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Caux F, Patsatsi A, Karakioulaki M, Antiga E, Baselga E, Borradori L, Caproni M, Cardones AR, Chandran NS, Dräger S, Drenovska K, Goebeler M, Günther C, Hofmann SC, Ioannides D, Joly P, Marinović B, Mariotti EB, Marzano AV, Morel KD, Murrell DF, Prost C, Sárdy M, Setterfield J, Skiljevic D, Uzun S, Vassileva S, Zambruno G, Schmidt E. S2k guidelines on diagnosis and treatment of linear IgA dermatosis initiated by the European Academy of Dermatology and Venereology. J Eur Acad Dermatol Venereol 2024; 38:1006-1023. [PMID: 38421060 DOI: 10.1111/jdv.19880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 01/19/2024] [Indexed: 03/02/2024]
Abstract
INTRODUCTION Linear IgA dermatosis (LAD) is a rare subepidermal autoimmune bullous disease (AIBD) defined by predominant or exclusive immune deposits of immunoglobulin A at the basement membrane zone of skin or mucous membranes. This disorder is a rare, clinically and immunologically heterogeneous disease occurring both in children and in adults. The aim of this project is to present the main clinical features of LAD, to propose a diagnostic algorithm and provide management guidelines based primarily on experts' opinion because of the lack of large methodologically sound clinical studies. METHODS These guidelines were initiated by the European Academy of Dermatology and Venereology (EADV) Task Force Autoimmune Bullous Diseases (AIBD). To achieve a broad consensus for these S2k consensus-based guidelines, a total of 29 experts from different countries, both European and non-European, including dermatologists, paediatric dermatologists and paediatricians were invited. All members of the guidelines committee agreed to develop consensus-based (S2k) guidelines. Prior to a first virtual consensus meeting, each of the invited authors elaborated a section of the present guidelines focusing on a selected topic, based on the relevant literature. All drafts were circulated among members of the writing group, and recommendations were discussed and voted during two hybrid consensus meetings. RESULTS The guidelines summarizes evidence-based and expert opinion-based recommendations (S2 level) on the diagnosis and treatment of LAD. CONCLUSION These guidelines will support dermatologists to improve their knowledge on the diagnosis and management of LAD.
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Affiliation(s)
- Frédéric Caux
- Department of Dermatology and Referral Center for Autoimmune Bullous Diseases, Groupe Hospitalier Paris Seine-Saint-Denis, AP-HP and University Paris 13, Bobigny, France
| | - Aikaterini Patsatsi
- Autoimmune Bullous Diseases Unit, 2nd Department of Dermatology, Aristotle University School of Medicine, Papageorgiou General Hospital, Thessaloniki, Greece
| | - Meropi Karakioulaki
- Department of Dermatology and Venereology, Medical Center, University Hospital Freiburg, Freiburg, Germany
| | - Emiliano Antiga
- Department of Health Sciences, Section of Dermatology, Azienda USL Toscana Centro, Rare Diseases Unit, European Reference Network-Skin Member, University of Florence, Florence, Italy
| | - Eulalia Baselga
- Department of Dermatology, Hospital Sant Joan de Deu, Barcelona, Spain
| | - Luca Borradori
- Department of Dermatology, University of Bern, Inselspital, Berne, Switzerland
| | - Marzia Caproni
- Department of Health Sciences, Section of Dermatology, Azienda USL Toscana Centro, Rare Diseases Unit, European Reference Network-Skin Member, University of Florence, Florence, Italy
| | - Adela R Cardones
- Division of Dermatology, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Nisha Suyien Chandran
- Division of Dermatology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Sören Dräger
- Department of Dermatology, Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Kossara Drenovska
- Department of Dermatology and Venereology, University Hospital "Alexandrovska", Medical University-Sofia, Sofia, Bulgaria
| | - Matthias Goebeler
- Department of Dermatology, Venereology and Allergology, University Hospital Würzburg, Würzburg, Germany
| | - Claudia Günther
- Department of Dermatology, University Hospital, Technical University Dresden, Dresden, Germany
| | - Silke C Hofmann
- Department of Dermatology, Allergy and Dermatosurgery, Helios University Hospital Wuppertal, University Witten-Herdecke, Wuppertal, Germany
| | - Dimitrios Ioannides
- 1st Department of Dermatology, Aristotle University School of Medicine, Hospital of Skin and Venereal Diseases, Thessaloniki, Greece
| | - Pascal Joly
- Department of Dermatology, Rouen University Hospital, INSERM 1234, Normandie University, Rouen, France
| | - Branka Marinović
- Department of Dermatology and Venereology, University Hospital Centre Zagreb, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Elena Biancamaria Mariotti
- Department of Health Sciences, Section of Dermatology, Azienda USL Toscana Centro, Rare Diseases Unit, European Reference Network-Skin Member, University of Florence, Florence, Italy
| | - Angelo Valerio Marzano
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Kimberly D Morel
- Departments of Dermatology and Pediatrics at Columbia University Medical Center, Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Dedee F Murrell
- Department of Dermatology, St George Hospital, University of New South Wales, Sydney, New South Wales, Australia
| | - Catherine Prost
- Department of Dermatology and Referral Center for Autoimmune Bullous Diseases, Groupe Hospitalier Paris Seine-Saint-Denis, AP-HP and University Paris 13, Bobigny, France
| | - Miklós Sárdy
- Department of Dermatology, Venereology and Dermatooncology, Semmelweis University, Budapest, Hungary
- Department of Dermatology and Allergy, University Hospital, LMU, Munich, Germany
| | - Jane Setterfield
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Centre for Host-Microbiome Interactions, King's College London Faculty of Dentistry, Oral & Craniofacial Sciences, London, UK
| | - Dusan Skiljevic
- Department of Dermatovenereology, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Soner Uzun
- Department of Dermatology, Akdeniz University Faculty of Medicine, Antalya, Turkey
| | - Snejina Vassileva
- Department of Dermatology and Venereology, University Hospital "Alexandrovska", Medical University-Sofia, Sofia, Bulgaria
| | - Giovanna Zambruno
- Genodermatosis Unit, Translational Pediatrics and Clinical Genetics Research Division, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Enno Schmidt
- Department of Dermatology, Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
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Jing K, Jordan TJM, Li N, Burette S, Yang B, Marinkovich MP, Diaz LA, Googe P, Thomas NE, Feng S, Liu Z. Anti-NC16A IgA from Patients with Linear IgA Bullous Dermatosis Induce Neutrophil-Dependent Subepidermal Blistering in Mice. J Invest Dermatol 2024; 144:24-32.e1. [PMID: 37437774 PMCID: PMC10776798 DOI: 10.1016/j.jid.2023.05.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 05/02/2023] [Accepted: 05/15/2023] [Indexed: 07/14/2023]
Abstract
Linear IgA bullous dermatosis (LABD) is an acquired autoimmune subepidermal blistering skin disease characterized by circulating and tissue-bound IgA autoantibodies that recognize epitopes within the hemidesmosomal protein BP180, including its NC16A domain. Histologically, LABD has long been defined by neutrophil infiltration and dermal-epidermal separation. However, the pathogenic roles of anti-NC16A IgA and neutrophils in LABD, as well as their interactions, have not been thoroughly studied. We show that passive transfer of patient-derived anti-NC16A IgA induce clinical and histologic LABD pathology in humanized NC16A mice that are reconstituted locally or systemically with human neutrophils. The lesional skin of mice exhibits significantly elevated levels of the neutrophil chemoattractants CXCL-1 and CXCL-2. Furthermore, we show significantly increased levels of the neutrophil chemoattractant IL-8 in blister fluids of patients with LABD. This study provides direct evidence that anti-NC16A IgA in patients with LABD are pathogenic and interact with neutrophils to mediate tissue injury and subepidermal blister formation. This study further corroborates the importance of neutrophil-mediated tissue injury in LABD disease physiology and establishes a clinically relevant in vivo model system that can be used to systematically dissect the immunopathogenesis of LABD.
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Affiliation(s)
- Ke Jing
- Department of Dermatology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA; Hospital for Skin Diseases, Institute of Dermatology, Chinese Academy of Medical Sciences & Peking Union Medical College, Nanjing, P.R. China
| | - Tyler J M Jordan
- Department of Dermatology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA; Department of Clinical Sciences, North Carolina State University, Raleigh, North Carolina, USA
| | - Ning Li
- Department of Dermatology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Susan Burette
- Department of Dermatology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Baoqi Yang
- Departmentof Dermatology, Shandong Provincial Hospital for Skin Diseases & Shandong Provincial Institute of Dermatology and Venereology, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, Shandong, China
| | - M Peter Marinkovich
- Department of Dermatology, Stanford University, Stanford, and Dermatology, Veteran's Affairs Medical Center, Palo Alto, California, USA
| | - Luis A Diaz
- Department of Dermatology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Paul Googe
- Department of Dermatology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Nancy E Thomas
- Department of Dermatology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Suying Feng
- Hospital for Skin Diseases, Institute of Dermatology, Chinese Academy of Medical Sciences & Peking Union Medical College, Nanjing, P.R. China
| | - Zhi Liu
- Department of Dermatology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA; Microbiology and Immunology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.
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Crespo-Bravo M, Thorlacius-Ussing J, Nissen NI, Pedersen RS, Boisen MK, Liljefors M, Johansen AZ, Johansen JS, Karsdal MA, Willumsen N. Levels of type XVII collagen (BP180) ectodomain are elevated in circulation from patients with multiple cancer types and is prognostic for patients with metastatic colorectal cancer. BMC Cancer 2023; 23:949. [PMID: 37803411 PMCID: PMC10557271 DOI: 10.1186/s12885-023-11470-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 10/02/2023] [Indexed: 10/08/2023] Open
Abstract
BACKGROUND Collagens are the major components of the extracellular matrix (ECM) and are known to contribute to tumor progression and metastasis. There are 28 different types of collagens each with unique functions in maintaining tissue structure and function. Type XVII collagen (BP180) is a type II transmembrane protein that provides stable adhesion between epithelial cells and the underlying basement membrane. Aberrant expression and ectodomain shedding of type XVII collagen have been associated with epithelial damage, tumor invasiveness, and metastasis in multiple tumor types and may consequently be used as a potential (non-invasive) biomarker in cancer and treatment target. METHOD An ELISA targeting the type XVII collagen ectodomain (PRO-C17) was developed for use in serum. PRO-C17 was measured in a cohort of patients with 11 different cancer types (n = 214) and compared to healthy controls (n = 23) (cohort 1). Based on the findings from cohort 1, PRO-C17 and its association with survival was explored in patients with metastatic colorectal cancer (mCRC) treated with bevacizumab in combination with chemotherapy (n = 212) (cohort 2). RESULTS PRO-C17 was robust and specific towards the ectodomain of type XVII collagen. In cohort 1, PRO-C17 levels were elevated (p < 0.05) in serum from patients with CRC, kidney, ovarian, bladder, breast, and head and neck cancer compared to healthy controls. PRO-C17 was especially good at discriminating between CRC patients and healthy controls with an AUROC of 0.904. In cohort 2, patients with mCRC and high levels (tertile 3) of PRO-C17 had shorter overall survival (OS) with a median OS of 390 days compared to 539 days for patients with low levels of PRO-C17. When evaluated by multivariate Cox regression analysis, high PRO-C17 was predictive for poor OS independent of risk factors and the tumor fibrosis biomarker PRO-C3. CONCLUSION PRO-C17 measures the ectodomain of type XVII collagen in serum and is a promising non-invasive biomarker that can aid in understanding tumor heterogeneity as well as elaborate on the role of collagen XVII in tumor progression. Moreover, the findings in the study proposes PRO-C17 as novel biomarker of epithelial damage in specific cancer types including CRC.
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Affiliation(s)
- Marina Crespo-Bravo
- Nordic Bioscience A/S, Herlev, 2730, Denmark.
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen, 2200, Denmark.
| | | | | | - Rasmus S Pedersen
- Nordic Bioscience A/S, Herlev, 2730, Denmark
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen, 2200, Denmark
| | - Mogens K Boisen
- Department of Oncology, Copenhagen University Hospital - Herlev and Gentofte, Herlev, 2730, Denmark
| | - Maria Liljefors
- Department of Clinical Science, Intervention and Technology, Karolinska University Hospital Huddinge, Stockholm, 141 57, Sweden
| | - Astrid Z Johansen
- Department of Oncology, Copenhagen University Hospital - Herlev and Gentofte, Herlev, 2730, Denmark
| | - Julia S Johansen
- Department of Oncology, Copenhagen University Hospital - Herlev and Gentofte, Herlev, 2730, Denmark
- Department of Medicine, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Copenhagen, 2730, 2900, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, 2200, Denmark
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Opelka B, Schmidt E, Goletz S. Type XVII collagen: Relevance of distinct epitopes, complement-independent effects, and association with neurological disorders in pemphigoid disorders. Front Immunol 2022; 13:948108. [PMID: 36032160 PMCID: PMC9400597 DOI: 10.3389/fimmu.2022.948108] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 07/07/2022] [Indexed: 11/13/2022] Open
Abstract
Pemphigoid diseases (PD) are autoimmune skin blistering diseases characterized by autoantibodies directed against proteins of the cutaneous basement membrane zone (BMZ). One of the major antigens is type XVII collagen (BP180), a transmembrane glycoprotein, which is targeted in four PDs: bullous pemphigoid, mucous membrane pemphigoid, linear IgA dermatosis, and pemphigoid gestationis. To date, different epitopes on BP180 have been described to be recognized by PD disease patients’ autoantibodies. Different BP180 epitopes were associated with distinct clinical phenotypes while the underlying mechanisms are not yet fully understood. So far, the main effects of anti-BP180 reactivity are mediated by Fcγ-receptors on immune cells. More precisely, the autoantibody–antigen interaction leads to activation of complement at the BMZ and infiltration of immune cells into the upper dermis and, by the release of specific enzymes and reactive oxygen species, to the degradation of BP180 and other BMZ components, finally manifesting as blisters and erosions. On the other hand, inflammatory responses independent of Fcγ-receptors have also been reported, including the release of proinflammatory cytokines and internalization and depletion of BP180. Autoantibodies against BP180 can also be found in patients with neurological diseases. The assumption that the clinical expression of PD depends on epitope specificity in addition to target antigens, autoantibody isotypes, and antibody glycosylation is supported by the observation that epitopes of PD patients differ from those of PD patients. The aim of the present review is to describe the fine specificities of anti-BP180 autoantibodies in different PDs and highlight the associated clinical differences. Furthermore, the direct effects after binding of the autoantibodies to their target are summarized.
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Affiliation(s)
- Bianca Opelka
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Enno Schmidt
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Stephanie Goletz
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
- *Correspondence: Stephanie Goletz,
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5
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Gornowicz-Porowska J, Jałowska M, Seraszek-Jaros A, Bowszyc-Dmochowska M, Kaczmarek E, Dmochowski M. A Probing of the Issue of Detecting IgG, IgG4 and IgA Antibodies to Laminin 332 Epitopes in Mucous Membrane Pemphigoid: A Clinical-Laboratory Experience of a Single Central European University Dermatology Department. Clin Cosmet Investig Dermatol 2022; 15:783-790. [PMID: 35510222 PMCID: PMC9059205 DOI: 10.2147/ccid.s359589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 04/06/2022] [Indexed: 11/23/2022]
Abstract
Purpose Mucous membrane pemphigoid (MMP) is a very rare autoimmune bullous disease, affecting predominantly the mucosae and characterized by autoantibodies to the epithelial basement membrane components. Laminin 332 (Ln-332) is one of the most probable antigens with association with malignancy. The laboratory diagnosis of Ln-332-mediated autoimmunity is troublesome. The aim here was to comparatively examine IgG, IgG4, and IgA autoantibodies specific to α3, β3 or γ2 subunits of Ln-322 in MMP patients using the BIOCHIP mosaic-based indirect immunofluorescence technique (IIF). Patients and Methods Sera from 15 MMP patients were studied. BIOCHIP mosaic-based Ln-332 IIF, direct immunofluorescence, ELISA tests for anti-BP180/BP20 IgG antibodies and statistical analyses were performed. Results Of all the 15 sera examined for IgG4 antibodies, only 1 (6.67%) reacted with the α3 chain, 0 with the β3 chain, and 0 with the γ2 chain. No positive reactivity was seen with the IgG and IgA antibodies. BIOCHIP mosaic-based IIF with Ln-332 showed 100% sensitivity, 8% specificity, 21% positive predictive value, and 100% negative predictive value in relation to the diagnostic gold standard of DIF. The concomitant malignancies were revealed in three cases. Conclusion The detection of antibodies to Ln-332 chains is occasional in Polish MMP sufferers. Still, the evaluation of IgG4 antibodies in MMP can reduce the false-negative results.
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Affiliation(s)
- Justyna Gornowicz-Porowska
- Department and Division of Practical Cosmetology and Skin Diseases Prophylaxis, Poznan University of Medical Sciences, Poznan, Poland
| | - Magdalena Jałowska
- Autoimmune Blistering Dermatoses Section, Department of Dermatology, Poznan University of Medical Sciences, Poznan, Poland
| | - Agnieszka Seraszek-Jaros
- Department of Bioinformatics and Computational Biology, Poznan University of Medical Sciences, Poznan, Poland
| | - Monika Bowszyc-Dmochowska
- Cutaneous Histopathology and Immunopathology Section, Department of Dermatology, Poznan University of Medical Sciences, Poznan, Poland
| | - Elżbieta Kaczmarek
- Department of Bioinformatics and Computational Biology, Poznan University of Medical Sciences, Poznan, Poland
| | - Marian Dmochowski
- Autoimmune Blistering Dermatoses Section, Department of Dermatology, Poznan University of Medical Sciences, Poznan, Poland
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Leiferman KM, Snook JP, Khalighi MA, Kuechle MK, Zone JJ. Diagnostics for Dermatologic Diseases with Autoantibodies. J Appl Lab Med 2022; 7:165-196. [DOI: 10.1093/jalm/jfab147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 10/25/2021] [Indexed: 11/12/2022]
Abstract
Abstract
Background
Dermatologic diseases with autoantibodies were recognized early as autoimmunity became accepted as a pathogenic immunologic concept. Laboratory testing to identify disease-defining autoantibodies and investigate their role in pathophysiology has evolved since.
Content
Blistering dermatologic diseases, profiled by autoantibody production, target epithelial components critical in cell–cell and cell–matrix adhesion, resulting in epithelial separation and other characteristic features of the disorders. This review covers the clinical indications for dermatologic disease-related autoantibody testing, the specifics of procuring specimens to test, the available diagnostic tests, and information provided by the testing. Atypical, uncharacteristic, and less well-known clinical and autoantibody profiles as well as several of the many future prospects for expansion of the testing applications are elaborated on in the online Data Supplement.
Summary
Autoantibody-associated dermatologic diseases are acquired immunologic disorders that have considerable clinical implications affecting essential barrier functions of skin and mucous membranes and causing discomfort, including pain and pruritus. Certain of the diseases can have life-threatening manifestations, and treatments can have significant side-effects. The skin diseases may presage other clinical associations that are important to recognize and treat. Laboratory testing aids in the diagnosis of these diseases through identification of the autoantibodies and is essential for prompt and precise knowledge of the disease type for prognosis, further clinical evaluations, and treatment decisions.
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Affiliation(s)
- Kristin M Leiferman
- Immunodermatology Laboratory, Department of Dermatology, University of Utah, UT, USA
| | - Jeremy P Snook
- Immunodermatology Laboratory, Department of Dermatology, University of Utah, UT, USA
| | - Mazdak A Khalighi
- Immunodermatology Laboratory, Department of Dermatology, University of Utah, UT, USA
| | - Melanie K Kuechle
- Immunodermatology Laboratory, Department of Dermatology, University of Utah, UT, USA
- Puget Sound Dermatology, Edmonds, WA. USA
| | - John J Zone
- Immunodermatology Laboratory, Department of Dermatology, University of Utah, UT, USA
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Hashimoto T, Yamagami J, Zone JJ. History, Diagnosis, Pathogenesis, and Nomenclature in Sublamina Densa-Type Linear IgA Disease. JAMA Dermatol 2021; 157:907-909. [PMID: 34160568 DOI: 10.1001/jamadermatol.2021.0761] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Takashi Hashimoto
- Department of Dermatology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Jun Yamagami
- Department of Dermatology, Keio University School of Medicine, Tokyo, Japan
| | - John J Zone
- Department of Dermatology, University of Utah School of Medicine, Salt Lake City
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Cheraghlou S, Levy LL. Fixed drug eruptions, bullous drug eruptions, and lichenoid drug eruptions. Clin Dermatol 2020; 38:679-692. [PMID: 33341201 DOI: 10.1016/j.clindermatol.2020.06.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Drug reactions are among the most common reasons for inpatient dermatology consultation. These reactions are important to identify because discontinuation of the offending agent may lead to disease remission. With the rising use of immunomodulatory and targeted therapeutics in cancer care and the increased incidence in associated reactions to these drugs, the need for accurate identification and treatment of such eruptions has led to the development of the "oncodermatology" subspecialty of dermatology. Immunobullous drug reactions are a dermatologic urgency, with patients often losing a significant proportion of their epithelial barrier; early diagnosis is critical in these cases to prevent complications and worsening disease. Lichenoid drug reactions have myriad causes and can take several months to occur, often leading to difficulties identifying the offending drug. Fixed drug eruptions can often mimic other systemic eruptions, such as immunobullous disease and Stevens-Johnson syndrome, and must be differentiated from them for effective therapy to be initiated. We review the clinical features, pathogenesis, and treatment of immunobullous, fixed, and lichenoid drug reactions with attention to key clinical features and differential diagnosis.
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Affiliation(s)
| | - Lauren L Levy
- Private Practice, New York, New York, USA; Private Practice, Westport, Connecticut, USA.
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9
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Olbrich M, Künstner A, Witte M, Busch H, Fähnrich A. Genetics and Omics Analysis of Autoimmune Skin Blistering Diseases. Front Immunol 2019; 10:2327. [PMID: 31749790 PMCID: PMC6843061 DOI: 10.3389/fimmu.2019.02327] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 09/16/2019] [Indexed: 12/18/2022] Open
Abstract
Autoimmune blistering diseases (AIBDs) of the skin are characterized by autoantibodies against different intra-/extracellular structures within the epidermis and at the basement membrane zone (BMZ). Binding of the antibodies to their target antigen leads to inflammation at the respective binding site and degradation of these structures, resulting in the separation of the affected skin layers. Clinically, blistering, erythema and lesions of the skin and/or mucous membranes can be observed. Based on the localization of the autoantigen, AIBDs can be divided into pemphigus (intra-epidermal blistering diseases) and pemphigoid diseases (sub-epidermal blistering diseases), respectively. Although autoantigens have been extensively characterized, the underlying causes that trigger the diseases are still poorly understood. Besides the environment, genetic factors seem to play an important role in a predisposition to AIBDs. Here, we review currently known genetic and immunological mechanisms that contribute to the pathogenesis of AIBDs. Among the most commonly encountered genetic predispositions for AIBDs are the HLA gene region, and deleterious mutations of key genes for the immune system. Particularly, HLA class II genes such as the HLA-DR and HLA-DQ alleles have been shown to be prevalent in patients. This has prompted further epidemiological studies as well as unbiased Omics approaches on the transcriptome, microbiome, and proteome level to elucidate common and individual genetic risk factors as well as the molecular pathways that lead to the pathogenesis of AIBDs.
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Affiliation(s)
- Michael Olbrich
- Medical Systems Biology, Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
- Institute of Cardiogenetics, University of Lübeck, Lübeck, Germany
| | - Axel Künstner
- Medical Systems Biology, Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
- Institute of Cardiogenetics, University of Lübeck, Lübeck, Germany
| | - Mareike Witte
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Hauke Busch
- Medical Systems Biology, Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
- Institute of Cardiogenetics, University of Lübeck, Lübeck, Germany
| | - Anke Fähnrich
- Medical Systems Biology, Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
- Institute of Cardiogenetics, University of Lübeck, Lübeck, Germany
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Natsuga K, Watanabe M, Nishie W, Shimizu H. Life before and beyond blistering: The role of collagen XVII in epidermal physiology. Exp Dermatol 2019; 28:1135-1141. [PMID: 29604146 DOI: 10.1111/exd.13550] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2018] [Indexed: 12/15/2022]
Abstract
Type XVII collagen (COL17) is a transmembranous protein that is mainly expressed in the epidermal basal keratinocytes. Epidermal-dermal attachment requires COL17 expression at the hemidesmosomes of the epidermal basement membrane zone because congenital COL17 deficiency leads to junctional epidermolysis bullosa and acquired autoimmunity to COL17 induces bullous pemphigoid. Recently, in addition to facilitating epidermal-dermal attachment, COL17 has been reported to serve as a niche for hair follicle stem cells, to regulate proliferation in the interfollicular epidermis and to be present along the non-hemidesmosomal plasma membrane of epidermal basal keratinocytes. This review focuses on the physiological properties of COL17 in the epidermis, its role in maintaining stem cells and its association with signalling pathways. We propose possible solutions to unanswered questions in this field.
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Affiliation(s)
- Ken Natsuga
- Department of Dermatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Mika Watanabe
- Department of Dermatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Wataru Nishie
- Department of Dermatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Hiroshi Shimizu
- Department of Dermatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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11
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Bullous Diseases of the Skin and Mucous Membranes. Clin Immunol 2019. [DOI: 10.1016/b978-0-7020-6896-6.00063-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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12
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Znamenskaya LF, Chikin VV, Nefedova MA. Linear IgA bullous dermatosis. VESTNIK DERMATOLOGII I VENEROLOGII 2018. [DOI: 10.25208/0042-4609-2018-94-6-42-51] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Aim: to present a clinical case of linear IgA bullous dermatosis.Materials and methods. A 44 years old patient complaining of skin rashes on the trunk and extremities, accompanied by severe itching was examined. We carried out a morphological investigation of biopsy samples derived from the lesion and apparently unaffected skin areas using the method of indirect immunofluorescence.Results. The patient having rashes in the form of multiple vesicles and small bubbles with a tight cover, which had been grouped into figures resembling pearl necklaces, demonstrated the presence of focal subepidermal cracks (subepidermal bubble in one location), as well as a linear deposition of IgA along the epidermal basement membrane. According to the clinical picture and following the histological and immunofluorescent investigation of skin biopsies, the patient was diagnosed with linear IgA bullous dermatosis. Lesion regression was achieved as a result of systemic therapy with prednisolone at a dose of 50 mg per day.Conclusion. The diagnosis of linear IgA bullous dermatosis should be made on the basis of skin biopsy investigation by the method of indirect immunofluorescence. Systemic glucocorticosteroids are seen as an effective approach to the treatment of such patients.
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13
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Witte M, Zillikens D, Schmidt E. Diagnosis of Autoimmune Blistering Diseases. Front Med (Lausanne) 2018; 5:296. [PMID: 30450358 PMCID: PMC6224342 DOI: 10.3389/fmed.2018.00296] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 10/05/2018] [Indexed: 12/11/2022] Open
Abstract
Autoimmune skin blistering diseases (AIBD) are characterized by autoantibodies that are directed against structural proteins in the skin and adjacent mucous membranes. Some clinical signs are typical for a specific AIBD, however, correct diagnosis requires the detection of tissue-bound or circulating autoantibodies. The gold standard for diagnosis of AIBD is the detection of autoantibodies or complement component 3 by direct immunofluorescence (DIF) microscopy of a perilesional biopsy. Circulating antibodies can be detected via indirect immunofluorescence (IIF) microscopy of different tissue substrates including human skin, monkey esophagus, and more recently, recombinant forms of the different target antigens. Latter are also employed in various commercial ELISA systems and by immunoblotting in in-house assays available in specialized laboratories. ELISA systems are also particularly valuable for monitoring of the disease activity during the disease course which can be helpful for treatment decisions. Exact diagnosis is essential for both treatment and prognosis, since some AIBD are associated with malign tumors such as paraneoplastic pemphigus and anti-laminin 332 mucous membrane pemphigoid. This review presents clinical and immunopathological features of AIBD for the state-of the art diagnosis of these disorders.
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Affiliation(s)
- Mareike Witte
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Detlef Zillikens
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Enno Schmidt
- Department of Dermatology, University of Lübeck, Lübeck, Germany
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14
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Didona D, Di Zenzo G. Humoral Epitope Spreading in Autoimmune Bullous Diseases. Front Immunol 2018; 9:779. [PMID: 29719538 PMCID: PMC5913575 DOI: 10.3389/fimmu.2018.00779] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 03/28/2018] [Indexed: 12/15/2022] Open
Abstract
Autoimmune blistering diseases are characterized by autoantibodies against structural adhesion proteins of the skin and mucous membranes. Extensive characterization of their autoantibody targets has improved understanding of pathogenesis and laid the basis for the study of antigens/epitopes diversification, a process termed epitope spreading (ES). In this review, we have reported and discussed ES phenomena in autoimmune bullous diseases and underlined their functional role in disease pathogenesis. A functional ES has been proposed: (1) in bullous pemphigoid patients and correlates with the initial phase of the disease, (2) in pemphigus vulgaris patients with mucosal involvement during the clinical transition to a mucocutaneous form, (3) in endemic pemphigus foliaceus, underlining its role in disease pathogenesis, and (4) in numerous cases of disease transition associated with an intermolecular diversification of immune response. All these findings could give useful information to better understand autoimmune disease pathogenesis and to design antigen/epitope specific therapeutic approaches.
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Affiliation(s)
- Dario Didona
- Clinic for Dermatology and Allergology, University Hospital Marburg, University of Marburg, Marburg, Germany
| | - Giovanni Di Zenzo
- Molecular and Cell Biology Laboratory, Istituto Dermopatico dell’Immacolata (IDI)-IRCCS, Rome, Italy
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15
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Hashimoto T, Ishii N, Tsuruta D. Production of Neoepitopes by Dynamic Structural Changes on BP180/Type XVII Collagen. J Invest Dermatol 2017; 137:2462-2464. [PMID: 29169459 DOI: 10.1016/j.jid.2017.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 09/03/2017] [Accepted: 09/05/2017] [Indexed: 11/20/2022]
Abstract
Linear IgA bullous dermatosis is characterized by IgA autoantibodies reactive with LAD-1 and LABD97, truncated forms of BP180 (type XVII collagen), but not with full-length BP180. Toyonaga et al. determined that cleavage within both the C-terminal region and NC16A domain plays a role in exposure of neoepitopes on the 15th collagenous domain of BP180.
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Affiliation(s)
- Takashi Hashimoto
- Department of Dermatology, Osaka City University Graduate School of Medicine, Osaka, Japan.
| | - Norito Ishii
- Department of Dermatology, Kurume University School of Medicine, Fukuoka, Japan
| | - Daisuke Tsuruta
- Department of Dermatology, Osaka City University Graduate School of Medicine, Osaka, Japan
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16
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Toyonaga E, Nishie W, Izumi K, Natsuga K, Ujiie H, Iwata H, Yamagami J, Hirako Y, Sawamura D, Fujimoto W, Shimizu H. C-Terminal Processing of Collagen XVII Induces Neoepitopes for Linear IgA Dermatosis Autoantibodies. J Invest Dermatol 2017; 137:2552-2559. [PMID: 28842325 DOI: 10.1016/j.jid.2017.07.831] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Revised: 07/23/2017] [Accepted: 07/31/2017] [Indexed: 11/23/2022]
Abstract
Transmembrane collagen XVII (COL17) is a hemidesmosomal component of basal keratinocytes that can be targeted by autoantibodies in autoimmune blistering disorders, including linear IgA dermatosis (LAD). COL17 can be physiologically cleaved within the juxtamembranous extracellular NC16A domain, and LAD autoantibodies preferentially react with the processed ectodomains, indicating that the processing induces neoepitopes. However, the details of how neoepitopes develop have not been elucidated. In this study, we show that C-terminal processing of COL17 also plays a role in inducing neoepitopes for LAD autoantibodies. First, the mAb hC17-ect15 targeting the 15th collagenous domain of COL17 was produced, which showed characteristics similar to LAD autoantibodies. The mAbs preferentially reacted with C-terminally deleted (up to 682 amino acids) recombinant COL17, suggesting that C-terminal processing shows neoepitopes on the 15th collagenous domain. The LAD autoantibodies also react with C-terminal deleted COL17. Therefore, neoepitopes for LAD autoantibodies also develop after C-terminal processing. Finally, the passive transfer of the mAb hC17-ect15 into human COL17-expressing transgenic mice failed to induce blistering disease, suggesting that neoepitope-targeting antibodies are not always pathogenic. In summary, this study shows that C-terminal processing induces dynamic structural changes and neoepitopes for LAD autoantibodies on COL17.
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Affiliation(s)
- Ellen Toyonaga
- Department of Dermatology, Hokkaido University, Graduate School of Medicine, Sapporo, Japan
| | - Wataru Nishie
- Department of Dermatology, Hokkaido University, Graduate School of Medicine, Sapporo, Japan.
| | - Kentaro Izumi
- Department of Dermatology, Hokkaido University, Graduate School of Medicine, Sapporo, Japan
| | - Ken Natsuga
- Department of Dermatology, Hokkaido University, Graduate School of Medicine, Sapporo, Japan
| | - Hideyuki Ujiie
- Department of Dermatology, Hokkaido University, Graduate School of Medicine, Sapporo, Japan
| | - Hiroaki Iwata
- Department of Dermatology, Hokkaido University, Graduate School of Medicine, Sapporo, Japan
| | - Jun Yamagami
- Department of Dermatology, Keio University School of Medicine, Tokyo, Japan
| | - Yoshiaki Hirako
- Division of Biological Science, Graduate School of Science, Nagoya University, Nagoya, Japan
| | - Daisuke Sawamura
- Department of Dermatology, Hirosaki University, Graduate School of Medicine, Aomori, Japan
| | - Wataru Fujimoto
- Department of Dermatology, Kawasaki Medical School, Okayama, Japan
| | - Hiroshi Shimizu
- Department of Dermatology, Hokkaido University, Graduate School of Medicine, Sapporo, Japan.
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17
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Gottlieb J, Ingen-Housz-Oro S, Alexandre M, Grootenboer-Mignot S, Aucouturier F, Sbidian E, Tancrede E, Schneider P, Regnier E, Picard-Dahan C, Begon E, Pauwels C, Cury K, Hüe S, Bernardeschi C, Ortonne N, Caux F, Wolkenstein P, Chosidow O, Prost-Squarcioni C. Idiopathic linear IgA bullous dermatosis: prognostic factors based on a case series of 72 adults. Br J Dermatol 2017; 177:212-222. [PMID: 27995619 DOI: 10.1111/bjd.15244] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND Linear IgA bullous dermatosis (LABD) is a clinically and immunologically heterogeneous, subepidermal, autoimmune bullous disease (AIBD), for which the long-term evolution is poorly described. OBJECTIVES To investigate the clinical and immunological characteristics, follow-up and prognostic factors of adult idiopathic LABD. METHODS This retrospective study, conducted in our AIBD referral centre, included adults, diagnosed between 1995 and 2012, with idiopathic LABD, defined as pure or predominant IgA deposits by direct immunofluorescence. Clinical, histological and immunological findings were collected from charts. Standard histology was systematically reviewed, and indirect immunofluorescence (IIF) on salt-split skin (SSS) and immunoblots (IBs) on amniotic membrane extracts using anti-IgA secondary antibodies were performed, when biopsies and sera obtained at diagnosis were available. Prognostic factors for complete remission (CR) were identified using univariate and multivariate analyses. RESULTS Of the 72 patients included (median age 54 years), 60% had mucous membrane (MM) involvement. IgA IIF on SSS was positive for 21 of 35 patients tested; 15 had epidermal and dermal labellings. Immunoelectron microscopy performed on the biopsies of 31 patients labelled lamina lucida (LL) (26%), lamina densa (23%), anchoring-fibril zone (AFz) (19%) and LL+AFz (23%). Of the 34 IgA IBs, 22 were positive, mostly for LAD-1/LABD97 (44%) and full-length BP180 (33%). The median follow-up was 39 months. Overall, 24 patients (36%) achieved sustained CR, 19 (29%) relapsed and 35% had chronic disease. CR was significantly associated with age > 70 years or no MM involvement. No prognostic immunological factor was identified. CONCLUSIONS Patients with LABD who are < 70 years old and have MM involvement are at risk for chronic evolution.
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Affiliation(s)
- J Gottlieb
- Dermatology Department, APHP, Henri-Mondor Hospital, Créteil, France.,Referral Center for Autoimmune Blistering Diseases, Île-de-France, France
| | - S Ingen-Housz-Oro
- Dermatology Department, APHP, Henri-Mondor Hospital, Créteil, France.,Referral Center for Autoimmune Blistering Diseases, Île-de-France, France.,Université Paris-Est Créteil Val de Marne, UPEC, DHU VIC, IRM, EA 7379 EpiDermE, Créteil, France
| | - M Alexandre
- Referral Center for Autoimmune Blistering Diseases, Île-de-France, France.,Dermatology Department, APHP, Avicenne Hospital, Bobigny, France
| | - S Grootenboer-Mignot
- Referral Center for Autoimmune Blistering Diseases, Île-de-France, France.,Department of Autoimmunity and Hypersensitivity, APHP, Bichat Hospital, Paris, France
| | - F Aucouturier
- Referral Center for Autoimmune Blistering Diseases, Île-de-France, France.,Immunology Department, APHP, Saint-Louis Hospital, Paris, France
| | - E Sbidian
- Dermatology Department, APHP, Henri-Mondor Hospital, Créteil, France.,Université Paris-Est Créteil Val de Marne, UPEC, DHU VIC, IRM, EA 7379 EpiDermE, Créteil, France.,Inserm, Centre d'Investigation Clinique 1430, Créteil, France
| | - E Tancrede
- Referral Center for Autoimmune Blistering Diseases, Île-de-France, France.,Dermatology Department, APHP, Saint-Louis Hospital, Paris, France
| | - P Schneider
- Referral Center for Autoimmune Blistering Diseases, Île-de-France, France.,Dermatology Department, APHP, Saint-Louis Hospital, Paris, France.,Pathology Department, APHP, Saint-Louis Hospital, Paris, France
| | - E Regnier
- Referral Center for Autoimmune Blistering Diseases, Île-de-France, France.,Dermatology Department, APHP, Tarnier Hospital, Paris, France
| | - C Picard-Dahan
- Referral Center for Autoimmune Blistering Diseases, Île-de-France, France.,Dermatology Department, APHP, Bichat Hospital, Paris, France
| | - E Begon
- Dermatology Department, René-Dubos Hospital, Pontoise, France
| | - C Pauwels
- Dermatology Department, Saint-Germain Hospital, Saint-Germain, France
| | - K Cury
- Referral Center for Autoimmune Blistering Diseases, Île-de-France, France.,Dermatology Department, APHP, Tenon Hospital, Paris, France
| | - S Hüe
- Referral Center for Autoimmune Blistering Diseases, Île-de-France, France.,Université Paris-Est Créteil Val de Marne, UPEC, DHU VIC, IRM, EA 7379 EpiDermE, Créteil, France.,Immunology Department, APHP, Henri-Mondor Hospital, Créteil, France
| | - C Bernardeschi
- Referral Center for Autoimmune Blistering Diseases, Île-de-France, France.,Pathology Department, APHP, Saint-Louis Hospital, Paris, France
| | - N Ortonne
- Referral Center for Autoimmune Blistering Diseases, Île-de-France, France.,Université Paris-Est Créteil Val de Marne, UPEC, DHU VIC, IRM, EA 7379 EpiDermE, Créteil, France.,Pathology Department, APHP, Henri-Mondor Hospital, Créteil, France
| | - F Caux
- Referral Center for Autoimmune Blistering Diseases, Île-de-France, France.,Dermatology Department, APHP, Avicenne Hospital, Bobigny, France.,Université Paris 13, Bobigny, France
| | - P Wolkenstein
- Dermatology Department, APHP, Henri-Mondor Hospital, Créteil, France.,Referral Center for Autoimmune Blistering Diseases, Île-de-France, France.,Université Paris-Est Créteil Val de Marne, UPEC, DHU VIC, IRM, EA 7379 EpiDermE, Créteil, France
| | - O Chosidow
- Dermatology Department, APHP, Henri-Mondor Hospital, Créteil, France.,Referral Center for Autoimmune Blistering Diseases, Île-de-France, France.,Université Paris-Est Créteil Val de Marne, UPEC, DHU VIC, IRM, EA 7379 EpiDermE, Créteil, France.,Inserm, Centre d'Investigation Clinique 1430, Créteil, France
| | - C Prost-Squarcioni
- Referral Center for Autoimmune Blistering Diseases, Île-de-France, France.,Dermatology Department, APHP, Avicenne Hospital, Bobigny, France.,Université Paris 13, Bobigny, France.,Pathology Department, APHP, Avicenne Hospital, Bobigny, France
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18
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Patsatsi A, Meltzanidou P, Katafigiotis S, Sotiriadis D, Schmidt E, Lambropoulos A. Chronic bullous disease of childhood with IgG reactivity to p200 antigen. Int J Dermatol 2017; 56:773-775. [DOI: 10.1111/ijd.13616] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2016] [Revised: 12/28/2016] [Accepted: 03/10/2017] [Indexed: 11/26/2022]
Affiliation(s)
- Aikaterini Patsatsi
- 2nd University Dermatology Department; Aristotle University School of Medicine; Papageorgiou General Hospital; Thessaloniki Greece
| | - Parthena Meltzanidou
- Molecular Biology Laboratory; 1st Department of Obstetrics and Gynecology; Aristotle University School of Medicine; Papageorgiou General Hospital; Thessaloniki Greece
| | - Socrates Katafigiotis
- Molecular Biology Laboratory; 1st Department of Obstetrics and Gynecology; Aristotle University School of Medicine; Papageorgiou General Hospital; Thessaloniki Greece
| | - Dimitrios Sotiriadis
- 2nd University Dermatology Department; Aristotle University School of Medicine; Papageorgiou General Hospital; Thessaloniki Greece
| | - Enno Schmidt
- Department of Dermatology; University of Luebeck; Luebeck Germany
| | - Alexandros Lambropoulos
- Molecular Biology Laboratory; 1st Department of Obstetrics and Gynecology; Aristotle University School of Medicine; Papageorgiou General Hospital; Thessaloniki Greece
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19
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Orime M, Tomiyama K, Hashidate H, Yoshida S, Hokari S, Tsuda A, Yokoyama H, Narita JI, Uchida Y, Kanekura T, Abe R, Ishii N, Hashimoto T, Kawai K. Non-paraneoplastic autoimmune subepidermal bullous disease associated with fatal bronchiolitis obliterans. J Dermatol 2017; 44:461-464. [PMID: 27914107 DOI: 10.1111/1346-8138.13706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 10/21/2016] [Indexed: 11/29/2022]
Abstract
Bronchiolitis obliterans is a small-airway obstructive lung disease for which immunologically mediated pathogenesis is supposed. Frequent association of bronchiolitis obliterans with paraneoplastic pemphigus is well known, but its association with other autoimmune bullous diseases has not been reported except for a case of anti-laminin-332-type mucous membrane pemphigoid in a patient with chronic graft-versus-host disease. We report a case of non-paraneoplastic autoimmune subepidermal bullous disease associated with fatal bronchiolitis obliterans in a patient without transplantation. Although the patient's serum contained immunoglobulin (Ig)A antibodies to the 180-kDa bullous pemphigoid antigen/type XVII collagen and IgG antibodies to laminin-332, diagnosis of either linear IgA bullous dermatosis or mucous membrane pemphigoid could not be made because of the failure to detect linear IgA deposition at the basement membrane zone by direct immunofluorescence and the lack of mucous membrane lesions. Physicians should be aware that autoimmune bullous diseases other than paraneoplastic pemphigus can also associate with this rare but potentially fatal lung disease.
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Affiliation(s)
- Mari Orime
- Division of Dermatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Katsuhiro Tomiyama
- Department of Dermatology, Niigata City General Hospital, Niigata, Japan
| | - Hideki Hashidate
- Department of Pathology, Niigata City General Hospital, Niigata, Japan
| | - Satoru Yoshida
- Department of Emergency and Critical Care Medicine Center, Niigata City General Hospital, Niigata, Japan
| | - Satoshi Hokari
- Department of Respiratory Medicine and Infectious Diseases, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Akiko Tsuda
- Department of Endocrinology and Metabolism, Kido Hospital, Niigata, Japan
| | - Hisashi Yokoyama
- Department of Gastroenterology and Hepatology, Kido Hospital, Niigata, Japan
| | - Jun-Ichi Narita
- Department of Respiratory Medicine, Kido Hospital, Niigata, Japan
| | - Youhei Uchida
- Department of Dermatology, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Takuro Kanekura
- Department of Dermatology, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Riichiro Abe
- Division of Dermatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Norito Ishii
- Department of Dermatology, Kurume University School of Medicine and Kurume University Institute of Cutaneous Cell Biology, Kurume, Japan
| | - Takashi Hashimoto
- Department of Dermatology, Kurume University School of Medicine and Kurume University Institute of Cutaneous Cell Biology, Kurume, Japan
| | - Kazuhiro Kawai
- Department of Dermatology, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
- Department of Dermatology, Kido Hospital, Niigata, Japan
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20
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Ohata C, Ishii N, Koga H, Nakama T. A clinical and serological study of linear IgA bullous dermatosis without linear immunoglobulin deposition other than IgA at the basement membrane zone using direct immunofluorescence. Br J Dermatol 2017; 177:152-157. [DOI: 10.1111/bjd.15232] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/25/2016] [Indexed: 11/29/2022]
Affiliation(s)
- C. Ohata
- Department of Dermatology; Kurume University School of Medicine; Kurume 830-0011 Japan
| | - N. Ishii
- Department of Dermatology; Kurume University School of Medicine; Kurume 830-0011 Japan
| | - H. Koga
- Department of Dermatology; Kurume University School of Medicine; Kurume 830-0011 Japan
| | - T. Nakama
- Department of Dermatology; Kurume University School of Medicine; Kurume 830-0011 Japan
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21
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Kartan S, Shi VY, Clark AK, Chan LS. Paraneoplastic Pemphigus and Autoimmune Blistering Diseases Associated with Neoplasm: Characteristics, Diagnosis, Associated Neoplasms, Proposed Pathogenesis, Treatment. Am J Clin Dermatol 2017; 18:105-126. [PMID: 27878477 DOI: 10.1007/s40257-016-0235-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Autoimmune paraneoplastic and neoplasm-associated skin syndromes are characterized by autoimmune-mediated cutaneous lesions in the presence of a neoplasm. The identification of these syndromes provides information about the underlying tumor, systemic symptoms, and debilitating complications. The recognition of these syndromes is particularly helpful in cases of skin lesions presenting as the first sign of the malignancy, and the underlying malignancy can be treated in a timely manner. Autoimmune paraneoplastic and neoplasm-associated bullous skin syndromes are characterized by blister formation due to an autoimmune response to components of the epidermis or basement membrane in the context of a neoplasm. The clinical manifestations, histopathology and immunopathology findings, target antigens, associated neoplasm, current diagnostic criteria, current understanding of pathogenesis, and treatment options for a selection of four diseases are reviewed. Paraneoplastic pemphigus manifests with clinically distinct painful mucosal erosions and polymorphic cutaneous lesions, and is often associated with lymphoproliferative neoplasm. In contrast, bullous pemphigoid associated with neoplasm presents with large tense subepidermal bullae of the skin, and mild mucosal involvement, but without unique clinical features. Mucous membrane pemphigoid associated with neoplasm is a disorder of chronic subepithelial blisters that evolve into erosions and ulcerations that heal with scarring, and involves stratified squamous mucosal surfaces. Linear IgA dermatosis associated with neoplasm is characterized by annularly grouped pruritic papules, vesicles, and bullae along the extensor surfaces of elbows, knees, and buttocks. Physicians should be aware that these autoimmune paraneoplastic and neoplasm-associated syndromes can manifest distinct or similar clinical features as compared with the non-neoplastic counterparts.
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22
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Ishii K. Importance of serological tests in diagnosis of autoimmune blistering diseases. J Dermatol 2016; 42:3-10. [PMID: 25558946 DOI: 10.1111/1346-8138.12703] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Accepted: 10/08/2014] [Indexed: 01/07/2023]
Abstract
Autoimmune blistering diseases are organ-specific autoimmune diseases characterized by autoantibodies against structural proteins that maintain cell-cell (pemphigus diseases) and cell-matrix adhesions (pemphigoid diseases) in the skin and mucous membranes. Over the last few decades, identification of autoantigens and extensive characterization of autoantibodies have improved understanding of the pathogenesis of these diseases. In addition, the development of new sensitive and specific immunoassays enabled accurate diagnosis and proper evaluation of disease activity in autoimmune blistering diseases. In this review, we describe practical updates for molecular diagnostic tests for autoimmune blistering diseases and the basis for interpreting the results of the assays.
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Affiliation(s)
- Ken Ishii
- Department of Dermatology, Toho University Omori Medical Center, Tokyo, Japan
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23
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Retrospective analysis of pemphigoid gestationis in 32 Saudi patients - Clinicopathological features and a literature review. J Reprod Immunol 2016; 116:42-5. [PMID: 27175516 DOI: 10.1016/j.jri.2016.04.286] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Revised: 03/23/2016] [Accepted: 04/20/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND OBJECTIVES Pemphigoid gestationis (PG) is a rare autoimmune-mediated blistering disease that mainly affects pregnant women in their 2nd or 3rd trimester and immediate postpartum period. In addition to the clinical assessment, the diagnosis of PG is usually confirmed by histological and immunological studies. PG usually flares up at the time of delivery and spontaneously improves postpartum. Prompt recognition and appropriate management may reduce morbidity associated with this disorder. This study aimed to determine the clinical, histopathological features and treatment of PG of Saudi patients. MATERIALS AND METHODS A retrospective study of 32 patients with pemphigoid gestationis (PG) was conducted from 1990 to 2014 at King Khalid University Hospital and Derma Medical Center, Riyadh, Saudi Arabia. Data regarding epidemiology, medical histories, clinical course, diagnostic test results and management were collected and analyzed. RESULTS A total of 32 patients with PG were analyzed. The mean age was 31.9 years. Seventy-four percent of the patients were multigravidas, and 2 patients were primigravidas. One hundred percent of the cases were singleton pregnancies. Eighty-four percent of the cases had the onset of PG during the 2nd and 3rd trimesters. One hundred percent of patients complained of pruritus, and 94% reported this as the first symptom. Erythematous plaques and vesiculobullous eruption were the most common skin presentation. The primary sites of involvement were the abdomen, trunk, lower (mainly thighs) and upper limbs. The face and mucus membranes were rarely involved. Fifty percent of patients had recurrent symptoms with their next pregnancy. Direct immunofluorescence revealed a linear deposition of the third component of the complement along the basement membrane zone in all cases (C3),while most of the cases showed positive linear deposition of IgG. Seventy five percent of our patients had a good response to oral corticosteroids, and only one patient needed IVIG. The vast majority of the patients (61%) became free of symptoms within 1-2 months of treatment. In 53% of the patients, maternal and fetal outcomes were good with no complications. Six pregnancies were complicated by preterm labor, 2 experienced IUGR (intrauterine growth restriction), and 2 had an abortion or stillbirth. CONCLUSION Our study does not differ dramatically when comparing the onset of PG, the high frequency of multigravida women, the clinical course and good patient outcomes but we observed that the first attack extended from primigravida to 11th pregnancy and slight increase in recurrence rate. Finally the timely diagnosis and appropriate management of PG may improve both maternal and neonatal outcome.
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El-Domyati M, Abdel-Wahab H, Ahmad H. Immunohistochemical localization of basement membrane laminin 5 and collagen IV in adult linear IgA disease. Int J Dermatol 2015; 54:922-8. [PMID: 25771892 DOI: 10.1111/ijd.12532] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Revised: 09/21/2013] [Accepted: 10/01/2013] [Indexed: 01/29/2023]
Abstract
BACKGROUND Linear immunoglobulin A disease (LAD), also known as linear IgA bullous dermatosis, is an autoimmune disorder characterized by subepidermal bullae caused by IgA autoantibodies directed against several antigens located in the basement membrane zone of the skin. Laminin 5 (laminin-332) is considered a key component of the lamina lucida/lamina densa interface, which provides stable attachment of the epidermis to the dermis. Meanwhile, collagen IV is a major component of the lamina densa. Laminin 5 and collagen IV bind to the cell membrane and induce cytoskeletal rearrangements, which contribute to the basement membrane's final mat-like structure. The study aimed to evaluate the immunohistochemical staining of laminin 5 and collagen IV and to identify the site of blister formation in formalin-fixed, paraffin-embedded skin biopsies from adults with LAD. METHODS Skin biopsies from 20 adult patients with LAD were subjected to routine hematoxylin-eosin as well as immunohistochemical staining of collagen IV and laminin 5. RESULTS Linear staining was positive on the floor of the blister for laminin 5 in 65% and collagen IV in 90% of biopsies denoting that the site of separation in most cases of LAD is above the lamina densa. CONCLUSIONS The use of laminin 5 and collagen IV immunohistochemistry can be considered as an adjuvant diagnostic tool and may aid in the identification of the site of blister formation in routine skin biopsies in adults with LAD.
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Affiliation(s)
- Moetaz El-Domyati
- Department of Dermatology, Faculty of Medicine, Al-Minya University, Al-Minya, Egypt
| | - Hossam Abdel-Wahab
- Department of Dermatology, Faculty of Medicine, Al-Minya University, Al-Minya, Egypt
| | - Hesham Ahmad
- Department of Dermatology, Faculty of Medicine, Al-Minya University, Al-Minya, Egypt
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Nishie W, Natsuga K, Iwata H, Izumi K, Ujiie H, Toyonaga E, Hata H, Nakamura H, Shimizu H. Context-Dependent Regulation of Collagen XVII Ectodomain Shedding in Skin. THE AMERICAN JOURNAL OF PATHOLOGY 2015; 185:1361-71. [PMID: 25773176 DOI: 10.1016/j.ajpath.2015.01.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Revised: 01/11/2015] [Accepted: 01/15/2015] [Indexed: 10/23/2022]
Abstract
Pemphigoid is a common autoimmune blistering disorder in which autoantibodies target transmembrane collagen XVII (COL17), a component of hemidesmosomes in basal keratinocytes. The ectodomain of COL17 can be cleaved from the cell surface within the juxtamembranous extracellular NC16A domain, and, interestingly, certain autoantibodies of pemphigoid patients preferentially react with the shed ectodomain. These findings suggest that COL17 ectodomain shedding generates neoepitopes on the shed form; however, the regulatory mechanism of the shedding in in vivo skin and the pathogenicity of the neoepitope-targeting antibodies still are uncertain. To address these issues, we produced rabbit antibodies specifically reacting with N-terminal cleavage sites of the shed COL17 ectodomain. The antibodies showed that certain amounts of the human COL17 ectodomain are cleaved physiologically at Gln(525) in in vivo skin. In contrast, migrating human keratinocytes cleave COL17 at Leu(524) but not at Gln(525). The passive transfer of antibodies reacting with an N-terminal cleavage site of the mouse COL17 ectodomain into neonatal wild-type mice failed to induce blister formation, even though the antibodies bound to the dermal-epidermal junctions, indicating that cleavage site-specific antibodies have reduced or absent pathogenicity for blister formation. This study shows the ectodomain shedding of COL17 to be a physiological event in in vivo human skin that probably generates nonpathologic epitopes on the cleavage sites.
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Affiliation(s)
- Wataru Nishie
- Department of Dermatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan.
| | - Ken Natsuga
- Department of Dermatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Hiroaki Iwata
- Department of Dermatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Kentaro Izumi
- Department of Dermatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Hideyuki Ujiie
- Department of Dermatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Ellen Toyonaga
- Department of Dermatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Hiroo Hata
- Department of Dermatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Hideki Nakamura
- Department of Dermatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Hiroshi Shimizu
- Department of Dermatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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Turcan I, Jonkman MF. Blistering disease: insight from the hemidesmosome and other components of the dermal-epidermal junction. Cell Tissue Res 2014; 360:545-69. [PMID: 25502077 DOI: 10.1007/s00441-014-2021-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2014] [Accepted: 09/25/2014] [Indexed: 02/07/2023]
Abstract
The hemidesmosome is a specialized transmembrane complex that mediates the binding of epithelial cells to the underlying basement membrane. In the skin, this multiprotein structure can be regarded as the chief adhesion unit at the site of the dermal-epidermal junction. Focal adhesions are additional specialized attachment structures located between hemidesmosomes. The integrity of the skin relies on well-assembled and functional hemidesmosomes and focal adhesions (also known as integrin adhesomes). However, if these adhesion structures are impaired, e.g., as a result of circulating autoantibodies or inherited genetic mutations, the mechanical strength of the skin is compromised, leading to blistering and/or tissue inflammation. A particular clinical presentation emerges subject to the molecule that is targeted. None of these junctional complexes are simply compounds of adhesion molecules; they also play a significant role in signalling pathways involved in the differentiation and migration of epithelial cells such as during wound healing and in tumour invasion. We summarize current knowledge about hereditary and acquired blistering diseases emerging from pathologies of the hemidesmosome and its neighbouring proteins as components of the dermal-epidermal junction.
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Affiliation(s)
- Iana Turcan
- Centre for Blistering Diseases, Department of Dermatology, University Medical Centre Groningen, University of Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands,
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Tani N, Kimura Y, Koga H, Kawakami T, Ohata C, Ishii N, Hashimoto T. Clinical and immunological profiles of 25 patients with pemphigoid gestationis. Br J Dermatol 2014; 172:120-9. [DOI: 10.1111/bjd.13374] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/19/2014] [Indexed: 11/26/2022]
Affiliation(s)
- N. Tani
- Department of Dermatology; Kurume University School of Medicine, and Kurume University Institute of Cutaneous Cell Biology; 67 Asahimachi Kurume Fukuoka 830-0011 Japan
| | - Y. Kimura
- Department of Dermatology; Kurume University School of Medicine, and Kurume University Institute of Cutaneous Cell Biology; 67 Asahimachi Kurume Fukuoka 830-0011 Japan
| | - H. Koga
- Department of Dermatology; Kurume University School of Medicine, and Kurume University Institute of Cutaneous Cell Biology; 67 Asahimachi Kurume Fukuoka 830-0011 Japan
| | - T. Kawakami
- Department of Dermatology; Kurume University School of Medicine, and Kurume University Institute of Cutaneous Cell Biology; 67 Asahimachi Kurume Fukuoka 830-0011 Japan
| | - C. Ohata
- Department of Dermatology; Kurume University School of Medicine, and Kurume University Institute of Cutaneous Cell Biology; 67 Asahimachi Kurume Fukuoka 830-0011 Japan
| | - N. Ishii
- Department of Dermatology; Kurume University School of Medicine, and Kurume University Institute of Cutaneous Cell Biology; 67 Asahimachi Kurume Fukuoka 830-0011 Japan
| | - T. Hashimoto
- Department of Dermatology; Kurume University School of Medicine, and Kurume University Institute of Cutaneous Cell Biology; 67 Asahimachi Kurume Fukuoka 830-0011 Japan
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Yamauchi T, Matsushita S, Hashimoto T, Hirako Y. Major cleavage-dependent epitopes for linear IgA bullous dermatosis are formed at the boundary between the non-collagenous 16A and collagenous 15 domains of BP180. J Dermatol Sci 2014; 76:25-33. [PMID: 25176590 DOI: 10.1016/j.jdermsci.2014.07.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Revised: 07/16/2014] [Accepted: 07/21/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND The autoantigen for the major type of linear IgA bullous dermatosis (LAD, lamina lucida type) is the shed ectodomain of BP180. However, it is unknown why most LAD sera react with the shed ectodomain but not with the intact BP180/type XVII collagen. OBJECTIVE The aim of this study was to characterize the unique cleavage-dependent epitope(s) in the shed ectodomain. METHODS We used a monoclonal antibody (MAb-1337) and six LAD sera, which reacted preferentially with the shed ectodomain of BP180. The location and characteristics of the epitopes for these antibodies were analyzed mainly by immunoblotting using chimeric bovine-human BP180 mammalian recombinant proteins and variously truncated bacterial recombinant proteins. RESULTS LAD sera and MAb-1337 reacted with the plasmin-digested products of full-length BP180. Four of the six LAD sera reacted to a bacterial recombinant protein consisting of the human non-collagenous 16th A (NC16A) and the collagenous 15th (C15) domains, while these sera were negative or only faintly reactive with the NC16A and C15 recombinants. The epitope for MAb-1337 was localized to the COOH-terminal 21 amino acid region within the NC16A domain. CONCLUSION The results in this study indicate that the major epitopes for LAD sera are formed or exposed by a cleavage-induced conformational change, but not by a post-translational modification that occurs only in the shed ectodomain, and are located at the boundary between the NC16A and C15 domains.
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Affiliation(s)
- Tomoe Yamauchi
- Division of Biological Science, Graduate School of Science, Nagoya University, Nagoya, Aichi, Japan
| | - Satoshi Matsushita
- Division of Biological Science, Graduate School of Science, Nagoya University, Nagoya, Aichi, Japan
| | - Takashi Hashimoto
- Department of Dermatology, Kurume University School of Medicine, and Kurume University Institute of Cutaneous Cell Biology, Kurume, Fukuoka, Japan
| | - Yoshiaki Hirako
- Division of Biological Science, Graduate School of Science, Nagoya University, Nagoya, Aichi, Japan.
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Geller S, Gat A, Zeeli T, Hafner A, Eming R, Hertl M, Sprecher E. The expanding spectrum of IgA pemphigus: a case report and review of the literature. Br J Dermatol 2014; 171:650-6. [PMID: 24601812 DOI: 10.1111/bjd.12940] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/26/2014] [Indexed: 12/01/2022]
Abstract
IgA pemphigus (IGAP) is a rare, distinct variant of pemphigus, currently classified, depending upon the histological features, immunofluorescence staining pattern and autoantibody profile, into two types: subcorneal pustular dermatosis (SPD) and intraepidermal neutrophilic IgA dermatosis. In a patient with a widespread blistering disease of the skin resembling SPD-type IGAP, we demonstrate the coexistence of IgA reactivity to both epidermal (desmocollins 2 and 3) and basement membrane-associated (BP180) proteins, suggesting the coexistence of atypical IGAP and linear IgA bullous dermatosis, respectively. This case, together with 20 previous reports of atypical IGAP, underscores the limitations of current classification schemes. Therefore, we suggest reclassifying these cases under the general term 'IGAP spectrum'.
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Affiliation(s)
- S Geller
- Department of Dermatology, Tel Aviv Sourasky Medical Center, 6, Weizmann Street, Tel Aviv, 64239, Israel
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Recke A, Trog LM, Pas HH, Vorobyev A, Abadpour A, Jonkman MF, van Zandbergen G, Kauderer C, Zillikens D, Vidarsson G, Ludwig RJ. Recombinant Human IgA1 and IgA2 Autoantibodies to Type VII Collagen Induce Subepidermal Blistering Ex Vivo. THE JOURNAL OF IMMUNOLOGY 2014; 193:1600-8. [DOI: 10.4049/jimmunol.1400160] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Di Zenzo G, Carrozzo M, Chan LS. Urban legend series: mucous membrane pemphigoid. Oral Dis 2013; 20:35-54. [DOI: 10.1111/odi.12193] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Revised: 09/17/2013] [Accepted: 10/02/2013] [Indexed: 11/28/2022]
Affiliation(s)
- G Di Zenzo
- Molecular and Cell Biology Laboratory; Istituto Dermopatico dell'Immacolata; IDI-IRCCS; Rome Italy
| | - M Carrozzo
- Department of Oral Medicine; Centre for Oral Health Research; Newcastle University; Newcastle upon Tyne UK
| | - LS Chan
- Department of Dermatology and Immunology/Microbiology; University of Illinois College of Medicine; Chicago IL USA
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Verma R, Vasudevan B, Pragasam V, Dabbas D. Linear IgA disease in an adult with unusual clinical features. Indian Dermatol Online J 2013; 4:115-8. [PMID: 23741669 PMCID: PMC3673376 DOI: 10.4103/2229-5178.110637] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
A 19-year-old male presented with complaints of fluid-filled lesions on the body of 2 weeks duration. On examination, he was found to have multiple tense bullae distributed on the flexures, face, and genitalia with associated oral ulcers and “cluster of jewels” sign. The diagnosis was confirmed by histopathology and direct immunofluorescence. There are very few reports of linear IgA earlier from India according to the literature available so far, that too from the Southern part of the country. The patient had bullous pemphigoid-like lesions typically seen in adults, but the distribution of lesions was akin to that of the “chronic bullous disease of childhood variant” found in children. This case has been reported for rarity in this region and also because the patient had atypical morphology and distribution of lesions.
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Affiliation(s)
- Rajesh Verma
- Department of Dermatology, Command Hospital (Southern Command), Wanowrie, Pune, Maharashtra, India
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Edhegard KD, Hall RP. Bullous diseases of the skin and mucous membranes. Clin Immunol 2013. [DOI: 10.1016/b978-0-7234-3691-1.00076-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Krenacs T, Kiszner G, Stelkovics E, Balla P, Teleki I, Nemeth I, Varga E, Korom I, Barbai T, Plotar V, Timar J, Raso E. Collagen XVII is expressed in malignant but not in benign melanocytic tumors and it can mediate antibody induced melanoma apoptosis. Histochem Cell Biol 2012; 138:653-67. [PMID: 22688676 DOI: 10.1007/s00418-012-0981-9] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/26/2012] [Indexed: 10/28/2022]
Abstract
The 180 kDa transmembrane collagen XVII is known to anchor undifferentiated keratinocytes to the basement membrane in hemidesmosomes while constitutively shedding a 120 kDa ectodomain. Inherited mutations or auto-antibodies targeting collagen XVII cause blistering skin disease. Collagen XVII is down-regulated in mature keratinocytes but re-expressed in skin cancer. By recently detecting collagen XVII in melanocyte hyperplasia, here we tested its expression in benign and malignant melanocytic tumors using endodomain and ectodomain selective antibodies. We found the full-length collagen XVII protein in proliferating tissue melanocytes, basal keratinocytes and squamous cell carcinoma whereas resting melanocytes were negative. Furthermore, the cell-residual 60 kDa endodomain was exclusively detected in 62/79 primary and 15/18 metastatic melanomas, 8/9 melanoma cell lines, HT199 metastatic melanoma xenografts and atypical nests in 8/63 dysplastic nevi. The rest of 19 nevi including common, blue and Spitz subtypes were also negative. In line with the defective ectodomain, sequencing of COL17A1 gene revealed aberrations in the ectodomain coding region including point mutations. Collagen XVII immunoreaction-stained spindle cell melanomas, showed partly overlapping profiles with those of S100B, Melan A and HMB45. It was concentrated at vertical melanoma fronts and statistically associated with invasive phenotype. Antibody targeting the extracellular aa507-529 terminus of collagen XVII endodomain promoted apoptosis and cell adhesion, while inhibiting proliferation in HT199 cells. These results suggest that the accumulation of collagen XVII endodomain in melanocytic tumors is associated with malignant transformation to be a potential marker of malignancy and a target for antibody-induced melanoma apoptosis.
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Affiliation(s)
- T Krenacs
- 1st Department of Pathology and Experimental Cancer Research, Semmelweis University, Ulloi ut 26, Budapest 1085, Hungary.
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Magro CM, Roberts-Barnes J, Crowson AN. Direct Immunofluorescence Testing in the Diagnosis of Immunobullous Disease, Collagen Vascular Disease, and Vascular Injury Syndromes. Dermatol Clin 2012; 30:763-98, viii. [DOI: 10.1016/j.det.2012.06.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Abstract
Linear immunoglobulin A (IgA) bullous dermatosis, also known as linear IgA disease, is an autoimmune mucocutaneous disorder characterized by subepithelial bullae, with IgA autoantibodies directed against several different antigens in the basement membrane zone. Its immunopathologic characteristic resides in the presence of a continuous linear IgA deposit along the basement membrane zone, which is clearly visible on direct immunofluorescence. This disorder shows different clinical features and distribution when adult-onset of linear IgA disease is compared with childhood-onset. Diagnosis is achieved via clinical, histopathologic, and immunopathologic examinations. Two common therapies are dapsone and sulfapyridine, which reduce the inflammatory response and achieve disease remission in a variable period of time.
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Affiliation(s)
- Giulio Fortuna
- Department of Dermatology, Program in Epithelial Biology, Stanford University School of Medicine, CA 94305, USA
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Kanayama Y, Tsuruta D, Tateishi C, Hasegawa Y, Amo K, Fukai K, Kobayashi H, Ishii M. Two cases of infantile linear immunoglobulin A/immunoglobulin G bullous dermatosis. J Dermatol 2012; 39:176-8. [PMID: 21767293 DOI: 10.1111/j.1346-8138.2011.01239.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Kasperkiewicz M, Zillikens D, Schmidt E. Pemphigoid diseases: Pathogenesis, diagnosis, and treatment. Autoimmunity 2011; 45:55-70. [DOI: 10.3109/08916934.2011.606447] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Jukić IL, Marinović B. Significance of immunofluorescence in the diagnosis of autoimmune bullous dermatoses. Clin Dermatol 2011; 29:389-97. [DOI: 10.1016/j.clindermatol.2011.01.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Csorba K, Schmidt S, Florea F, Ishii N, Hashimoto T, Hertl M, Kárpáti S, Bruckner-Tuderman L, Nishie W, Sitaru C. Development of an ELISA for sensitive and specific detection of IgA autoantibodies against BP180 in pemphigoid diseases. Orphanet J Rare Dis 2011; 6:31. [PMID: 21619684 PMCID: PMC3126693 DOI: 10.1186/1750-1172-6-31] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2010] [Accepted: 05/28/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pemphigoids are rare diseases associated with IgG, IgE and IgA autoantibodies against collagen XVII/BP180. An entity of the pemphigoid group is the lamina lucida-type of linear IgA disease (IgA pemphigoid) characterized by IgA autoantibodies against BP180. While for the detection of IgG and IgE autoantibodies specific to collagen XVII several ELISA systems have been established, no quantitative immunoassay has been yet developed for IgA autoantibodies. Therefore, the aim of the present study was to develop an ELISA to detect IgA autoantibodies against collagen XVII in the sera of patients with pemphigoids. METHODS We expressed a soluble recombinant form of the collagen XVII ectodomain in mammalian cells. Reactivity of IgA autoantibodies from patients with IgA pemphigoid was assessed by immunofluorescence microscopy and immunoblot analysis. ELISA test conditions were determined by chessboard titration experiments. The sensitivity, specificity and the cut-off were determined by receiver-operating characteristics analysis. RESULTS The optimized assay was carried out using sera from patients with IgA pemphigoid (n = 30) and healthy donors (n=105). By receiver operating characteristics (ROC) analysis, an area under the curve of 0.993 was calculated, indicating an excellent discriminatory capacity. Thus, a sensitivity and specificity of 83.3% and 100%, respectively, was determined for a cut-off point of 0.48. As additional control groups, sera from patients with bullous pemphigoid (n=31) and dermatitis herpetiformis (n = 50), a disease associated with IgA autoantibodies against epidermal transglutaminase, were tested. In 26% of bullous pemphigoid patients, IgA autoantibodies recognized the ectodomain of collagen XVII. One of 50 (2%) of dermatitis herpetiformis patients sera slightly topped the cut-off value. CONCLUSIONS We developed the first ELISA for the specific and sensitive detection of serum IgA autoantibodies specific to collagen XVII in patients with pemphigoids. This immunoassay should prove a useful tool for clinical and translational research and should essentially improve the diagnosis and disease monitoring of patients with IgA pemphigoid. Moreover, our findings strongly suggest that IgA pemphigoid and IgG bullous pemphigoid represent two ends of the clinical spectrum of an immunological loss of tolerance against components of hemidesmosomes, which is mediated by both IgG and IgA autoantibodies.
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Affiliation(s)
- Kinga Csorba
- Department of Dermatology, University of Freiburg, Hauptstrasse 7, 79104, Freiburg, Germany
- Faculty of Biology, University of Freiburg, Schaenzlestrasse 1, 79104, Freiburg, Germany
| | - Sabine Schmidt
- Department of Dermatology, University of Freiburg, Hauptstrasse 7, 79104, Freiburg, Germany
| | - Florina Florea
- Department of Dermatology, University of Freiburg, Hauptstrasse 7, 79104, Freiburg, Germany
| | - Norito Ishii
- Department of Dermatology, Kurume University, 67 Asahimachi, Kurume, Fukuoka 830-0011, Japan
| | - Takashi Hashimoto
- Department of Dermatology, Kurume University, 67 Asahimachi, Kurume, Fukuoka 830-0011, Japan
| | - Michael Hertl
- Department of Dermatology and Allergology, University of Marburg, Deutschhausstrasse 9, 35037, Marburg, Germany
| | - Sarolta Kárpáti
- Department of Dermatology, Venerology and Dermatooncology, Faculty of Medicine, Semmelweis University, Maria street 41, 1085, Budapest, Hungary
| | | | - Wataru Nishie
- Department of Dermatology, University of Freiburg, Hauptstrasse 7, 79104, Freiburg, Germany
| | - Cassian Sitaru
- Department of Dermatology, University of Freiburg, Hauptstrasse 7, 79104, Freiburg, Germany
- BIOSS Center for Biological Signaling Studies, University of Freiburg, Hebelstrasse 25, 79104, Freiburg, Germany
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Morita K, Fujisawa A, Yagi Y, Makiura M, Fukuda S, Ishii N, Ohyama B, Hashimoto T. Immunoglobulin A anti-BP230 autoantibodies in linear immunoglobulin A/immunoglobulin G bullous dermatosis. J Dermatol 2011; 38:1030-2. [PMID: 21366677 DOI: 10.1111/j.1346-8138.2010.01158.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Ingen-Housz-Oro S. Dermatose à IgA linéaire : revue de la littérature. Ann Dermatol Venereol 2011; 138:214-20. [DOI: 10.1016/j.annder.2011.01.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2010] [Accepted: 01/06/2011] [Indexed: 10/18/2022]
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Choi Y, Lee SE, Fukuda S, Hashimoto T, Kim SC. Mucous membrane pemphigoid with immunoglobulin G autoantibodies against full-length and 120-kDa ectodomain of BP180. J Dermatol 2011; 38:169-72. [PMID: 21269314 DOI: 10.1111/j.1346-8138.2010.01072.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Mucous membrane pemphigoid (MMP) is a rare autoimmune, subepidermal, bullous disease characterized by erosive lesions on the mucous membranes and skin. MMP reacts with various target antigens including BP180, laminin-332, β4 integrin, α6 integrin or type VII collagen. We present a 67-year-old male MMP patient who had lesions on the oral and ocular mucous membranes and facial skin. By immunoblot analyses, immunoglobulin G autoantibodies in the patient's sera reacted with full-length BP180 and the 120-kDa ectodomain of BP180 (LAD-1).
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Affiliation(s)
- Yuri Choi
- Department of Dermatology and Cutaneous Biology Research Institute, Yonsei University College of Medicine, Gangnam Severance Hospital, Seoul, Korea
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Nishie W, Lamer S, Schlosser A, Licarete E, Franzke CW, Hofmann SC, Jackow J, Sitaru C, Bruckner-Tuderman L. Ectodomain shedding generates Neoepitopes on collagen XVII, the major autoantigen for bullous pemphigoid. JOURNAL OF IMMUNOLOGY (BALTIMORE, MD. : 1950) 2010; 185:4938-47. [PMID: 20861347 DOI: 10.4049/jimmunol.1001524] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
As a type II transmembrane protein in basal keratinocytes, collagen XVII provides stable adhesion between epidermis and dermis in the skin. Its ectodomain can be shed from the cell surface, and autoantibodies in certain blistering diseases preferentially recognize the shed form. Major epitopes of collagen XVII are clustered within the juxtamembranous noncollagenous 16th A domain, and ectodomain shedding occurs within this region, suggesting that cleavage generates neoepitopes. However, the candidate cleavage sites have been controversial, and the mechanism of neoepitope generation is unclear. In this study, we investigated cleavage sites in the noncollagenous 16th A domain to understand the generation of neoepitopes and their pathological role. Polyclonal Abs recognizing the stretch Leu(524)-Gly(532) preferentially reacted with the shed ectodomain, but not with the full-length form, indicating that a neoepitope was localized at this site. The neoepitope-specific Ab fixed complement and induced granulocyte-dependent dermal-epidermal separation in cryosections of normal human skin. The physiological cleavage sites were identified using mass spectrometry. N termini were found at Asp(514), Leu(524), Glu(525), and Gly(526), among which Asp(514) and Glu(525) were blocked by acetylation and pyroglutaminate. In silico prediction of B cell epitopes indicated that the antigenicity of the Leu(524)-Gly(532) region increased substantially after shedding, regardless of the cleavage sites. Correspondingly, neoepitopes were found in the skin and blister fluids of patients with bullous pemphigoid, and bullous pemphigoid sera reacted with the peptide Leu(524)-Gly(532). Taken together, these data demonstrate that physiological shedding of collagen XVII generates neoepitopes, which may serve as a target of blister-inducing autoantibodies.
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Affiliation(s)
- Wataru Nishie
- Department of Dermatology, University Medical Center Freiburg, Freiburg, Germany
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Horváth B, Niedermeier A, Podstawa E, Müller R, Hunzelmann N, Kárpáti S, Hertl M. IgA autoantibodies in the pemphigoids and linear IgA bullous dermatosis. Exp Dermatol 2010; 19:648-53. [PMID: 20500772 DOI: 10.1111/j.1600-0625.2010.01080.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Patients with bullous pemphigoid (BP), mucous membrane pemphigoid (MMP) and pemphigoid gestationis (PG) have IgG antibodies against BP180 and BP230, components of the hemidesmosomes. Patients with linear IgA bullous dermatosis (LABD) have IgA autoantibodies against a 97/120-kDa protein which is highly homologous to a shedded fragment of the BP180-ectodomain. OBJECTIVES The aim of our study was to determine the incidence of IgA autoantibodies directed against BP180/BP230 in the pemphigoids and LABD and to determine the antigenic regions that are targeted by IgA autoantibodies. METHODS Utilizing baculovirus-expressed recombinant BP180 and BP230 proteins, we performed immunoblot analyses for IgA reactivity of sera from patients with BP (n = 30), MMP (n = 10), PG (n = 6), LABD (n = 6) and from control patients with non-related pruritic dermatoses (n = 8). RESULTS IgA reactivity against BP180 and/or BP230 was detected in 19/30 of the BP, in 7/10 of the MMP, in 6/6 of the LABD and in 3/6 of the PG sera, respectively, but not in the control group. In all subgroups, the major antigenic site recognized by IgA antibodies was located within the NH(2)-terminus of the BP180-ectodomain, but only a minority of the sera showed also IgA reactivity against the BP180-NC16a-domain. IgA reactivity against the central domain of BP180 was more frequently seen than against its COOH-terminus. IgA against the COOH- and NH(2)-terminus of BP230, respectively, was detected in 6/30 of the BP, 1/10 of the MMP, 1/6 of the LABD and 0/8 control sera. CONCLUSION IgA reactivity against BP180 and/or BP230 is a common finding in the pemphigoids.
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Affiliation(s)
- Barbara Horváth
- Philipps University, Department of Dermatology and Allergology, Marburg, Germany.
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Hofmann SC, Voith U, Schönau V, Sorokin L, Bruckner-Tuderman L, Franzke CW. Plasmin plays a role in the in vitro generation of the linear IgA dermatosis antigen LADB97. J Invest Dermatol 2009; 129:1730-9. [PMID: 19158842 DOI: 10.1038/jid.2008.424] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Collagen XVII (BP180) and its shed ectodomain represent major autoantigens in dermatoses of the pemphigoid group. The 120 kDa ectodomain is constitutively shed from the cell surface by disintegrin-metalloproteinases (ADAMs). Part of it is further processed to a 97 kDa fragment (LABD97), an autoantigen in linear IgA dermatosis (LAD), but the responsible proteinases remain elusive. In this study, we identified the 120 and the 97 kDa ectodomain in blister fluids of bullous pemphigoid patients using new mAbs. As blister fluids contain significant plasmin-like serine protease activity, HaCaT keratinocytes or purified 120 kDa ectodomain were incubated with several human serine proteases. In vitro, only plasmin generated a stable 97 kDa fragment that was also targeted by LAD sera. Characterization of the plasmin-derived 97 kDa fragment with domain-specific collagen XVII antibodies, heparin binding and N-glycosylation studies indicates that the N-terminus is located approximately at AA 515 and the C-terminus N-terminally from AA 1,421. Interestingly, plasmin-derived LABD97 was also generated in the presence of ADAM inhibitors and remained stable over more than 12 hours incubation at 37 degrees C, indicating that this disease relevant collagen XVII fragment can also arise in an ADAM-independent manner through direct action by plasmin.
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Affiliation(s)
- Silke C Hofmann
- Department of Dermatology, University Medical Center Freiburg, Freiburg, Germany
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Liu Z, Sui W, Zhao M, Li Z, Li N, Thresher R, Giudice GJ, Fairley JA, Sitaru C, Zillikens D, Ning G, Marinkovich MP, Diaz LA. Subepidermal blistering induced by human autoantibodies to BP180 requires innate immune players in a humanized bullous pemphigoid mouse model. J Autoimmun 2008; 31:331-8. [PMID: 18922680 PMCID: PMC2642586 DOI: 10.1016/j.jaut.2008.08.009] [Citation(s) in RCA: 99] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2008] [Revised: 08/18/2008] [Accepted: 08/21/2008] [Indexed: 10/21/2022]
Abstract
Bullous pemphigoid (BP) is a cutaneous autoimmune inflammatory disease associated with subepidermal blistering and autoantibodies against BP180, a transmembrane collagen and major component of the hemidesmosome. Numerous inflammatory cells infiltrate the upper dermis in BP. IgG autoantibodies in BP fix complement and target multiple BP180 epitopes that are highly clustered within a non-collagen linker domain, termed NC16A. Anti-BP180 antibodies induce BP in mice. In this study, we generated a humanized mouse strain, in which the murine BP180NC14A is replaced with the homologous human BP180NC16A epitope cluster region. We show that the humanized NC16A (NC16A+/+) mice injected with anti-BP180NC16A autoantibodies develop BP-like subepidermal blisters. The F(ab')(2) fragments of pathogenic IgG fail to activate the complement cascade and are no longer pathogenic. The NC16A+/+ mice pretreated with mast cell activation blocker or depleted of complement or neutrophils become resistant to BP. These findings suggest that the humoral response in BP critically depends on innate immune system players.
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Affiliation(s)
- Zhi Liu
- Department of Dermatology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA.
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Clinical and Molecular Characterization of Autoimmune Bullous Diseases. J Invest Dermatol 2008; 128 Suppl 3:E19-21. [DOI: 10.1038/skinbio.2008.3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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