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Im D, Ueda K, Niwa H, Tanaka K, Iwata H. Low pH condition impairs BP-IgG binding to the basement membrane zone. J Dermatol 2024; 51:643-648. [PMID: 38482975 DOI: 10.1111/1346-8138.17175] [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: 12/18/2023] [Revised: 02/09/2024] [Accepted: 02/15/2024] [Indexed: 05/03/2024]
Abstract
Bullous pemphigoid (BP), an autoimmune subepidermal blistering disease, shows tense blisters associated with urticarial erythema. Tissue-bound Immunoglobulin G (IgG) at the basement membrane zone (BMZ) detected by direct immunofluorescence (DIF) is strong evidence for a diagnosis of BP. The sensitivity of DIF is higher in complement component 3 (C3) than in IgG, but the reason for this different sensitivity is not fully understood. In this study, we performed several ex vivo studies to investigate the possible mechanism of IgG negativity and C3 positivity at the BMZ by DIF in some BP cases. First, sera from BP patients showing IgG negativity by DIF were found to clearly react to the BMZ in their own DIF skin samples. Next, indirect immunofluorescence (IIF) was performed using sera diluted with different pH phosphate-buffered saline (PBS), pH 7.4, 6.0, and 3.0. Patients' sera diluted with pH 7.4 PBS showed linear staining at the BMZ, but sera diluted with pH 6.0 PBS and pH 3.0 PBS showed lower fluorescence intensities. Finally, sections of skin from BP patients were pre-incubated with different pH PBS (pH 3.0, 6.0, and 7.4), followed by staining with anti-human IgG and C3. The fluorescence intensities were notably lower for IgG and C3 that had been pre-incubated with pH 3.0 PBS and pH 6.0 PBS than for IgG and C3 that had been pre-incubated with pH 7.4 PBS. These results suggest that a low pH condition hinders the binding of autoantibodies to the BMZ, that is, the drop in tissue pH induced by inflammation inhibits autoantibodies from depositing at the BMZ. Furthermore, the drop in tissue pH causes tissue-bound autoantibodies to detach from the BMZ. Complement fragments are activated not only on IgG but also on the cell surface of cells close to IgG during complement activation. IgG may detach from the BMZ under low pH condition induced by inflammation, but some complement fragments remain at the BMZ. These phenomena may help to explain why C3 is more sensitive than IgG when DIF is used to diagnose BP.
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Affiliation(s)
- Dongjun Im
- Department of Dermatology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Keisuke Ueda
- Department of Dermatology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Hirofumi Niwa
- Department of Dermatology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Kayoko Tanaka
- Department of Dermatology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Hiroaki Iwata
- Department of Dermatology, Gifu University Graduate School of Medicine, Gifu, Japan
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2
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Mahmood MN. Direct Immunofluorescence of Skin and Oral Mucosa: Guidelines for Selecting the Optimum Biopsy Site. Dermatopathology (Basel) 2024; 11:52-61. [PMID: 38390848 PMCID: PMC10885087 DOI: 10.3390/dermatopathology11010006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 01/17/2024] [Accepted: 01/18/2024] [Indexed: 02/24/2024] Open
Abstract
Direct immunofluorescence is a vital diagnostic test for assessing vesiculobullous disorders, vasculitides, and connective tissue diseases. It is a robust and valuable technique that offers essential diagnostic information for many critical dermatoses. Dermatopathologists depend heavily on the data obtained from direct immunofluorescence evaluation to confirm final diagnoses. Selecting the most appropriate biopsy site is necessary for maximizing diagnostic accuracy, and the best site may vary depending on the clinical differential diagnosis. Inaccurate biopsy site selection can significantly impact the accuracy of the results. To optimize the use of direct immunofluorescence studies, this review provides helpful guidelines and some practical tips for selecting the best biopsy site.
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Affiliation(s)
- Muhammad N Mahmood
- Department of Laboratory Medicine and Pathology, University of Alberta Hospital, Edmonton, AB T6G 2B7, Canada
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3
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Chen XY, Zhou G, Zhang J. Optical coherence tomography: Promising imaging technique for the diagnosis of oral mucosal diseases. Oral Dis 2024. [PMID: 38191786 DOI: 10.1111/odi.14851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 11/02/2023] [Accepted: 12/15/2023] [Indexed: 01/10/2024]
Abstract
OBJECTIVE This review aims to summarize the latest application of optical coherence tomography (OCT) in oral mucosal diseases, promoting an accurate and earlier diagnosis of such disorders, which are difficult to be differentiated. SUBJECTIVE AND METHODS References on the application of OCT in oral mucosal diseases were mainly obtained from PubMed, Embase, Web of Science and Scopus databases, using the keywords: "optical coherence tomography and 'oral mucosa/oral cancers/oral potentially malignant diseases/oral lichen planus/oral leukoplakia/oral erythroplakia/discoid lupus erythematosus/oral autoimmune bullous diseases/oral ulcers/erythema multiforme/oral mucositis'". RESULTS It is found that OCT is showing a promising application potential in the early detection, diagnosis, differential diagnosis, monitoring of oral cancer and oral dysplastic lesions, as well as the delineation of tumor margins. OCT is also playing an increasingly important role in the diagnosis of oral potentially malignant disorders, oral mucosal bullous diseases, oral ulcerative diseases, erythema multiforme, and the early detection of oral mucositis. CONCLUSION Optical coherence tomography, as a novel optical technique featured by real-time, noninvasive, dynamic and high-resolution imaging, is of great use to serve as an adjunct tool for the diagnosis, differential diagnosis, monitoring and therapy evaluation of oral mucosal diseases.
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Affiliation(s)
- Xu-Ya Chen
- State Key Laboratory of Oral & Maxillofacial Reconstruction and Regeneration, Key Laboratory of Oral Biomedicine Ministry of Education, Hubei Key Laboratory of Stomatology, School & Hospital of Stomatology, Wuhan University, Wuhan, China
| | - Gang Zhou
- State Key Laboratory of Oral & Maxillofacial Reconstruction and Regeneration, Key Laboratory of Oral Biomedicine Ministry of Education, Hubei Key Laboratory of Stomatology, School & Hospital of Stomatology, Wuhan University, Wuhan, China
- Department of Oral Medicine, School and Hospital of Stomatology, Wuhan University, Wuhan, China
| | - Jing Zhang
- State Key Laboratory of Oral & Maxillofacial Reconstruction and Regeneration, Key Laboratory of Oral Biomedicine Ministry of Education, Hubei Key Laboratory of Stomatology, School & Hospital of Stomatology, Wuhan University, Wuhan, China
- Department of Oral Medicine, School and Hospital of Stomatology, Wuhan University, Wuhan, China
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4
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Fallah M, Najafi A, Balighi K, Daneshpazhooh M, Ebrahimpour-Koujan S. Association of alternative healthy eating index and severity of pemphigus vulgaris: A cross-sectional study. PLoS One 2023; 18:e0295026. [PMID: 38079404 PMCID: PMC10712852 DOI: 10.1371/journal.pone.0295026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 11/14/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Evidence on the association between following healthy eating and the severity of pemphigus vulgaris (PV) is scarce. Therefore, the aim of this cross-sectional study aimed to investigate the relationship between adherence to the alternative healthy eating index (AHEI) and the severity of Pemphigus vulgaris disease in adults. METHODS In this hospital-based cross-sectional study, a total of 138 pemphigus vulgaris cases were studied, of which 108 had pemphigus disease area index (PDAI) ≤15, and 30 had PDAI>15. Dietary intakes were assessed using a valid 168-item food frequency questionnaire (FFQ). To calculate the AHEI, the data received from the diet were used. The subjects of this index received a score of 1-10. The final AHEI was calculated by summing the component scores. RESULTS After adjusting for age and sex, we found that individuals with the highest AHEI score were 72% less likely to have increased PV severity compared with those with the lowest score (OR: 0.28; 95% CI: 0.08-0.92, P trend = 0.020). Further control for another potential confounder, intake energy, made the association stronger (OR: 0.24; 95% CI: 0.06-0.88, P trend = 0.017). Also, after controlling the body mass index (BMI) confounding factor, it maintained its strong relationship (OR: 0.24; 95% CI: 0.06-0.88, P trend = 0.016). CONCLUSION The evidence of our study shows that following the healthy eating index is associated with a reduction in the severity of pemphigus vulgaris. Prospective cohort studies are needed to confirm these findings.
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Affiliation(s)
- Maryam Fallah
- Students’ Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Department of Clinical Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran
| | - Anahita Najafi
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Kamran Balighi
- Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Department of Dermatology, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Daneshpazhooh
- Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Department of Dermatology, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Soraiya Ebrahimpour-Koujan
- Department of Clinical Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran
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5
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Jakubowska B, Pietrzyk E, Maciejewicz P, Kowalewski C, Wozniak K. Diagnostic and prognostic values of conjunctival and oral biopsies analyzed by direct immunofluorescence in patients with mucous membrane pemphigoid. Front Med (Lausanne) 2023; 10:1257288. [PMID: 38020098 PMCID: PMC10663220 DOI: 10.3389/fmed.2023.1257288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 10/05/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Mucous membrane pemphigoid (MMP) is diagnosed on the basis of a characteristic clinical picture (a predilection for mucosal involvement and scarring in the affected tissues) and a positive direct immunofluorescence (DIF) result. Methods In this study, we compare the diagnostic and prognostic values of conjunctival and oral biopsies analyzed by DIF in patients with MMP. Sixteen patients with MMP and mucosal involvement as a predominant symptom were classified into three groups based on the clinical picture. Oral and conjunctival DIF were performed on all patients. Results Our study showed that patients with simultaneous oral and conjunctival involvement had a positive oral DIF in 83% and a positive ocular DIF in 100% of the examined cases, respectively. Patients with isolated ocular MMP had a positive oral DIF in 50% and a positive ocular DIF in 66% of the examined cases, respectively. Patients with only oral involvement with MMP had a positive oral DIF in 100% and a positive ocular DIF in 50% of the examined cases, respectively. Discussion Oral biopsy should be performed first and is usually sufficient for the diagnosis, even in patients with exclusively ocular MMP, whereas in patients without clinical ocular involvement, ocular DIF is positive in half of the cases and may be a predictive factor for ocular lesions in the future.
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Affiliation(s)
- Beata Jakubowska
- Department of Immunodermatology, Medical University of Warsaw, Warsaw, Poland
| | - Ewelina Pietrzyk
- Department of Immunodermatology, National Medical Institute of the Ministry of Interior and Administration, Warsaw, Poland
| | - Piotr Maciejewicz
- Department of Ophthalmology, Medical University of Warsaw, Warsaw, Poland
| | - Cezary Kowalewski
- Department of Immunodermatology, National Medical Institute of the Ministry of Interior and Administration, Warsaw, Poland
| | - Katarzyna Wozniak
- Department of Immunodermatology, National Medical Institute of the Ministry of Interior and Administration, Warsaw, Poland
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Zeng Q, Liu J, Mu J, Yang J, Gao Q, Wu F, Zhou H. Optimal biopsy site for the diagnosis of oral pemphigus vulgaris and mucous membrane pemphigoid: a systematic review and meta-analysis. Int J Oral Maxillofac Surg 2023; 52:1162-1172. [PMID: 37268547 DOI: 10.1016/j.ijom.2023.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 05/07/2023] [Accepted: 05/11/2023] [Indexed: 06/04/2023]
Abstract
The aim of this study was to critically evaluate the diagnostic yields of direct immunofluorescence (DIF) analysis on perilesional and normal-appearing mucosa biopsy samples, to determine the optimal biopsy site for patients presenting with oral pemphigus vulgaris (PV) or mucous membrane pemphigoid (MMP). Electronic databases and article bibliographies were searched in December 2022. The primary outcome was the rate of DIF positivity. Of 374 records identified after the elimination of duplicates, 21 studies with 1027 samples were ultimately included. Meta-analysis revealed a pooled DIF positivity rate of 99.6% (95% confidence interval (CI) 97.4-100.0%, I2 = 0%) for PV and 92.6% (95% CI 87.9-96.5%, I2 = 44%) for MMP for biopsies from perilesional sites, and of 95.4% (95% CI 88.6-99.5%, I2 = 0%) for PV and 94.1% (95% CI 86.5-99.2%, I2 = 42%) for MMP for biopsies from normal-appearing sites. For MMP, there was no significant difference in the rate of DIF positivity between the two biopsy sites (odds ratio 1.91, 95% CI 0.91-4.01, I2 = 0%). The results suggest that the perilesional mucosa remains the optimal biopsy site for DIF diagnosis of oral PV, while the normal-appearing mucosa biopsy is optimal for oral MMP.
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Affiliation(s)
- Q Zeng
- State Key Laboratory of Oral Diseases, National Center of Stomatology, National Clinical Research Center for Oral Diseases, Frontier Innovation Center for Dental Medicine Plus, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - J Liu
- State Key Laboratory of Oral Diseases, National Center of Stomatology, National Clinical Research Center for Oral Diseases, Frontier Innovation Center for Dental Medicine Plus, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - J Mu
- State Key Laboratory of Oral Diseases, National Center of Stomatology, National Clinical Research Center for Oral Diseases, Frontier Innovation Center for Dental Medicine Plus, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - J Yang
- State Key Laboratory of Oral Diseases, National Center of Stomatology, National Clinical Research Center for Oral Diseases, Frontier Innovation Center for Dental Medicine Plus, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Q Gao
- Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - F Wu
- State Key Laboratory of Oral Diseases, National Center of Stomatology, National Clinical Research Center for Oral Diseases, Frontier Innovation Center for Dental Medicine Plus, West China Hospital of Stomatology, Sichuan University, Chengdu, China.
| | - H Zhou
- State Key Laboratory of Oral Diseases, National Center of Stomatology, National Clinical Research Center for Oral Diseases, Frontier Innovation Center for Dental Medicine Plus, West China Hospital of Stomatology, Sichuan University, Chengdu, China
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Didona D, Schmidt MF, Maglie R, Solimani F. Pemphigus and pemphigoids: Clinical presentation, diagnosis and therapy. J Dtsch Dermatol Ges 2023; 21:1188-1209. [PMID: 37587612 DOI: 10.1111/ddg.15174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 06/11/2023] [Indexed: 08/18/2023]
Abstract
Pemphigus and pemphigoid are two potentially life-threatening groups of autoimmune diseases, characterized by autoantibodies targeting structural components of desmosomes or hemidesmosomes, respectively. Affected patients typically show itchy/painful plaques or blistering skin lesions and/or impairing mucosal blistering and erosions, which may strongly impact their quality of life. Since the milestone work of Walter Lever in 1953, who differentiated these two groups of diseases by histopathological analysis of the level of antibody-mediated skin cleavage, enormous progresses occurred. Achievements made in laboratory diagnostics now allow to identify antigen specific structural proteins of the skin that are targeted by pathogenic autoantibodies. These progresses were accompanied by an increased understanding of the pathogenesis of these diseases thanks to the establishment of animal models reproducing disease and on studies on skin and blood of affected individuals, which have been leading to novel and disease-specific treatments. Yet, given their phenotypical overlap with more common dermatological diseases, correct diagnosis and appropriate treatment are often delayed, in some cases leading to irreversible sequelae, including organ dysfunction (i.e., loss of vision in mucous membrane pemphigoid). Here, we provide a concise overview of the clinical appearance, diagnosis and therapeutic management of pemphigus and pemphigoid diseases.
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Affiliation(s)
- Dario Didona
- Department of Dermatology and Allergology, Philipps-Universität Marburg, Marburg, Germany
| | - Morna F Schmidt
- Department of Dermatology and Allergology, University Hospital RWTH Aachen, Aachen, Germany
| | - Roberto Maglie
- Department of Dermatology and Allergology, Philipps-Universität Marburg, Marburg, Germany
- Department of Health Sciences, Section of Dermatology, University of Florence, Florence, Italy
| | - Farzan Solimani
- Department of Dermatology, Venereology and Allergology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Clinician Scientist Program, Germany
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Didona D, Schmidt MF, Maglie R, Solimani F. Pemphigus- und Pemphigoid-Erkrankungen: Klinik, Diagnostik und Therapie: Pemphigus and pemphigoids: Clinical presentation, diagnosis and therapy. J Dtsch Dermatol Ges 2023; 21:1188-1211. [PMID: 37845066 DOI: 10.1111/ddg.15174_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 06/11/2023] [Indexed: 10/18/2023]
Abstract
ZusammenfassungPemphigus und Pemphigoid sind seltene Autoimmunkrankheiten der Haut mit potenziell lebensbedrohlichem Verlauf. Autoantikörper gegen epidermale und junktionale Strukturproteine (Desmosomen sowie Hemidesmosomen) führen bei Betroffenen typischerweise zu juckenden, schmerzhaften Plaques oder Blasen an der Haut und/oder Blasenbildung und Erosionen der Schleimhäute mit möglicher Einschränkung der Lebensqualität. Seit der bahnbrechenden Arbeit von Walter Lever im Jahr 1953, dem es gelang, mittels histopathologischer Untersuchung diese beiden Krankheitsgruppen anhand des Musters der Antikörper‐vermittelten Blasenbildung zu differenzieren, wurden enorme Fortschritte im Verständnis der Erkrankungen erzielt. Die Errungenschaften in der Labordiagnostik ermöglichten die Identifikation von Zielstrukturen zur präzisen Unterscheidung verschiedener Varianten der bullösen Autoimmunerkrankungen. Diese Fortschritte gingen dank der Entwicklung von Tiermodellen mit einem besseren Verständnis der Pathogenese einher. Außerdem haben Studien an Haut und Blut betroffener Patienten zu neuen und krankheitsspezifischen Behandlungen geführt. Aufgrund ihrer Seltenheit und der klinischen Ähnlichkeit mit anderen dermatologischen Erkrankungen verzögern sich die korrekte Diagnosestellung und die Einleitung einer entsprechenden Therapie häufig, was in einigen Fällen zu irreversiblen Folgeerscheinungen, einschließlich Funktionsstörungen von Organen (zum Beispiel Verlust des Sehvermögens beim Schleimhautpemphigoid) führt. Wir geben hier einen Überblick über das klinische Erscheinungsbild, den Diagnosealgorithmus und das therapeutische Management von Pemphigus‐ und Pemphigoid‐Erkrankungen.
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Affiliation(s)
- Dario Didona
- Klinik für Dermatologie und Allergologie, Philipps-Universität Marburg, Marburg, Deutschland
| | - Morna F Schmidt
- Klinik für Dermatologie und Allergologie, Uniklinik RWTH Aachen, Aachen, Deutschland
| | - Roberto Maglie
- Klinik für Dermatologie und Allergologie, Philipps-Universität Marburg, Marburg, Deutschland
- Abteilung für Gesundheitswissenschaften, Abteilung für Dermatologie, Universität Florenz, Florenz, Italien
| | - Farzan Solimani
- Klinik für Dermatologie, Venerologie und Allergologie, Charité - Universitätsmedizin Berlin, Korporatives Mitglied der Freien Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Deutschland
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Clinician Scientist Program, Berlin, Deutschland
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Chen J, Tang H, Zhang D, Tang Y, Li W, Liu G, Liu B. A rare case of pemphigus vulgaris disguised as a malignant gingival ulcer. BMC Oral Health 2023; 23:319. [PMID: 37221480 DOI: 10.1186/s12903-023-02980-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 04/19/2023] [Indexed: 05/25/2023] Open
Abstract
BACKGROUND Pemphigus vulgaris (PV) is a kind of rare and severe autoimmune bullous disease. In this case, the specificity of oral PV lies in the clinical manifestations of a single palatal ulcer, and no blisters were found in the oral mucosa. This case provides a powerful reference for dentists diagnosing and treating oral PV with atypical clinical presentations. CASE PRESENTATION A 54 years old female patient presented with a non-healing palatal gingival ulcer for over three months. By histopathological H&E staining and the direct immunofluorescence (DIF) test, the final diagnosis was oral PV. After topical glucocorticoid therapy, the affected area was cured. CONCLUSIONS In patients with prolonged erosion of the skin or oral mucosa, even if complete blisters are not visible, the physician should consider autoimmune bullous diseases and pay attention to avoid diagnostic defects.
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Affiliation(s)
- Jun Chen
- Department of Periodontics and Oral Medicine, Xiangya Stomatological Hospital & Xiangya School of Stomatology, Hunan Key Laboratory of Oral Health Research & Hunan Clinical Research Center of Oral Major Diseases and Oral Health & Academician Workstation for Oral-maxillofacial and Regenerative Medicine, Central South University, Changsha, 410008, China
| | - Hui Tang
- Department of Periodontics and Oral Medicine, Xiangya Stomatological Hospital & Xiangya School of Stomatology, Hunan Key Laboratory of Oral Health Research & Hunan Clinical Research Center of Oral Major Diseases and Oral Health & Academician Workstation for Oral-maxillofacial and Regenerative Medicine, Central South University, Changsha, 410008, China
| | - Ding Zhang
- Department of Periodontics and Oral Medicine, Xiangya Stomatological Hospital & Xiangya School of Stomatology, Hunan Key Laboratory of Oral Health Research & Hunan Clinical Research Center of Oral Major Diseases and Oral Health & Academician Workstation for Oral-maxillofacial and Regenerative Medicine, Central South University, Changsha, 410008, China
| | - Yuqi Tang
- Department of Periodontics and Oral Medicine, Xiangya Stomatological Hospital & Xiangya School of Stomatology, Hunan Key Laboratory of Oral Health Research & Hunan Clinical Research Center of Oral Major Diseases and Oral Health & Academician Workstation for Oral-maxillofacial and Regenerative Medicine, Central South University, Changsha, 410008, China
| | - Wenjie Li
- Department of Periodontics and Oral Medicine, Xiangya Stomatological Hospital & Xiangya School of Stomatology, Hunan Key Laboratory of Oral Health Research & Hunan Clinical Research Center of Oral Major Diseases and Oral Health & Academician Workstation for Oral-maxillofacial and Regenerative Medicine, Central South University, Changsha, 410008, China
- Department of Orthodontics, Xiangya Stomatological Hospital & Xiangya School of Stomatology, Central South University, Changsha, 410008, China
| | - Gui Liu
- Department of Oral Pathology, Xiangya Stomatological Hospital & Xiangya School of Stomatology, Central South University, Changsha, 410008, China.
| | - Binjie Liu
- Department of Periodontics and Oral Medicine, Xiangya Stomatological Hospital & Xiangya School of Stomatology, Hunan Key Laboratory of Oral Health Research & Hunan Clinical Research Center of Oral Major Diseases and Oral Health & Academician Workstation for Oral-maxillofacial and Regenerative Medicine, Central South University, Changsha, 410008, China.
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10
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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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11
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Du G, Patzelt S, van Beek N, Schmidt E. Mucous membrane pemphigoid. Clin Exp Rheumatol 2022; 21:103036. [PMID: 34995762 DOI: 10.1016/j.autrev.2022.103036] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Accepted: 01/01/2022] [Indexed: 12/19/2022]
Abstract
Mucous membrane pemphigoid (MMP) is a clinically and immunopathologically heterogenous disease with an incidence of about 2/million inhabitants/year in central Europe. Pemphigoid diseases are characterized by autoantibodies against structural proteins of the epidermis and/or surface-close epithelia. MMP has been defined as pemphigoid disease with predominant mucosal lesions. Most frequently, the oral cavity and the conjunctivae are affected. Lesions outside the mouth tend to heal with scarring leading to visual impairment and finally blindness, as well as, more rarely, impairment of breathing and food intake. Autoantibodies target BP180 (collagen type XVII), laminin 332, BP230 (nearly always in conjunction with other antigens), and type VII collagen in about 75%, 10-20%, 10-30%, and <5% of MMP patients, respectively. While the main autoantibody isotype is IgG, additional, and less frequently, exclusive IgA autoantibodies can be detected in the majority of patients. Assaying for anti-laminin 332 reactivity is pivotal, since in about a quarter of patients with anti-laminin 332 MMP, a malignancy, mainly solid cancers, is associated. The pathophysiology of MMP is yet incompletely understood. A recent mouse model of anti-laminin 332 MMP replicating characteristic clinical and immunopathological findings of the human disease may be helpful to close this knowledge gap. Diagnosis is established by the clinical picture with predominant mucosal lesions and visualization of tissue-bound anti-basement membrane zone antibodies by direct immunofluorescence microscopy. In recent S3 guidelines initiated by the European Academy of Dermatology and Venereology, the clinical spectrum and diagnostic strategies are detailed. In addition, treatment regimens for different clinical situations including patients with exclusive oral or ocular involvement are outlined. Future studies are needed to better understand the clinal complexity and associations as well as to establish widely available diagnostic assays and evidence-based therapeutic strategies.
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Affiliation(s)
- Gefei Du
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany; Department of Oral Medicine, School and Hospital of Stomatology, Wuhan University, Wuhan, China
| | - Sabrina Patzelt
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Nina van Beek
- Department of Dermatology, 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.
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12
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Rashid H, Meijer JM, Bolling MC, Diercks GFH, Pas HH, Horváth B. Insights in clinical and diagnostic findings and treatment responses in patients with mucous membrane pemphigoid, a retrospective cohort study. J Am Acad Dermatol 2021; 87:48-55. [PMID: 34896128 DOI: 10.1016/j.jaad.2021.11.061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 11/03/2021] [Accepted: 11/22/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND The variable clinical severity of MMP often leads to a diagnostic and therapeutic delay. OBJECTIVE To describe the characteristics in a large cohort of patients with MMP. METHODS A retrospective review study of clinical and diagnostic characteristics and treatment response in 145 patients with MMP. RESULTS Monosite involvement was seen in 41.4% and multisite involvement in 58.6% patients. The oral mucosa was affected in 86.9%, followed by the ocular mucosa (30.3%), skin (26.2%), genital mucosa (25.5%), nasal mucosa (23.4%) and pharyngeal and/or laryngeal mucosa (17.2%). Ocular disease developed during disease course in 41.7% of patients with initially other mucosal site involvement. The malignancy rate was significantly higher in patients with autoantibodies against laminin-332 compared to MMP patients without laminin-332 autoantibodies (35.3% vs. 10.9%, p=0.007). Systemic immunosuppressive or immunomodulatory therapy were administered in 77.1% of the patients, mainly in patients with multisite involvement (p<0.001), ocular involvement (p<0.001) and pharyngeal and laryngeal involvement (p=0.002). The remaining patients (22.9%) received topical therapy. Adverse events were frequently reported. LIMITATIONS Retrospective design. CONCLUSION MMP presents with a heterogeneous clinical presentation and new symptoms may develop during the disease course. Cancer screening should be considered in MMP and in particular with autoantibodies against laminin-332.
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Affiliation(s)
- Hanan Rashid
- University of Groningen, University Medical Center Groningen, Department of Dermatology, Center of Blistering Diseases, European Reference Network-Skin Member, Groningen, the Netherlands.
| | - Joost M Meijer
- University of Groningen, University Medical Center Groningen, Department of Dermatology, Center of Blistering Diseases, European Reference Network-Skin Member, Groningen, the Netherlands
| | - Maria C Bolling
- University of Groningen, University Medical Center Groningen, Department of Dermatology, Center of Blistering Diseases, European Reference Network-Skin Member, Groningen, the Netherlands
| | - Gilles F H Diercks
- University of Groningen, University Medical Center Groningen, Department of Pathology, Groningen, the Netherlands
| | - Hendri H Pas
- University of Groningen, University Medical Center Groningen, Department of Dermatology, Center of Blistering Diseases, European Reference Network-Skin Member, Groningen, the Netherlands
| | - Barbara Horváth
- University of Groningen, University Medical Center Groningen, Department of Dermatology, Center of Blistering Diseases, European Reference Network-Skin Member, Groningen, the Netherlands
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13
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Kuriyama K, Kitamura Y, Tsuji T, Nishikawa R, Nagata H, Ohshiro M, Sugitani M, Hirakawa Y, Matsumoto Y, Iwai T, Uchiyama H. Successful treatment of paraneoplastic pemphigus and bronchiolitis obliterans associated with follicular lymphoma with obinutuzumab and bendamustine. Curr Probl Cancer 2021; 46:100813. [PMID: 34844771 DOI: 10.1016/j.currproblcancer.2021.100813] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
We herein report the rare case of a 72-year-old female who presented with paraneoplastic pemphigus (PNP) and bronchiolitis obliterans (BO) associated with follicular lymphoma (FL), who was successfully treated with obinutuzumab (GA101; G) and bendamustine (B). The patient had severe erosive stomatitis and bilateral conjunctival hyperemia that persisted for more than 6 months. A huge mass was found in the abdominal cavity, and a biopsy revealed grade 1 FL (stage IV). Based on a lip biopsy result, the patient was diagnosed with PNP associated FL. The patient received bendamustine and obinutuzumab (BG) chemotherapy and FL and PNP responded very well, but BO was additionally associated during the course of BG. BO progressed without exacerbation as BG therapy progressed to a 2 year maintenance therapy with G, and combination of azithromycin, inhaled bronchodilator therapy, and corticosteroid. She was followed up at the outpatient department with no pulmonary function decline or FL and PNP recurrence. Our case suggests that BG could be a promising treatment option for PNP and BO.
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Affiliation(s)
- Kodai Kuriyama
- Department of Hematology, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan. kuriyama-_-kodai-@hotmail.co.jp
| | - Yoshimi Kitamura
- Department of Dermatology, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan; Department of Dermatology, Kyoto City Hospital, Kyoto, Japan
| | - Taisuke Tsuji
- Department of Respiratory Medicine, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Rina Nishikawa
- Department of Hematology, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Hiroaki Nagata
- Department of Hematology, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Muneo Ohshiro
- Department of Hematology, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Mio Sugitani
- Department of Hematology, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Yoshiko Hirakawa
- Department of Hematology, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Yosuke Matsumoto
- Department of Hematology, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Toshiki Iwai
- Department of Hematology, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Hitoji Uchiyama
- Department of Hematology, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
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14
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Moussaoui E, Oueslati Y, Oualha L, Denguezli M, Sriha B, Douki N. Simultaneous Oral and Umbilical Locations as a First Sign of Pemphigus Vulgaris. Case Rep Dent 2021; 2021:7792360. [PMID: 34733562 PMCID: PMC8560286 DOI: 10.1155/2021/7792360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 10/09/2021] [Indexed: 11/17/2022] Open
Abstract
The place of pemphigus vulgaris (PV) among autoimmune bullous diseases (AIBD) is well established. It is an acquired chronic, autoimmune, vesiculobullous disease in which IgG antibodies target desmosomal proteins to produce intraepithelial mucocutaneous blistering. The diagnosis is often challenging for the clinicians. It requires a combination of three major features: clinical, histopathological, and immunological. Clinically, oral lesions are the first manifestations of the disease in 50-90% of the patients with widespread blisters affecting the oral mucosa. On the skin, lesions are characterized by flaccid blisters that rapidly progress into erosions and crust formation. Umbilical lesions as a clinical manifestation of PV are peculiar and have rarely been reported, and they are not yet completely elucidated. Umbilical region involvement in patients with pemphigus was assessed in a limited study totalling just 10 patients. This localisation may be a valuable hint easing the diagnosis at the clinical level for patients with oral mucosal blisters. Dentists must be familiar with the clinical manifestations of PV to make an early diagnosis and start an early treatment which determines the prognosis of the disease. To the best of the authors' knowledge, the coexistence of these lesions with the oral lesions as a first sign of PV in the absence of skin involvement was reported in only one case of pemphigus vegetans (PVe). In this paper, we describe an observation of a female patient that was diagnosed with PV that begun with simultaneous oral and umbilical locations which coexisted for a period of 4 months before the appearance of other cutaneous lesions. We highlight the role of dentists, by being familiar with the clinical manifestations of PV, to make an early diagnosis to start an early treatment which determines the prognosis of the disease and to follow closely the evolution of lesions to change treatment if required. We also discuss the clinical, histological, and immunological features of the disease that enabled the differential diagnosis as well as the appropriate therapeutic management.
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Affiliation(s)
- Eya Moussaoui
- Department of Dental Medicine, Sahloul Hospital (Sousse), Dental Faculty of Monastir, University of Monastir, Tunisia
- Laboratory of Oral Health and Maxillofacial Rehabilitation (LR12ES11), University of Monastir, Tunisia
| | - Yassine Oueslati
- Department of Dental Medicine, Sahloul Hospital (Sousse), Dental Faculty of Monastir, University of Monastir, Tunisia
- Laboratory of Oral Health and Maxillofacial Rehabilitation (LR12ES11), University of Monastir, Tunisia
| | - Lamia Oualha
- Department of Dental Medicine, Sahloul Hospital (Sousse), Dental Faculty of Monastir, University of Monastir, Tunisia
- Laboratory of Oral Health and Maxillofacial Rehabilitation (LR12ES11), University of Monastir, Tunisia
| | - Mohamed Denguezli
- Dermatology Department, Farhat Hached Hospital (Sousse), University of Sousse, Tunisia
| | - Badreddine Sriha
- Cytology and Pathological Anatomy Department, Farhat Hached Hospital (Sousse), University of Sousse, Tunisia
| | - Nabiha Douki
- Department of Dental Medicine, Sahloul Hospital (Sousse), Dental Faculty of Monastir, University of Monastir, Tunisia
- Laboratory of Oral Health and Maxillofacial Rehabilitation (LR12ES11), University of Monastir, Tunisia
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15
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Schmidt E, Rashid H, Marzano A, Lamberts A, Di Zenzo G, Diercks G, Alberti‐Violetti S, Barry R, Borradori L, Caproni M, Carey B, Carrozzo M, Cianchini G, Corrà A, Dikkers F, Feliciani C, Geerling G, Genovese G, Hertl M, Joly P, Meijer J, Mercadante V, Murrell D, Ormond M, Pas H, Patsatsi A, Rauz S, van Rhijn B, Roth M, Setterfield J, Zillikens D, C.Prost, Zambruno G, Horváth B, Caux F. European Guidelines (S3) on diagnosis and management of mucous membrane pemphigoid, initiated by the European Academy of Dermatology and Venereology - Part II. J Eur Acad Dermatol Venereol 2021; 35:1926-1948. [PMID: 34309078 PMCID: PMC8518905 DOI: 10.1111/jdv.17395] [Citation(s) in RCA: 71] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 03/24/2021] [Indexed: 01/21/2023]
Abstract
This guideline has been initiated by the task force Autoimmune Blistering Diseases of the European Academy of Dermatology and Venereology, including physicians from all relevant disciplines and patient organizations. It is a S3 consensus-based guideline that systematically reviewed the literature on mucous membrane pemphigoid (MMP) in the MEDLINE and EMBASE databases until June 2019, with no limitations on language. While the first part of this guideline addressed methodology, as well as epidemiology, terminology, aetiology, clinical presentation and outcome measures in MMP, the second part presents the diagnostics and management of MMP. MMP should be suspected in cases with predominant mucosal lesions. Direct immunofluorescence microscopy to detect tissue-bound IgG, IgA and/or complement C3, combined with serological testing for circulating autoantibodies are recommended. In most patients, serum autoantibodies are present only in low levels and in variable proportions, depending on the clinical sites involved. Circulating autoantibodies are determined by indirect IF assays using tissue substrates, or ELISA using different recombinant forms of the target antigens or immunoblotting using different substrates. The major target antigen in MMP is type XVII collagen (BP180), although in 10-25% of patients laminin 332 is recognized. In 25-30% of MMP patients with anti-laminin 332 reactivity, malignancies have been associated. As first-line treatment of mild/moderate MMP, dapsone, methotrexate or tetracyclines and/or topical corticosteroids are recommended. For severe MMP, dapsone and oral or intravenous cyclophosphamide and/or oral corticosteroids are recommended as first-line regimens. Additional recommendations are given, tailored to treatment of single-site MMP such as oral, ocular, laryngeal, oesophageal and genital MMP, as well as the diagnosis of ocular MMP. Treatment recommendations are limited by the complete lack of high-quality randomized controlled trials.
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16
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He W, Li K, Hu X, Hua H, Wei P. Direct immunofluorescence analysis of oral Tzanck smears for pemphigus vulgaris: A diagnostic test. J Oral Pathol Med 2021; 50:1050-1056. [PMID: 34536966 DOI: 10.1111/jop.13239] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 08/18/2021] [Accepted: 09/03/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Pemphigus vulgaris (PV) is a rare and potentially fatal autoimmune blistering disease. Direct immunofluorescence (DIF) and histopathological analysis are crucial methods for PV diagnosis, but oral tissue biopsy is difficult to perform because of the fragile characteristics of the oral mucosa. However, no well-designed diagnostic studies addressing the validity of DIF analysis of oral Tzanck smears for the diagnosis of PV exist. We aimed to design a diagnostic test based on DIF analysis combined with oral Tzanck smears and evaluate its diagnostic accuracy for PV. METHODS We enrolled 81 patients with oral erosive lesions, of whom 41 patients had PV and 40 were non-PV controls. Oral Tzanck smears were obtained from oral mucosal lesions and observed under a fluorescence microscope after fixing and fluorescence staining. The diagnostic efficacy indexes including sensitivity, specificity, predictive value, Youden index, diagnostic odds ratio, and likelihood ratio were calculated. RESULTS Of the 41 PV patients, 36 showed DIF-positive findings for oral Tzanck smears, and all 36 DIF-positive PV patients showed IgG and/or C3 deposition, with seven also showing IgA and/or IgM positivity. None of the non-PV controls showed DIF positivity. The sensitivity and specificity of DIF analysis with oral Tzanck smears were 87.80% and 100%, respectively. The area under the receiver operator characteristic curve (ROC) was 0.939, with the test demonstrating significantly high diagnostic efficacy. CONCLUSION DIF analysis of oral Tzanck smears is a minimally invasive and easy-to-operate technique that can assist the rapid and accurate diagnosis of PV in dental clinic.
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Affiliation(s)
- Wenxiu He
- Department of Oral Medicine, Peking University School and Hospital of Stomatology, National Center of Stomatology, National Clinical Research Center for Oral Diseases, National Engineering Laboratory for Digital and Material Technology of Stomatology, Beijing Key Laboratory of Digital Stomatology, Research Center of Engineering and Technology for Computerized Dentistry Ministry of Health, NMPA Key Laboratory for Dental Materials, Beijing, China
| | - Kaiyi Li
- Department of Oral Medicine, Peking University School and Hospital of Stomatology, National Center of Stomatology, National Clinical Research Center for Oral Diseases, National Engineering Laboratory for Digital and Material Technology of Stomatology, Beijing Key Laboratory of Digital Stomatology, Research Center of Engineering and Technology for Computerized Dentistry Ministry of Health, NMPA Key Laboratory for Dental Materials, Beijing, China
| | - Xiaosheng Hu
- Department of Oral Medicine, Peking University School and Hospital of Stomatology, National Center of Stomatology, National Clinical Research Center for Oral Diseases, National Engineering Laboratory for Digital and Material Technology of Stomatology, Beijing Key Laboratory of Digital Stomatology, Research Center of Engineering and Technology for Computerized Dentistry Ministry of Health, NMPA Key Laboratory for Dental Materials, Beijing, China
| | - Hong Hua
- Department of Oral Medicine, Peking University School and Hospital of Stomatology, National Center of Stomatology, National Clinical Research Center for Oral Diseases, National Engineering Laboratory for Digital and Material Technology of Stomatology, Beijing Key Laboratory of Digital Stomatology, Research Center of Engineering and Technology for Computerized Dentistry Ministry of Health, NMPA Key Laboratory for Dental Materials, Beijing, China
| | - Pan Wei
- Department of Oral Medicine, Peking University School and Hospital of Stomatology, National Center of Stomatology, National Clinical Research Center for Oral Diseases, National Engineering Laboratory for Digital and Material Technology of Stomatology, Beijing Key Laboratory of Digital Stomatology, Research Center of Engineering and Technology for Computerized Dentistry Ministry of Health, NMPA Key Laboratory for Dental Materials, Beijing, China
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17
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Diagnostic Concordance between Optical Coherence Tomography and Histological Investigations for Immune-Mediated Desquamative Gingivitis: Observational Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18179095. [PMID: 34501683 PMCID: PMC8430736 DOI: 10.3390/ijerph18179095] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 08/21/2021] [Accepted: 08/25/2021] [Indexed: 12/28/2022]
Abstract
Desquamative gingivitis (DG) denotes a heterogeneous immune-mediated disease for which early diagnosis represents a great challenge. The main aim of this study is to validate diagnostic concordance between specific Optical Coherence Tomography (OTC) patterns for DG related to oral Lichen Planus (OLP), Pemphigus Vulgaris (PV), and Mucous Membrane Pemphigoid (MMP) and definitive histological diagnosis. Forty-three patients with suspected immune-mediated DGs, were progressively recruited. Before biopsy, an OCT preliminary evaluation was performed using specific pre-determined OCT diagnostic patterns (i.e., morphology and localization of blisters, status of the basal membrane, epithelial thickness, presence/absence of acantholytic cells into blister and/or inflammatory infiltrate) related to OLP, PV and MMP. After histological confirmation, OCT and histological diagnoses were compared. Using pre-determined patterns, OCT diagnoses of DGs were: 22 (51%) OLP, of which 11 (26%) were with the bullous variant, 4 (9%) PV and 6 (14%) MMP. The same diagnoses were found by histological investigations (with the main OCT discriminatory potential for the bullous variant of OLP). The concordance between the two diagnostic methods was confirmed by the Fisher exact test (p-value < 0.01). These specific OCT patterns show a diagnostic reliability in 100% of the cases investigated, suggesting their accuracy to support the complex diagnosis and management of immune-mediated DGs.
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18
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Panzarella V, Bartolone A, Rodolico V, Capocasale G, Maniscalco L, Matranga D, Di Fede O, Campisi G. Immune-Mediated Desquamative Gingivitis and Optical Coherence Tomography Diagnostic Patterns: Clinical Implication from a Systematic Review. Diagnostics (Basel) 2021; 11:diagnostics11081453. [PMID: 34441387 PMCID: PMC8394405 DOI: 10.3390/diagnostics11081453] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/09/2021] [Accepted: 08/10/2021] [Indexed: 12/13/2022] Open
Abstract
Desquamative Gingivitis (DG) comprises heterogeneous clinical manifestations of numerous immune-mediated muco-cutaneous diseases. Optical Coherence Tomography (OCT) has been proposed as a valuable diagnostic support even if, to date, there are no standardized OCT-diagnostic patterns applicable to DGs. A systematic review was performed to detect existing data on in vivo OCT diagnostic patterns of the most common immune-mediated DGs (i.e., pemphigus vulgaris, mucous membrane pemphigoid and oral lichen planus). It has been found that OCT exhibits specific patterns that address the diagnosis of DG by pemphigus vulgaris (i.e., intraepithelial unilocular blister, reduced epithelial thickness, presence of acantholytic cells in the blister) and by mucous membrane pemphigoid (i.e., subepithelial multilocular blister, presence of inflammatory infiltrate), but not by oral lichen planus. These patterns could offer an attractive diagnostic OCT framework to support the clinical preliminary assessment and monitoring of these complex pathological conditions.
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Affiliation(s)
- Vera Panzarella
- Department of Surgical, Oncological and Oral Sciences, University of Palermo, 90127 Palermo, Italy; (A.B.); (O.D.F.); (G.C.)
- Correspondence:
| | - Alessia Bartolone
- Department of Surgical, Oncological and Oral Sciences, University of Palermo, 90127 Palermo, Italy; (A.B.); (O.D.F.); (G.C.)
| | - Vito Rodolico
- Department ProMISE, University of Palermo, 90127 Palermo, Italy;
| | - Giorgia Capocasale
- Section of Dentistry and Maxillofacial Surgery, Department of Surgical Sciences, Paediatrics and Gynecology, University of Verona, 37134 Verona, Italy;
| | - Laura Maniscalco
- Department of Biomedicine, Neuroscience and Advanced Diagnostics, University of Palermo, 90127 Palermo, Italy;
| | - Domenica Matranga
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, 90127 Palermo, Italy;
| | - Olga Di Fede
- Department of Surgical, Oncological and Oral Sciences, University of Palermo, 90127 Palermo, Italy; (A.B.); (O.D.F.); (G.C.)
| | - Giuseppina Campisi
- Department of Surgical, Oncological and Oral Sciences, University of Palermo, 90127 Palermo, Italy; (A.B.); (O.D.F.); (G.C.)
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19
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Nili A, Salehi Farid A, Asgari M, Tavakolpour S, Mahmoudi H, Daneshpazhooh M. Current status and prospects for the diagnosis of pemphigus vulgaris. Expert Rev Clin Immunol 2021; 17:819-834. [PMID: 34162306 DOI: 10.1080/1744666x.2021.1945925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Pemphigus vulgaris (PV) is an intraepidermal autoimmune bullous disease (AIBD) characterized by autoantibodies against desmosomal adhesion proteins, most commonly desmoglein (Dsg)3, leading to the suprabasal cleft formation and acantholysis.Areas covered: Direct immunofluorescence (DIF) and indirect immunofluorescence (IIF) studies display the intercellular deposition of IgG/C3 throughout the epidermis and presence of circulating autoantibodies respectively, as a net-like pattern. However, the target antigen remains unknown using immunofluorescence techniques. Thanks to the development of Dsg ELISA, using recombinant technology, circulating antibodies against Dsg1 and 3 could be detected sensitively. It is possible to differentiate PV from pemphigus foliaceus (PF) using this assay. BIOCHIP mosaic and multivariant ELISA are two novel serologic methods with the added value of the ability to screen several AIBDs simultaneously.Non-Dsg1/3 antigens are also involved in the pathogenesis of PV and investigated more deeply thanks to the protein microarrays technique. Additionally, patients with high values of anti-Dsg1/3 may be lesion-free, suggesting the presence of nonpathogenic autoantibodies.Expert opinion: Newer diagnostic methods to replace traditional techniques should possess high sensitivity and specificity and be widely available, noninvasive, and relatively cheap. The newly developed methods need to be further evaluated before being recommended for routine use.
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Affiliation(s)
- Ali Nili
- Department of Dermatology, Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Salehi Farid
- Department of Dermatology, Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Masoud Asgari
- Department of Pathology and Laboratory Medicine, Yosemite Pathology Medical Group, San Ramon Regional Medical Center, San Ramon, CA, USA
| | - Soheil Tavakolpour
- Department of Dermatology, Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran.,Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Hamidreza Mahmoudi
- Department of Dermatology, Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Daneshpazhooh
- Department of Dermatology, Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran
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20
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Rodriguez Baisi K, Wentworth A, Chattha AJ, DiCaudo DJ, Mangold A, Nelson SA, Siegfried E, Wieland CN, Tollefson M. A rare case of childhood mucous membrane pemphigoid involving the oral and genital mucosa. Pediatr Dermatol 2021; 38:904-907. [PMID: 33977558 DOI: 10.1111/pde.14627] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Mucous membrane pemphigoid (MMP) is a rare chronic immunobullous disease that involves the mucous membranes and may result in significant scarring and complications if diagnosis is delayed. MMP typically occurs in elderly patients, with very few cases reported in children. Here, we present a 12-year-old female patient with childhood-onset oral and genital MMP, clinically suspected to be lichen sclerosus, but eventually diagnosed as MMP after multiple supportive biopsies and confirmatory direct immunofluorescence. Although treatment was challenging, the combined use of systemic corticosteroids, dapsone, and mycophenolate mofetil was ultimately successful in achieving disease control.
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Affiliation(s)
| | | | - Asma J Chattha
- Department of Pediatrics, Mayo Clinic, Rochester, MN, USA
| | - David J DiCaudo
- Department of Dermatology, Mayo Clinic, Scottsdale, AZ, USA.,Department of Laboratory Medicine and Pathology, Mayo Clinic, Scottsdale, AZ, USA
| | - Aaron Mangold
- Department of Dermatology, Mayo Clinic, Scottsdale, AZ, USA
| | | | - Elaine Siegfried
- Department of Pediatric Dermatology, Saint Louis University, Saint Louis, MO, USA
| | | | - Megha Tollefson
- Department of Pediatrics, Mayo Clinic, Rochester, MN, USA.,Department of Dermatology, Mayo Clinic, Rochester, MN, USA
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Tognetti L, Cinotti E, Suppa M, Guazzo R, Habougit C, Santi F, Diet G, Fontaine M, Berot V, Monnier J, Pianigiani E, Del Marmol V, Malvehy J, Perrot JL, Rubegni P. Line field confocal optical coherence tomography: An adjunctive tool in the diagnosis of autoimmune bullous diseases. JOURNAL OF BIOPHOTONICS 2021; 14:e202000449. [PMID: 33583143 DOI: 10.1002/jbio.202000449] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 12/14/2020] [Accepted: 01/27/2021] [Indexed: 05/12/2023]
Abstract
Autoimmune bullous diseases (AIBDs) still represent a considerable a source of morbidity and mortality: early identification of a specific AIBD is often difficult due to overlapping clinical and/or laboratory features and time-consuming invasive laboratory tests. We aimed to investigate the potential role of a new imaging technology, line-field confocal optical coherence tomography (LC-OCT), in the non-invasive diagnosis of AIBDs. LC-OCT was performed at lesional, perilesional and contralateral healthy sites in 30 patients, before histology and direct immunofluorescence. LC-OCT examination was able to identify the level of split (subcorneal/suprabasal/subepidermal/sublamina densa), to provide detailed images of the bulla roof morphology and content (eg, erythrocytes/acantholytic cells/polymorphonucleates). Areas of intra/subepidermal detachment were also detected also at clinically normal perilesional skin sites. LC-OCT can support physicians, real time and at bed-site, in the differential diagnosis of various AIBDs and their mimickers. Moreover, it can be used for the identification of subclinical lesions and therapy tapering.
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Affiliation(s)
- Linda Tognetti
- Dermatology Unit and Skin Bank, Department of Medical, Surgical and Neurosciences, Siena University Hospital, Siena, Italy
| | - Elisa Cinotti
- Dermatology Unit and Skin Bank, Department of Medical, Surgical and Neurosciences, Siena University Hospital, Siena, Italy
| | - Mariano Suppa
- Department of Dermatology, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
- Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
| | - Raffaella Guazzo
- Section of Pathology, Department of Medical Biotechnology, University of Siena, Siena, Italy
| | - Cyril Habougit
- Department of Pathology, University Hospital of Saint-Etienne, Saint Etienne, France
| | - Francesco Santi
- Dermatology Unit and Skin Bank, Department of Medical, Surgical and Neurosciences, Siena University Hospital, Siena, Italy
| | - Gwendoline Diet
- Department of Dermatology, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Margot Fontaine
- Department of Dermatology, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Vincent Berot
- Dermatology Unit, University Hospital of St-Etienne, Saint Etienne, France
| | - Jilliana Monnier
- Dermatology department, AP-HM, Aix-Marseille University, Marseille, France
| | - Elisa Pianigiani
- Dermatology Unit and Skin Bank, Department of Medical, Surgical and Neurosciences, Siena University Hospital, Siena, Italy
| | - Véronique Del Marmol
- Department of Dermatology, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Joseph Malvehy
- Melanoma Unit, Department of Dermatology, University of Barcelona, Barcelona, Spain
| | - Jean-Luc Perrot
- Dermatology Unit, University Hospital of St-Etienne, Saint Etienne, France
| | - Pietro Rubegni
- Dermatology Unit and Skin Bank, Department of Medical, Surgical and Neurosciences, Siena University Hospital, Siena, Italy
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22
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Subepithelial autoimmune blistering dermatoses: Clinical features and diagnosis. J Am Acad Dermatol 2021; 85:1-14. [PMID: 33684496 DOI: 10.1016/j.jaad.2020.11.076] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 11/01/2020] [Accepted: 11/02/2020] [Indexed: 01/19/2023]
Abstract
Subepithelial autoimmune blistering dermatoses are a group of rare skin disorders that are characterized by the disruption of the dermal-epidermal junction through the action of autoantibodies. The third article in this continuing medical education series explores the background, epidemiology, clinical features, and diagnostic criteria of each of the major subepithelial autoimmune blistering dermatoses, including bullous pemphigoid, pemphigoid gestationis, lichen planus pemphigoides, mucous membrane pemphigoid, linear IgA bullous dermatosis, and dermatitis herpetiformis.
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Montagnon CM, Tolkachjov SN, Murrell DF, Camilleri MJ, Lehman JS. Intraepithelial autoimmune blistering dermatoses: Clinical features and diagnosis. J Am Acad Dermatol 2021; 84:1507-1519. [PMID: 33684498 DOI: 10.1016/j.jaad.2020.11.075] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 11/01/2020] [Accepted: 11/02/2020] [Indexed: 01/21/2023]
Abstract
Intraepithelial autoimmune blistering dermatoses are a rare group of skin disorders characterized by the intraepithelial disruption of intercellular connections through the action of autoantibodies. The first article in this continuing medical education series explores the background, epidemiology, clinical features, and diagnostic criteria of each of the major intraepithelial autoimmune blistering dermatoses, including pemphigus foliaceus, pemphigus erythematosus, pemphigus herpetiformis, fogo selvagem, pemphigus vulgaris, pemphigus vegetans, drug-induced pemphigus, IgA pemphigus, IgG/IgA pemphigus, and paraneoplastic pemphigus/paraneoplastic autoimmune multiorgan syndrome.
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Affiliation(s)
| | | | - Dedee F Murrell
- Department of Dermatology, St. George Hospital, University of New South Wales, Sydney, Australia
| | - Michael J Camilleri
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Julia S Lehman
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
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24
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Walton R, Robinson M, Carrozzo M. A service evaluation of the diagnostic testing for mucous membrane pemphigoid in a UK oral medicine unit. J Oral Pathol Med 2020; 49:687-692. [PMID: 32516854 DOI: 10.1111/jop.13054] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 06/02/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Mucous membrane pemphigoid (MMP) is an uncommon bullous disease typically involving the oral cavity. The most commonly used laboratory test for the diagnosis of MMP is direct immunofluorescence (DIF) on fresh perilesional tissue; however, the sensitivity of this test may be hampered by technical difficulties. Immune-serological investigations can also be employed to render a diagnosis. The purpose of this paper was to present an evaluation of diagnostic testing for MMP within an Oral Medicine Unit in UK. METHODS A retrospective analysis of the medical records was undertaken for patients who had undergone biopsy and DIF testing from January 2016 to December 2018. Parameters analysed included clinical presentation, histopathological features, DIF, salt-split skin indirect immunofluorescence, ELISA anti-BP180 and BP 230 and HLA-DQB1*03:01 findings. RESULTS Thirty patients (23 females and 7 males, mean age 66.8 years old) were diagnosed with MMP through a combination of histopathology and serological testing. Sixteen patients (53%) were DIF positive, whereas in 14 (47%), MMP diagnosis was achieved using immune-serologic tests. HLA DQB1*03:01 status was undertaken in 15 DIF-positive and 12 DIF-negative patients, and HLA DQB1*03:01 was found in 73% and 58% of the cases, respectively. CONCLUSIONS This service evaluation has shown that when DIF is informative, it remains the gold standard technique for diagnosis of MMP. However, we have also highlighted the value of serological testing for increasing diagnostic yield for patients with suspected MMP and the potential for HLA DQB1*03:01 as an adjunctive test for the evaluation of MMP.
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Affiliation(s)
- Richard Walton
- Department of Oral Medicine, Newcastle School of Dental Sciences, Newcastle University, Newcastle, UK
| | - Max Robinson
- Department of Cellular Pathology, Royal Victoria Infirmary, Newcastle, UK
| | - Marco Carrozzo
- Department of Oral Medicine, Newcastle School of Dental Sciences, Newcastle University, Newcastle, UK
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25
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Finn DJ, Graham C, Holt DJ, Kelly R, Rajlawat BP, Yesudian PD. Management of mucous membrane pemphigoid in a joint oral medicine-dermatology clinic. Clin Exp Dermatol 2020; 45:685-690. [PMID: 32003042 DOI: 10.1111/ced.14188] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 01/28/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND Mucous membrane pemphigoid (MMP) comprises a group of immunobullous diseases involving the mucosa and skin. Potential sequelae include painful mucosal erosions, vision loss and laryngeal stenosis. AIM To characterize the features of patients with MMP seen within an Oral Medicine setting, including clinical features, immunofluorescence results and response to treatment. METHODS A retrospective case note analysis was undertaken. Treatment effect was divided into response and nonresponse using predetermined adjective terms. RESULTS In total, 42 cases of MMP were identified (18 men, 24 women), mean age 65 years (range 36-85 years). Oral involvement was most common on the gingivae (n = 38; 90.5%) while the most common extraoral sites involved were ocular (n = 13; 31.0%) and skin (n = 12; 28.6%). Features of MMP were found in 21 of 34 (61.8%) of routine biopsies, 31 of 34 (91.2%) direct immunofluorescence samples and 8 of 25 (32.0%) indirect immunofluorescence samples. Topical corticosteroids provided effective symptom control in 9 of 42 cases (21.4%), while systemic therapy was used in 31 of 42 patients (73.8%). Dapsone was prescribed for 25 patients, of whom 18 (72.0%) responded. Mycophenolate mofetil was used in 13 cases and had a response rate of 46.2%. Overall, 27 of 42 patients (64.3%) achieved a response using a tolerable topical or systemic treatment. CONCLUSION This series demonstrates that MMP has a female predominance and is a disease of older age, with a predilection for specific oral sites. Direct immunofluorescence has a high sensitivity in detecting features of MMP. Although some patients achieve adequate symptom control with topical corticosteroids, many require systemic therapy.
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Affiliation(s)
- D J Finn
- Department of Oral Medicine, Liverpool University Dental Hospital, Liverpool, UK
| | - C Graham
- Department of Oral Medicine, Liverpool University Dental Hospital, Liverpool, UK
| | - D J Holt
- Department of Oral Medicine, Liverpool University Dental Hospital, Liverpool, UK
| | - R Kelly
- Department of Oral Medicine, Liverpool University Dental Hospital, Liverpool, UK
| | - B P Rajlawat
- Department of Oral Medicine, Liverpool University Dental Hospital, Liverpool, UK
| | - P D Yesudian
- Department of Oral Medicine, Liverpool University Dental Hospital, Liverpool, UK
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26
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Oral Lesions in Autoimmune Bullous Diseases: An Overview of Clinical Characteristics and Diagnostic Algorithm. Am J Clin Dermatol 2019; 20:847-861. [PMID: 31313078 PMCID: PMC6872602 DOI: 10.1007/s40257-019-00461-7] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Autoimmune bullous diseases are a group of chronic inflammatory disorders caused by autoantibodies targeted against structural proteins of the desmosomal and hemidesmosomal plaques in the skin and mucosa, leading to intra-epithelial or subepithelial blistering. The oral mucosa is frequently affected in these diseases, in particular, in mucous membrane pemphigoid, pemphigus vulgaris, and paraneoplastic pemphigus. The clinical symptoms are heterogeneous and may present with erythema, blisters, erosions, and ulcers localized anywhere on the oral mucosa, and lead to severe complaints for the patients including pain, dysphagia, and foetor. Therefore, a quick and proper diagnosis with adequate treatment is needed. Clinical presentations of autoimmune bullous diseases often overlap and diagnosis cannot be made based on clinical features alone. Immunodiagnostic tests are of great importance in differentiating between the different diseases. Direct immunofluorescence microscopy shows depositions of autoantibodies along the epithelial basement membrane zone in mucous membrane pemphigoid subtypes, or depositions on the epithelial cell surface in pemphigus variants. Additional immunoserological tests are useful to discriminate between the different subtypes of pemphigoid, and are essential to differentiate between pemphigus and paraneoplastic pemphigus. This review gives an overview of the clinical characteristics of oral lesions and the diagnostic procedures in autoimmune blistering diseases, and provides a diagnostic algorithm for daily practice.
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27
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Melchionda V, Harman KE. Pemphigus vulgaris and pemphigus foliaceus: an overview of the clinical presentation, investigations and management. Clin Exp Dermatol 2019; 44:740-746. [DOI: 10.1111/ced.14041] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2019] [Indexed: 12/16/2022]
Affiliation(s)
- V. Melchionda
- Department of Dermatology Leicester Royal Infirmary Leicester UK
| | - K. E. Harman
- Department of Dermatology Leicester Royal Infirmary Leicester UK
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28
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Carey B, Setterfield J. Mucous membrane pemphigoid and oral blistering diseases. Clin Exp Dermatol 2019; 44:732-739. [DOI: 10.1111/ced.13996] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/2019] [Indexed: 01/30/2023]
Affiliation(s)
- B. Carey
- Oral Medicine Dental Institute Guy's and St Thomas’ NHS Foundation Trust London UK
| | - J. Setterfield
- Oral Medicine Dental Institute Guy's and St Thomas’ NHS Foundation Trust London UK
- Centre for Host‐Microbiome Interactions King's College London Faculty of Dentistry, Oral and Craniofacial Sciences London UK
- St John's Institute of Dermatology Guy's and St Thomas’ NHS Foundation Trust London UK
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