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Intraepithelial autoimmune bullous dermatoses disease activity assessment and therapy. J Am Acad Dermatol 2021; 84:1523-1537. [PMID: 33684497 DOI: 10.1016/j.jaad.2021.02.073] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 02/19/2021] [Accepted: 02/21/2021] [Indexed: 12/30/2022]
Abstract
Intraepithelial autoimmune blistering dermatoses are a rare group of skin disorders characterized by disruptions of inter-keratinocyte connections within the epidermis through the action of autoantibodies. The second article in this continuing medical education series presents validated disease activity scoring systems, serologic parameters of disease, treatments, and clinical trials for pemphigus and its subtypes.
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Paraneoplastic Pemphigus. A Life-Threatening Autoimmune Blistering Disease. ACTAS DERMO-SIFILIOGRAFICAS 2017; 108:902-910. [DOI: 10.1016/j.ad.2017.04.024] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2016] [Revised: 04/16/2017] [Accepted: 04/18/2017] [Indexed: 11/18/2022] Open
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3
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Tirado-Sánchez A, Bonifaz A. Paraneoplastic Pemphigus. A Life-Threatening Autoimmune Blistering Disease. ACTAS DERMO-SIFILIOGRAFICAS 2017. [DOI: 10.1016/j.adengl.2017.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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4
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Abstract
Pemphigus is a group of IgG-mediated autoimmune diseases of stratified squamous epithelia, such as the skin and oral mucosa, in which acantholysis (the loss of cell adhesion) causes blisters and erosions. Pemphigus has three major subtypes: pemphigus vulgaris, pemphigus foliaceus and paraneoplastic pemphigus. IgG autoantibodies are characteristically raised against desmoglein 1 and desmoglein 3, which are cell-cell adhesion molecules found in desmosomes. The sites of blister formation can be physiologically explained by the anti-desmoglein autoantibody profile and tissue-specific expression pattern of desmoglein isoforms. The pathophysiological roles of T cells and B cells have been characterized in mouse models of pemphigus and patients, revealing insights into the mechanisms of autoimmunity. Diagnosis is based on clinical manifestations and confirmed with histological and immunochemical testing. The current first-line treatment is systemic corticosteroids and adjuvant therapies, including immunosuppressive agents, intravenous immunoglobulin and plasmapheresis. Rituximab, a monoclonal antibody against CD20+ B cells, is a promising therapeutic option that may soon become first-line therapy. Pemphigus is one of the best-characterized human autoimmune diseases and provides an ideal paradigm for both basic and clinical research, especially towards the development of antigen-specific immune suppression treatments for autoimmune diseases.
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Ng PP, Rencic A, Nousari HC. Paraneoplastic Pemphigus: A Refractory Autoimmune Mucocutaneous Disease. J Cutan Med Surg 2016. [DOI: 10.1177/120347540200600505] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Objective: We report on a 42-year-old man with Stage IIA non-Hodgkin's lymphoma who developed a severe mucocutaneous blistering eruption. His diagnosis, paraneoplastic pemphigus, was based on clinical, histological, and immunofluorescence findings and confirmed by immunoprecipitation. Despite maximal therapy with plasmapheresis, corticosteroids, and mycophenolate mofetil and the subsequent addition of cyclophosphamide and cyclosporine, the condition was fatal. Conclusion: This case illustrates the refractory nature of this disease and the inadequacy of existing therapies.
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Affiliation(s)
- Patricia P.L. Ng
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Adrienne Rencic
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - H. Carlos Nousari
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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6
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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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7
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Vezzoli P, Berti E, Marzano AV. Rationale and efficacy for the use of rituximab in paraneoplastic pemphigus. Expert Rev Clin Immunol 2014; 4:351-63. [DOI: 10.1586/1744666x.4.3.351] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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8
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Cho JH, Kim NJ, Ko SM, Kim C, Ahn HK, Yun J, Park YH. A case report of paraneoplastic pemphigus associated with esophageal squamous cell carcinoma. Cancer Res Treat 2013; 45:70-3. [PMID: 23613673 PMCID: PMC3629366 DOI: 10.4143/crt.2013.45.1.70] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2011] [Accepted: 07/13/2011] [Indexed: 12/25/2022] Open
Abstract
Paraneoplastic pemphigus is an autoimmune blistering and erosive mucocutaneous syndrome associated with underlying neoplasm. It is primarily associated with lymphoproliferative disorders, and uncommonly with malignancies of epithelial origin. We report on a case of a 68-year-old male who presented with whole body bullous and erosive skin lesions. Findings on upper gastrointestinal endoscopy and skin biopsy revealed esophageal squamous cell carcinoma and paraneoplastic pemphigus. Palliative chemotherapy and systemic glucocorticoid were started, however, the patient died of overwhelming sepsis on the ninth day of chemotherapy. This case demonstrates that paraneoplastic pemphigus can occur in esophageal squamous cell carcinoma and could be a cause of morbidity.
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Affiliation(s)
- Jin Hyun Cho
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Frew JW, Murrell DF. Current management strategies in paraneoplastic pemphigus (paraneoplastic autoimmune multiorgan syndrome). Dermatol Clin 2011; 29:607-12. [PMID: 21925005 DOI: 10.1016/j.det.2011.06.016] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Paraneoplastic pemphigus (PNP) or paraneoplastic autoimmune multiorgan syndrome (PAMS) is a life-threatening autoimmune blistering disease commonly associated with lymphoproliferative neoplasms. This article focuses on current management strategies in PNP/PAMS, and reported instances of their treatment successes and failures. Due to the rarity of the condition and the high rates of treatment failure, no randomized control trials exist to guide the evidence-based treatment of this condition; all evidence to date on the efficacy of therapeutic modalities has been gained from individual case reports, small case series, and expert recommendations.
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Affiliation(s)
- John W Frew
- St George Hospital, Gray Street, Kogarah, Sydney, NSW 2217, Australia
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10
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Abstract
Autoimmune mucocutaneous blistering diseases (AMBD) are a rare group of dermatoses that can be potentially fatal. There are many subtypes and their clinical presentation can vary from being localized to general involvement. It is crucial that a diagnosis be made as early as possible and appropriate treatments are implemented. This article will discuss the diagnosis and available treatments of the major AMBDs. There are very few case-controlled studies regarding the treatments of these diseases. Most of the treatments used for these diseases are based on anecdotal reports. Hence, a synopsis of the conventional treatments and some brief recommendations will also be discussed. A brief discussion regarding "rescue" therapies that have been used for those patients with more recalcitrant cases of AMBD will also be presented.
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Affiliation(s)
- Naveed Sami
- Department of Dermatology, University of Alabama, 1720 University Blvd., Birmingham, AL 35294, USA.
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Billet SE, Grando SA, Pittelkow MR. Paraneoplastic autoimmune multiorgan syndrome: Review of the literature and support for a cytotoxic role in pathogenesis. Autoimmunity 2009; 39:617-30. [PMID: 17101506 DOI: 10.1080/08916930600972099] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Paraneoplastic autoimmune multiorgan syndrome (PAMS), first described as paraneoplastic pemphigus in 1990, is an autoimmune blistering disease associated with neoplasia. Patients with this rare disorder have severe blistering and painful erosions of the oral cavity and various other cutaneous findings ranging from classic pemphigus vulgaris-like erosions to targetoid lesions resembling erythema multiforme and papular to more confluent lichenoid eruptions. This syndrome involves multiple organ systems, and its high rate of mortality often stems from constrictive bronchiolitis obliterans. The histologic findings are as diverse as the clinical presentation, often making diagnosis difficult initially. Immunodermatologic and serologic laboratory findings typically establish the diagnosis. These results can be confirmed with immunoprecipitation profiling of specific molecular weight protein markers. The proposed pathogenesis of PAMS continues to evolve, and recent reports implicate the involvement of cell-mediated, cytotoxic immunity, in addition to humoral autoantibodies. This review characterizes and summarizes the clinical, pathologic, and immunohistologic features of PAMS and outlines the possible role of cytotoxic T lymphocytes in the pathogenesis of this syndrome.
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Affiliation(s)
- Sara E Billet
- Department of Dermatology, Mayo Clinic, Rochester, MN 55905, USA
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13
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Brodsky RA, Jones RJ. Intensive immunosuppression with high dose cyclophosphamide but without stem cell rescue for severe autoimmunity: advantages and disadvantages. Autoimmunity 2008; 41:596-600. [PMID: 18958751 PMCID: PMC3100525 DOI: 10.1080/08916930802197206] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Hematopoietic stem cell transplantation (HSCT) for the treatment of severe autoimmune disorders continues to show great promise. The morbidity and mortality of the approach is relatively low and clinical benefit has been demonstrated in many, but not all patients. Furthermore, relapse following HSCT is not uncommon. Most centers now prefer nonmyeloablative conditioning regimens using high dose cyclophosphamide prior to SCT; however, emerging data show that high dose cylophosphamide can be administered safely without the need for HSCT. Eliminating the use of HSCT after high dose cyclophosphamide shortens the duration of the procedure by several weeks, markedly reduces the cost of the procedure and eliminates the potential of reinfusing autoreactive lymphoctes with the autograft.
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Affiliation(s)
- Robert A Brodsky
- The Division of Hematology, Johns Hopkins University School of Medicine, Ross Research Building, Baltimore, MD 21205, USA.
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Deane S, Meyers FJ, Gershwin ME. On reversing the persistence of memory: Hematopoietic stem cell transplant for autoimmune disease in the first ten years. J Autoimmun 2008; 30:180-96. [DOI: 10.1016/j.jaut.2007.12.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Abstract
Autoimmune bullous diseases result from an immune response to molecular components of the desmosome or basement membrane. Bullous diseases are associated with a high degree of morbidity and occasional mortality. Therapy of bullous diseases consists of suppressing the immune system, controlling inflammation and improving healing of erosions. The therapeutic agents used in the treatment of bullous diseases may be associated with high morbidity and occasional mortality. Successful treatment requires understanding of the pathophysiology of the disease process and the pharmacology of the drugs being used.
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Affiliation(s)
- Diya F Mutasim
- Department of Dermatology, University of Cincinnati College of Medicine Cincinnati, OH, USA
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Martínez De Pablo MI, Iranzo P, Mascaró JM, Llambrich A, Baradad M, Herrero C. Paraneoplastic pemphigus associated with non-Hodgkin B-cell lymphoma and good response to prednisone. Acta Derm Venereol 2005; 85:233-5. [PMID: 16040408 DOI: 10.1080/00015550510025542] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
Paraneoplastic pemphigus is a life-threatening autoimmune bullous disease associated with neoplasia, generally of lymphoid origin. Immunosuppressive therapy is often disappointing and there are only a few reports of patients surviving more than 2 years. These cases were generally associated with benign neoplasms. We report here the case of a patient with paraneoplastic pemphigus associated with non-Hodgkin B-cell lymphoma who had a surprisingly good response to systemic corticosteroids and remains free of lesions more than 3 years later despite progression of her neoplasm.
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Klein WM, Rencic A, Munshi NC, Nousari CH. Multicentric plasma cell variant of Castleman's disease with cutaneous involvement. J Cutan Pathol 2004; 31:448-52. [PMID: 15186433 DOI: 10.1111/j.0303-6987.2004.00117.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Castleman's disease (CD) is a rare low-grade B-cell lymphoproliferative disorder that can be associated with a variety of antibody-mediated paraneoplastic syndromes. The disease is classified clinically by two forms and three histologic variants. METHODS We describe the clinical and pathological features of a 44-year-old woman who presented with an autoimmune hemolytic anemia, thrombocytosis, polyclonal gammopathy, axillary lymphadenopathy, hepatosplenomegaly, and several erythematous and violaceous nodules and plaques without scaling involving the trunk and extremities. RESULTS Histologic examination of the skin lesions revealed a deep dermal and subcutaneous nodular mononuclear infiltrate composed primarily of polyclonal plasmacytoid cells without atypia and an increased vascular proliferation. Additional studies including a bone marrow and lymph node biopsy, serum and urine protein electrophoresis, and computed tomography scans supported the diagnosis of multicentric plasma cell variant of CD with an associated autoimmune paraneoplastic hemolytic anemia. CONCLUSION Cutaneous involvement in CD is part of the multicentric nature and should be considered in the differential diagnosis of a polyclonal plasma cell-rich lymphoproliferative disorder associated with paraneoplastic autoimmune disease.
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Affiliation(s)
- Walter M Klein
- Department of Pathology, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
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18
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Mutasim DF. Management of autoimmune bullous diseases: Pharmacology and therapeutics. J Am Acad Dermatol 2004; 51:859-77; quiz 878-80. [PMID: 15583576 DOI: 10.1016/j.jaad.2004.02.013] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Bullous diseases are associated with high morbidity and mortality. They result from autoimmune response to one or more components of the basement membrane or desmosomes. Management consists of treating the immunologic basis of the disease, treating the inflammatory process involved in lesion formation, and providing supportive care both locally and systemically. Therapeutic agents are chosen based on their known pharmacologic properties and evidence of effectiveness derived from observations and studies. Learning objectives At the completion of this learning activity, participants should be able to understand the pharmacology of drugs used in the treatment of bullous diseases, the principles of therapy for various such diseases, and a practical approach to the management of these diseases.
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Affiliation(s)
- Diya F Mutasim
- Department of Dermatology, University of Cincinnati, College of Medicine, OH 45267-0592, USA.
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Iranzo P, Xaubet A, Carrera C, Mascaró JM, Campo E, Herrero C. Bronchiolitis Obliterans Associated With Paraneoplastic Pemphigus: a Paraneoplastic Autoimmune Multiorgan Syndrome. ACTA ACUST UNITED AC 2004; 40:240-3. [PMID: 15117625 DOI: 10.1016/s1579-2129(06)70091-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Paraneoplastic pemphigus is a mucocutaneous disease characterized by well defined clinical and immunopathological features associated with neoplasia. Recent evidence of bronchial epithelium involvement has led to the suggestion that this process is a paraneoplastic autoimmune multiorgan syndrome. CLINICAL OBSERVATION We report the case of a patient with lichenoid eruptions on the skin and mucous membranes who later developed progressive dyspnea. With a suspected diagnosis of paraneoplastic autoimmune multiorgan syndrome, the following diagnostic tests were performed: histology and immunofluorescence of the skin, oral mucosa, and bronchial epithelium; indirect immunofluorescence of serum; pulmonary function tests; and evaluation for an occult neoplasm. Findings of pathology and immunofluorescence confirmed the suspected diagnosis. The computed thoracoabdominal tomography revealed signs of bronchiolitis and the presence of a retroperitoneal tumor. CONCLUSIONS Awareness of the mucocutaneous manifestations of paraneoplastic autoimmune multiorgan syndrome, and confirmation of this diagnosis by simple laboratory techniques can facilitate the early detection of occult neoplasia and forestall respiratory involvement.
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Affiliation(s)
- P Iranzo
- Servicio de Dermatología, Hospital Clínic, IDIBAPS, Barcelona, Spain.
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20
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Bronquiolitis obliterante y pénfigo paraneoplásico: un síndrome paraneoplásico autoinmune multiorgánico. Arch Bronconeumol 2004. [DOI: 10.1016/s0300-2896(04)75512-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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21
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Oliva-Hemker MM, Loeb DM, Abraham SC, Lederman HM. Remission of severe autoimmune enteropathy after treatment with high-dose cyclophosphamide. J Pediatr Gastroenterol Nutr 2003; 36:639-43. [PMID: 12717089 DOI: 10.1097/00005176-200305000-00010] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Maria M Oliva-Hemker
- Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21187-2631, USA.
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Drachman DB, Jones RJ, Brodsky RA. Treatment of refractory myasthenia: "rebooting" with high-dose cyclophosphamide. Ann Neurol 2003; 53:29-34. [PMID: 12509845 DOI: 10.1002/ana.10400] [Citation(s) in RCA: 103] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Patients with myasthenia gravis (MG) who do not respond to conventional immunotherapeutic agents, or cannot tolerate their side effects, are considered "refractory." Ablation of the immune system followed by bone marrow transplant has been shown to cure experimental MG in rats. It is now known that immunoablative treatment with high-dose cyclophosphamide does not damage hematopoietic "stem cells," permitting repopulation of the immune system without bone marrow transplant. Recent evidence indicates that this treatment can induce durable remissions in autoimmune diseases. We treated three myasthenic patients, for whom treatment with thymectomy, plasmapheresis, and conventional immunotherapeutic agents failed, by using high-dose cyclophosphamide (50mg/kg/day intravenously for 4 days) followed by granulocyte colony stimulating factor. All three patients tolerated the treatment well and have had marked improvement in myasthenic weakness, permitting reduction of immunosuppressive medication to minimal levels. Acetylcholine receptor (AChR) antibody levels decreased in two AChR antibody-positive patients, and anti-MuSK antibody levels decreased in one "AChR antibody-negative" patient. The patients have been followed for up to 3.5 years, with no recurrence of symptoms. High-dose cyclophosphamide treatment appears to be an effective and safe treatment for selected patients with refractory MG. Further follow-up of these and additional patients will be needed to determine whether the benefit is durable.
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Affiliation(s)
- Daniel B Drachman
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA.
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Brannagan TH, Pradhan A, Heiman-Patterson T, Winkelman AC, Styler MJ, Topolsky DL, Crilley PA, Schwartzman RJ, Brodsky I, Gladstone DE. High-dose cyclophosphamide without stem-cell rescue for refractory CIDP. Neurology 2002; 58:1856-8. [PMID: 12084892 DOI: 10.1212/wnl.58.12.1856] [Citation(s) in RCA: 92] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Four patients with chronic inflammatory demyelinating polyneuropathy (CIDP) who were refractory to conventional treatment were treated with high-dose cyclophosphamide (200 mg/kg over 4 days). All improved in functional status and muscle strength. Nerve conduction studies improved in three of four. Other immunomodulatory medications have been discontinued. High-dose cyclophosphamide can be given safely to patients with CIDP and patients with disease persistence after standard therapy may have a response that lasts for over 3 years and results in long-term disease remission.
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Affiliation(s)
- T H Brannagan
- Department of Neurology, MCP-Hahnemann University, Philadelphia, PA, USA.
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25
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Moyo VM, Smith D, Brodsky I, Crilley P, Jones RJ, Brodsky RA. High-dose cyclophosphamide for refractory autoimmune hemolytic anemia. Blood 2002; 100:704-6. [PMID: 12091370 DOI: 10.1182/blood-2002-01-0087] [Citation(s) in RCA: 83] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
High-dose cyclophosphamide, without stem cell rescue, has been used successfully to treat aplastic anemia and other autoimmune disorders. To determine the safety and efficacy of high-dose cyclophosphamide among patients with severe refractory autoimmune hemolytic anemia, we treated 9 patients with cyclophosphamide (50 mg. kg(-1). d(-1) for 4 days) who had failed a median of 3 (range, 1-7) other treatments. The median hemoglobin before treatment was 6.7 g/dL (range, 5-10 g/dL). The median time to reach an absolute neutrophil count of 500/microL or greater was 16 days (range, 12-18 days). Six patients achieved complete remission (normal untransfused hemoglobin for age and sex), and none have relapsed after a median follow-up of 15 months (range, 4-29 months). Three patients achieved and continue in partial remission (hemoglobin at least 10 g/dL without transfusion support). High-dose cyclophosphamide was well tolerated and induced durable remissions in patients with severe refractory autoimmune hemolytic anemia.
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Affiliation(s)
- Victor M Moyo
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, USA
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Abstract
High-dose cyclophosphamide was developed as a conditioning regimen for allogeneic bone marrow transplantation. Later, it was discovered that high-dose cyclophosphamide spares early hematopoietic stem cells because of their relatively high levels of the enzyme aldehyde dehydrogenase; thus, high-dose cyclophosphamide is a potent immunosuppressive agent, but nonmyeloablative. Recent reports demonstrate that high-dose cyclophosphamide without bone marrow transplantation induces durable treatment-free remissions in severe aplastic anemia and a variety of other autoimmune disorders; however, there is lingering concern about the safety of this approach.
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Affiliation(s)
- Robert A Brodsky
- Johns Hopkins Oncology Center, Baltimore, Maryland 21231-1000, USA.
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Abstract
The autoimmune blistering diseases are a fascinating group of diseases characterized by the presence of blisters involving the skin and mucous membranes. Understanding of the diagnosis, pathophysiology, and advances in treatment of these diseases has grown enormously in recent years. In this article, the author discusses the major clinical and immunopathologic findings in bullous pemphigoid, mucous membrane pemphigoid, epidermolysis bullosa acquisita, linea IgA bullous disease, and pemphigus. The article focuses on the therapeutic management of patients with autoimmune blistering diseases, including the appropriate treatment of patients, with particular emphasis on the use of immunomodulating and immunosuppresive agents.
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Affiliation(s)
- N J Korman
- Department of Dermatology, University Hospitals of Cleveland, Case Western Reserve University, Cleveland, Ohio, USA
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28
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Heizmann M, Itin P, Wernli M, Borradori L, Bargetzi MJ. Successful treatment of paraneoplastic pemphigus in follicular NHL with rituximab: report of a case and review of treatment for paraneoplastic pemphigus in NHL and CLL. Am J Hematol 2001; 66:142-4. [PMID: 11421295 DOI: 10.1002/1096-8652(200102)66:2<142::aid-ajh1032>3.0.co;2-0] [Citation(s) in RCA: 108] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Paraneoplastic pemphigus is a severe mucocutaneous disease associated in most cases with B-cell lymphoproliferative disorders. Independent of the course of the underlying malignancy, this autoimmune skin disease is resistant to any treatment in most cases and may lead to death by infectious complications. We observed a patient with recovery of paraneoplastic pemphigus associated with follicular non-Hodgkin's-lymphoma after therapy with rituximab. In addition, we reviewed the literature and analyzed the few cases with comparable outcome with other treatment modalities.
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MESH Headings
- Aged
- Antibodies, Monoclonal/administration & dosage
- Antibodies, Monoclonal, Murine-Derived
- Antineoplastic Agents/administration & dosage
- Female
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/complications
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Lymphoma/complications
- Lymphoma/drug therapy
- Lymphoma, Follicular/complications
- Lymphoma, Follicular/drug therapy
- Paraneoplastic Syndromes/drug therapy
- Pemphigus/drug therapy
- Pemphigus/etiology
- Rituximab
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Affiliation(s)
- M Heizmann
- Center of Oncology, Hematology and Transfusion Medicine, Kantonsspital Aarau, Switzerland
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Abstract
Mycophenolic mofetil, azathioprine, thioguanine, methotrexate, and cyclophosphamide were initially used for the treatment of malignancies. Because of their immunosuppressive activity, the range of diseases responsive to these medications has expanded to include various autoimmune-related diseases. Discussion includes a historical perspective of each medication, recent updates on responsive dermatologic conditions, dosages, monitoring guidelines, and medication expense.
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Affiliation(s)
- N G Silvis
- Section of Dermatology, Department of Medicine, University of Arizona College of Medicine, Tucson, Arizona, USA
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30
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Moreno Giménez JC. ¿Qué hay de nuevo en terapéutica? ACTAS DERMO-SIFILIOGRAFICAS 2001. [DOI: 10.1016/s0001-7310(01)76445-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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31
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Hayag MV, Cohen JA, Kerdel FA. Immunoablative high-dose cyclophosphamide without stem cell rescue in a patient with pemphigus vulgaris. J Am Acad Dermatol 2000; 43:1065-9. [PMID: 11100024 DOI: 10.1067/mjd.2000.110397] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The use of ablative intravenous cyclophosphamide (50 mg/kg per day for 4 days) without stem cell rescue has been described in patients with refractory autoimmune diseases such as paraneoplastic pemphigus, systemic lupus erythematosus, and aplastic anemia. We describe a 33-year-old patient with pemphigus vulgaris recalcitrant to multiple therapies. The patient presented with numerous oral ulcerations, erosions, and hyperpigmented crusted plaques on his face, trunk, and arms. Findings of a skin biopsy and direct immunofluorescence were consistent with pemphigus vulgaris. The circulating pemphigus vulgaris autoantibodies were present at a titer of 1:640. The patient received immunoablative therapy (50 mg/kg of cyclophosphamide for a total of 4 days) and tolerated the regimen well. Complications such as thrombocytopenia and Pseudomonas septicemia were quickly treated. Four months after the 4-day therapy, his oral and skin lesions completely healed, and his pemphigus titers have decreased to zero. He is no longer receiving prednisone and no new lesions have developed. This provides further evidence that this regimen is relatively safe and provides a potential "cure" for refractory autoimmune diseases such as pemphigus vulgaris.
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Affiliation(s)
- M V Hayag
- Department of Dermatology and Cutaneous Surgery, University of Miami, Florida, USA
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Abstract
Cyclophosphamide is a potent immunosuppressive agent that has an important role in the treatment of autoimmune, neoplastic, granulomatous, and neutrophilic disorders. Pulse intravenous cyclophosphamide has been shown to be efficacious for several dermatologic disorders, particularly pemphigus vulgaris, with a low incidence of toxicity reported. As reported earlier, studies performed on the use of pulse intravenous cyclophosphamide in the treatment of a variety of dermatology-related diseases strongly suggest that the toxicities frequently noted with the use of oral cyclophosphamide therapy may be significantly less common with pulse intravenous administration of cyclophosphamide. The short follow-up period of patients treated with this modality so far, however, requires constant vigilance for the development of side effects, particularly secondary malignancy. At this time, pulse intravenous cyclophosphamide is a promising treatment modality with an acceptable risk profile for moderate-to-severe dermatologic diseases recalcitrant to standard therapy. Prospective comparative trials are needed to assess further the efficacy and toxicity of this therapy.
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Affiliation(s)
- L P Fox
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, USA
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Brodsky RA, Petri M, Jones RJ. Hematopoietic stem cell transplantation for systemic lupus erythematosus. Rheum Dis Clin North Am 2000; 26:377-87, viii. [PMID: 10768218 DOI: 10.1016/s0889-857x(05)70144-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Many institutions worldwide are conducting clinical studies using immunoablative therapy followed by hematopoietic stem cell transplantation for the treatment of SLE. Interpretation of these studies will be complicated by the differences in patient selection, conditioning regimens, and the method of stem cell collection. A major concern with this approach is that autoreactive effector cells will be re-infused with the autologous graft. The recent demonstration that immunoablative therapy (cyclophosphamide 200 mg/kg) can be safely delivered without the need for stem cell rescue offers a potential way to circumvent this problem. Early results employing immunoablative therapy, with or without stem cell rescue, are encouraging; however, longer follow-up and additional patients are necessary to validate this approach.
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Affiliation(s)
- R A Brodsky
- Division of Immunology and Hematopoiesis, Johns Hopkins Oncology Center, Baltimore, Maryland, USA.
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Abstract
The autoimmune vesiculobullous diseases of the skin and mucous membranes are a fascinating group of diseases characterized by blisters of the skin and mucous membranes. These diseases are among the most intriguing, well-characterized, and potentially serious skin diseases known. In recent years, there has been major progress made in the understanding of their pathophysiology, in the development of new diagnostic techniques and of new therapeutic approaches. These advances have placed the autoimmune blistering diseases of the skin and mucous membranes at the forefront of dermatologic advances in the late twentieth century. This article discusses several of the most important autoimmune blistering disease, including bullous pemphigoid, mucous membrane pemphigoid (formerly known as cicatricial pemphigoid), epidermolysis bullosa acquisita, linear IgA bullous dermatosis, pemphigus and paraneoplastic pemphigus, with particular emphasis on the use of new and emerging therapeutic approaches.
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Affiliation(s)
- N J Korman
- Department of Dermatology, University Hospitals of Cleveland, Case Western Reserve University, Ohio, USA
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Abstract
Pemphigus and bullous pemphigoid are distinct autoimmune blistering diseases that are characterised by the presence of autoantibodies directed against specific adhesion molecules of the skin and mucous membranes. The comparison and contrast of molecular mechanism of blister formation of these two diseases provide a rational diagnostic and therapeutic approach to affected patients.
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Affiliation(s)
- H C Nousari
- Department of Dermatology, Johns Hopkins Medical Institutions, Baltimore, MD 21205-2196, USA.
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