Pemphigus foliaceus induced by rifampicin

Drug-induced pemphigus: A systematic review of 170 patients

Pemphigus encompasses a rare heterogeneous group of autoimmune blistering diseases characterized by cutaneous and/or mucosal blistering. Multiple factors, such as some specific types of drugs, have been found to be involved in the induction of pemphigus. Here, we have designed a systematic review by searching PubMed/Medline and Embase databases to find the drugs, involved in pemphigus induction and exacerbation (updated on 19 August 2019). From 1856 initially found articles, 134 studies (198 patients; 170 patients in the drug-induced patients and 28 in exacerbation group) have been included. Regarding drug-induced cases, the mean age was 57.19 ± 16.9-year-old (ranged 8-105), and patients had developed pemphigus within a mean of 154.27 days. Pemphigus vulgaris (38.9%), pemphigus foliaceus (33.5%), and paraneoplastic pemphigus (3.6%) were the most common subtypes. Furthermore, penicillamine (33.1%), captopril (7.7%), and bucillamine (6.5%) were the most reported drugs related to pemphigus induction; penicillamine was associated with the most persistent disease. Regardless of disease subtype, cutaneous, mucocutaneous, and mucosal involvements were reported in 68.6%, 30.1%, and 1.3% of patients, respectively. In total, the IgG deposition in the pathological studies, being positive for autoreactive antibodies in the serum against desmoglein 3 (Dsg3), and desmoglein 1 (Dsg1), were reported in 93%, 34.9%, and 72.7% of reported patients, respectively. Regarding the management of such patients, in 75% of healed cases, treatment (mainly transient systemic and topical corticosteroids and/or azathioprine) was needed besides stopping the probable pemphigus-inducing culprit drug, while drug cessation was enough to control the disease in 25%. As the outcomes, the lesions in 129 of 147 (87.8%) patients had been healed, while in 18 (12.2%), no healing was reported; fifteen out of 18 had died. In conclusion, some specific groups of treatments can induce pemphigus, including penicillamine, captopril, and bucillamine; despite the similar clinical and pathological manifestations to classical pemphigus, most of the cases are less severe and have a better prognosis.

Diagnosis and clinical features of pemphigus foliaceus

Pemphigus foliaceus is an acquired autoimmune blistering disease in which the body's immune system produces IgG autoantibodies that target the intercellular adhesion glycoprotein desmoglein-1, which is principally expressed in the granular layer of the epidermis, resulting in the loss of intercellular connections between keratinocytes (acantholysis) and the formation of subcorneal blisters within the epidermis. This article summarizes the epidemiology, clinical features, techniques for diagnosis, and drugs associated with treatment of this rare disease.

Hypersensitivity reactions to rifampin. Pathogenetic mechanisms, clinical manifestations, management strategies, and review of the anaphylactic-like reactions

Many of the adverse events induced by rifampin have been considered allergic in origin. The flu-like syndrome and other hypersensitivity reactions seem to be caused by immune complexes, although their pathogenetic mechanisms are not fully elucidated. Many cases have been reported of the flu-like syndrome, thrombocytopenia, hemolytic anemia, and renal failure caused by rifampin. In almost all of the patients in whom they were sought, nonreaginic antirifampin antibodies were detected. On the other hand, anaphylactic reactions seem to be IgE-mediated. We have analyzed the 18 reported cases of anaphylactic reactions severe enough to cause marked hypotension. The interval between the onset of treatment and the anaphylactic reaction was highly variable. Most patients presented with prodromes, mainly rash, before the development of anaphylactic symptoms, and, in most cases, the reaction occurred after reexposure to rifampin. Clinical findings include a variety of symptoms, such as fever, exanthem, dyspnea, abdominal pain, and vomiting. Seven of the 9 patients in whom HIV status was known were seropositive, including the only 2 patients who died. We believe that, in case of a non-life-threatening adverse reaction caused by immune complexes, rifampin could be readministered, if necessary, at a more frequent and reduced dose, perhaps with the addition of corticosteroids. In case of anaphylactic reactions the drug should be avoided, although desensitization procedures may be useful. Certain laboratory findings may serve as a clue to predict anaphylactic reactions in patients who have experienced minor adverse events to rifampin. However, the diagnostic value of such findings is not well established and, therefore, patients with previous adverse reactions should be carefully monitored if reexposure to rifampin is essential.

In vitro acantholysis induced by D-penicillamine, captopril, and piroxicam on dead de-epidermized dermis

Drug-induced pemphigus has been recognized for 20 years, but the mechanisms leading to acantholysis are still unclear. It has recently been demonstrated that penicillamine, captopril, and thiopronin may produce acantholytic lesions, either by direct toxic or biochemical effect, in human skin explants. Our work confirms that penicillamine and captopril may induce acantholysis on the model of keratinocyte culture on dead, de-epidermized dermis. Moreover, it demonstrates that piroxicam, a new non-steroidal anti-inflammatory drug, of which one side effect is a pemphigus vulgaris-like eruption, is also able to produce in vitro acantholysis.

Endemic pemphigus foliaceus (fogo selvagem). I. Clinical features and immunopathology

Endemic pemphigus foliaceus is an autoimmune disease that has remarkable features. Endemic foci are found in characteristic environments within the interior of Brazil. The epidemiologic data strongly suggest that an environmental factor initiates the autoantibody response in the host. As such it is an important disease for in-depth study. A group of interested investigators in both Brazil and the United States has been formed to attempt to do just that. As part of the overall effort, this Cooperative Research Group for the Study of Fogo Selvagem presents a definition of the disease, a proposed clinical classification for various forms of the disease, and an outline of what is currently known of its immunopathologic characteristics.

Human pemphigus autoantibodies are pathogenic to squamous epithelium

In 1957, Witbesky et al. put forward several criteria that ideally should be fulfilled in order to prove the pathogenic role of an autoantibody in a putative autoimmune disease. There can now be very little doubt of the autoimmune nature of this disease and of the primary role of autoantibodies in its pathogenesis. The evidence that supports the concept that pemphigus autoantibodies are of primary pathogenic importance in the disease is as follows: IgG class autoantibodies can be found both circulating in the serum and bound to the epithelial cell surfaces in and around lesions in patients with pemphigus. These autoantibodies, purified from the serum of pemphigus patients, can induce acantholytic lesions typical of pemphigus both in experimental animals (neonatal mice) and in human and murine epidermal cell cultures. These autoantibodies react with a specific antigen of the epidermal cell. This purified antigen has been used to immunize rabbits and the resulting antibodies are capable of inducing pemphigus-like lesions in neonatal mice.

Exacerbation of pemphigus by rifampicin

Rifampicin therapy caused exacerbation of skin lesions, rising serum pemphigus antibody titres, and decreased serum betamethasone levels in a 59-year-old man with pemphigus vulgaris. Exacerbation of pemphigus was confined to the period of rifampicin therapy and seems to be best explained by the effect of rifampicin on the metabolism of betamethasone. Physicians prescribing rifampicin for the treatment of tuberculosis should be aware of its potential to produce such an important adverse reaction.