disease

Linear IgA disease (LAD) is a well recognized subepidermal blistering disorder characterized by linear deposits of IgA at the basement membrane zone. The aetiology is unknown but there is a recognized association with lymphoproliferative malignancies. We report a case of LAD occurring in a patient with multicentric Castleman's disease (angiofollicular lymph node hyperplasia), an association not previously recorded in the literature.

Linear IgA bullous dermatosis induced by atorvastatin

Linear IgA bullous dermatosis (LABD) is an autoimmune blistering skin disease characterized by circulating IgA antibodies binding the basement membrane zone. In most cases the origin is not clear, but in a minority of cases LABD is drug induced. We describe a patient in whom linear IgA disease developed shortly after beginning therapy with atorvastatin. In Western blotting analysis we detected IgA and IgG class antibodies targeting a 97-kd protein. To our knowledge this is the first reported case of atorvastatin-induced LABD.

Drug-induced linear IgA bullous dermatosis after vancomycin discontinuance in a patient with renal insufficiency

Linear IgA bullous dermatosis (LABD) is an autoimmune, subepidermal, vesiculobullous disease that has been commonly associated with the use of vancomycin hydrochloride. Lesions typically appear during vancomycin therapy, 24 hours to 15 days after the first dose. A 65-year-old white man with renal insufficiency developed pruritic, tense bullae on the right chest, right medial arm, right flank, abdomen, and right upper thigh 14 days after his last dose of vancomycin. Histopathologic examination and immunofluorescence studies were diagnostic of LABD. Vancomycin-related LABD may appear as long as 2 weeks after the drug is discontinued.

Clinical, demographic, and immunohistologic features of vancomycin-induced linear IgA bullous disease of the skin. Report of 2 cases and review of the literature

Administration of intravenous vancomycin has been associated with the development of linear IgA bullous disease (LABD). In contrast to the idiopathic variant, vancomycin-induced LABD (VILABD) appears to be more transient and to be associated with lower morbidity. The characteristics of this entity remain undefined. Our analysis of clinical, demographic, and immunopathologic features of 2 new and 14 previously reported patients with VILABD reveals that VILABD is clinically and immunopathologically indistinguishable from its idiopathic variant. A variety of premorbid conditions and concomitant medications were observed, none of which was consistently associated with the development of VILABD. VILABD occurs independently of vancomycin trough levels, resolves promptly upon discontinuation of vancomycin, and recurs more severely and with shorter onset latency with vancomycin rechallenge. This entity should be recognized as 1 of the adverse cutaneous effects of intravenous vancomycin, and warrants prompt diagnosis through direct immunofluorescence skin examination.