Paraneoplastic pemphigus: a subset of patients with pemphigus and neoplasia

Cutaneous paraneoplastic syndromes

A variety of cutaneous abnormalities can be seen in patients with malignant diseases, some of which are infectious, with others representing direct involvement of the skin by the underlying disorder. Yet another group of lesions can be regarded as associated markers of the malignant process, and, as such, are termed "paraneoplastic." This review considers the latter collection of conditions, grouping them by the generic type of malignancy that is usually linked to the paraneoplasia. Some of the processes show a predominant association with alimentary tract malignancies (acanthosis nigricans, acrodermatitis paraneoplastica, florid cutaneous papillomatosis, necrolytic migratory erythema, palmoplantar keratoderma, pancreatic fat necrosis, and pityriasis rotunda). Others are usually linked to a hematolymphoid malignancy (acquired ichthyosis, exfoliative erythroderma, necrobiotic xanthogranuloma, pemphigus paraneoplastica, plane xanthoma, pyoderma gangrenosum, scleromyxedema, Sweet syndrome, and leukocytoclastic vasculitis). Finally, yet another collection of paraneoplastic skin disorders can associate themselves with anatomically-diverse malignancies (Leser-Trelat syndrome, Trousseau syndrome, dermatomyositis, erythema gyratum repens, hypertrichosis lanuginosa acquisita, papuloerythroderma of Ofuji, tripe palms, and multicentric reticulohistiocytosis). Recognition of these processes by the pathologist can be a valuable step in the characterization of underlying malignant diseases.

Acute oral ulcers

Accurate diagnosis of acute oral ulcers can be challenging. Important historic details include the pattern of recurrence, anatomic areas of involvement within the mouth and elsewhere on the mucocutaneous surface, associated medical symptoms or comorbidities, and symptomology. Careful mucocutaneous examination is essential. When necessary, biopsy at an active site without ulceration is generally optimal. Depending on the clinical scenario, supplemental studies that may be useful include cultures; perilesional biopsy for direct immunofluorescence testing; and evaluation for infectious diseases, gluten sensitivity, inflammatory bowel disease, human immunodeficiency virus infection, connective tissue diseases, or hematinic deficiencies. Clinicians should maintain a broad differential diagnosis when evaluating patients with acute oral ulcers.

Imaging in the investigation of paraneoplastic syndromes

Paraneoplastic syndromes are a heterogeneous group of disease presentations caused by underlying tumours. As they are non-metastatic in nature an intensive diagnostic evaluation is warranted to identify potentially curable lesions. The selection of the appropriate method of imaging is important in these cases, especially when history and physical examination are unrevealing. In this review the important paraneoplastic syndromes and underlying malignancies are discussed along with relevant imaging strategies.

Paraneoplastic pemphigus without an underlying neoplasm

We describe a 52-year-old man with paraneoplastic pemphigus (PNP) without any evidence of an underlying neoplasm over an 8-year follow-up period. He had a chronic relapsing vesiculobullous eruption for approximately 7 years (from April 1998 to May 2005). Initially, scattered flaccid vesicles with crusts developed on the face and trunk, which waxed and waned several times. Our patient was diagnosed as having PNP based on immunopathological criteria for PNP, i.e. histopathological, immunoblotting and immunoprecipitation analyses. However, physical and laboratory examinations including serial blood tests with peripheral blood smear, whole-body positron emission tomography/computed tomography and abdominal ultrasound were unable to detect any underlying neoplasm over an 8-year follow-up period.

Antidesmoplakin antibodies in pemphigus vulgaris

BACKGROUND

Besides being present in paraneoplastic pemphigus (PNP), circulating antidesmoplakin (DP) antibodies have been found anecdotally in other bullous diseases, including pemphigus foliaceus and pemphigus vulgaris.

OBJECTIVES

To verify how frequent anti-DP antibodies are in pemphigus vulgaris.

METHODS

We studied 48 sera from patients with proven pemphigus vulgaris (29 mucosal dominant pemphigus and 19 mucocutaneous pemphigus) by indirect immunofluorescence (IIF) with rat bladder epithelium (RBE) as a substrate and by immunoblotting (IB) on human keratinocyte cultures enriched in DP.

RESULTS

Ten sera (21%) were positive in IIF on RBE. By IB, eight sera proved to have antibodies to both DP I (250 kDa) and DP II (210 kDa), one serum had antibodies directed to DP I only, and two sera to DP II only.

CONCLUSIONS

Our data confirm that RBE is not a specific IIF substrate for the serological diagnosis of PNP. It remains a sensitive and specific substrate for the detection of anti-DP antibodies, which, in patients with pemphigus vulgaris, are probably caused by an epitope-spreading phenomenon.

Pénfigo

Pemphigus is an infrequent, organ-specific, autoimmune bullous disease, which affects the skin, mucous membranes and appendages. Histopathologically, it is characterized by acantholysis. Pemphigus has classically been divided into two major groups, pemphigus vulgaris and pemphigus foliaceus, with their respective clinical variants pemphigus vegetans and pemphigus erythematosus. In recent years, new variants of pemphigus have been described: paraneoplastic pemphigus, IgA pemphigus and pemphigus herpetiformis. This article reviews the epidemiology, etiopathogenesis, clinical symptoms, diagnosis, treatment and prognosis of pemphigus. Advances in molecular biology techniques have made it possible to more precisely identify the different antigens against which antibodies are directed, and to fine-tune ELISA diagnostic techniques. Treating pemphigus vulgaris and foliaceus with general steroids has modified their prognosis; it is estimated that mortality in recent decades is less than 10 %. Managing the clinical complications that appear during the evolution of the pemphigus has contributed to reducing morbidity and mortality.

Paraneoplastic autoimmune multiorgan syndrome (paraneoplastic pemphigus) in a child: case report and review of the literature

Paraneoplastic autoimmune multiorgan syndrome, also known as paraneoplastic pemphigus, has been observed only rarely among children. We describe a 10-year-old boy with typical clinical and histologic findings of paraneoplastic pemphigus associated with Castleman's disease. His disease was refractory to resection of the tumor and aggressive combination immunosuppressive therapies. The patient died 1 year after presentation, as a result of complications of bronchiolitis obliterans. This case is unusual because of the young age of the patient.

Progressive Respiratory Failure in Paraneoplastic Pemphigus Associated with Chronic Lymphocytic Leukemia

A 70-year-old Caucasian man with chronic lymphocytic leukemia suffered from widespread, histologically proven cutaneous lichen planus responding to topical corticosteroids. 2 years later, he presented with painful erosive stomatitis and increasing dyspnea. Histology, direct and indirect immunofluorescence were diagnostic for paraneoplastic pemphigus. A full diagnostic workup could not disclose the cause of the progressive respiratory insufficiency. Despite aggressive treatment of the lymphocytic leukemia and the paraneoplastic pemphigus, the patient died 3 months after diagnosis. Paraneoplastic pemphigus may lead to pulmonary failure which is refractory to treatment and has a fatal outcome.

Paraneoplastic pemphigus: an association with fludarabine?

Paraneoplastic pemphigus is a relatively recently described immunobullous disease with characteristic features. We report three cases of paraneoplastic pemphigus in adult men with chronic lymphocytic leukaemia arising within a week of completion of treatment with fludarabine. In all cases, withdrawal of fludarabine and treatment of the blistering was associated with marked cutaneous improvement. Fludarabine, a synthetic nucleoside analogue, which has only been available in Britain since 1994, is known to be associated with autoimmune phenomena and may have been involved in the development of paraneoplastic pemphigus in these cases.

Paraneoplastic pemphigus in association with a retroperitoneal Castleman's disease presenting with a lichen planus pemphigoides-like eruption. A case report and review of literature

A 50-year-old man presented with severe mucosal erosions of the lips, oral cavity and perianal area, a lichen planus-like eruption on the trunk and extremities and scaly plaques of the palms and soles. The clinical impression was of Stevens--Johnson syndrome, or paraneoplastic pemphigus (PNP). Histopathology revealed vacuolar interface and lichenoid dermatitis with dyskeratosis and suprabasal acantholytic vesiculation. Direct immunofluorescence showed deposition of IgG in the intercellular space and linear deposition of C3 along the basal membrane zone. Indirect immunofluorescence revealed circulating IgG with intercellular staining of the epithelium of rat urinary bladder. Western blotting demonstrated bands of 250- and 230-kDa antigens. The clinical, histological and immunological features were consistent with the lichen planus pemphigoides variant of PNP. A retroperitoneal hyaline-vascular Castleman's disease was detected and excised. The skin lesions worsened initially after tumour resection but improved gradually, leaving extensive melanosis after cyclosporin and mycophenolate mofetil treatment.

Paraneoplastic pemphigus as the initial presentation of chronic lymphocytic leukemia

The case history of a 61-year-old male patient is described, who presented with severe stomatitis, conjunctivitis and leukocytosis. The diagnosis chronic lymphocytic leukemia (CLL) stage A (0) was made, for which no treatment was necessary. Progression of stomatitis and conjunctivitis and erythosquamous skin lesions with bullae and vesiculae formation developed. Under the diagnosis of bullous pemphigoid the patient was treated with corticosteroids. The histologic and immunofluorescence examination of a skin biopsy was compatible with this diagnosis, and antibodies to skin could not be detected in a first serum sample. Pseudomonas was cultured from all lesions, the corticosteroids were stopped and antibiotic treatment was started, without clear effect. Because of progression of skin lesions and debilitation, the patient finally declined all treatment and died five weeks after admission. Post-mortem examination showed enlarged lymphnodes in the cervical, aortal en iliacal areas, with histology confirming the diagnosis of CLL. Indirect immunofluorescence with the second serum sample showed auto-antibodies in high titer directed against the intercellular epithelial substance. Immunoblot studies showed binding with the classic target antigens in paraneoplastic pemphigus. Re-examination of the histologic skin specimen and the result of direct immunofluorescence were in retrospect compatible with the diagnosis of paraneoplastic pemphigus.

Sensitivity and specificity of clinical, histologic, and immunologic features in the diagnosis of paraneoplastic pemphigus

BACKGROUND

Paraneoplastic pemphigus (PNP) is an autoimmune blistering disease characterized by the production of autoantibodies mainly directed against proteins of the plakin family. An overlapping distribution of autoantibody specificities has been recently reported between PNP, pemphigus vulgaris (PV), and pemphigus foliaceus (PF), which suggests a relationship between the different types of pemphigus.

OBJECTIVE

Our purpose was to evaluate the sensitivity and the specificity of clinical, histologic, and immunologic features in the diagnosis of PNP.

METHODS

The clinical, histologic, and immunologic features of 22 PNP patients were retrospectively reviewed and compared with those of 81 PV and PF patients without neoplasia and of 8 PV and 4 PF patients with various neoplasms.

RESULTS

One clinical and 2 biologic features had both high sensitivity (82%-86%) and high specificity (83%-100%) whatever the control group considered: (1) association with a lymphoproliferative disorder, (2) indirect immunofluorescence (IIF) labeling of rat bladder, and (3) recognition of the envoplakin and/or periplakin bands in immunoblotting. Two clinicopathologic and two biologic features had high specificity (87%-100%) but poor sensitivity (27%-59%): (1) clinical presentation associating erosive oral lesions with erythema multiforme-like, bullous pemphigoid-like, or lichen planus-like cutaneous lesions; (2) histologic picture of suprabasal acantholysis with keratinocyte necrosis, interface changes, or lichenoid infiltrate; (3) presence of both anti-epithelial cell surface and anti-basement membrane zone antibodies by IIF; and (4) recognition of the desmoplakin I and/or BPAG1 bands in immunoblotting. Interestingly, 45% of patients with PNP presented initially with isolated oral erosions that were undistinguishable from those seen in PV patients, and 27% had histologic findings of only suprabasal acantholysis, which was in accordance with the frequent detection of anti-desmoglein 3 antibodies in PNP sera.

CONCLUSION

The association with a lymphoproliferative disorder, the IIF labeling of rat bladder, and the immunoblotting recognition of envoplakin and/or periplakin are both sensitive and specific features in the diagnosis of PNP.

Graft-versus-host disease-like immunophenotype and apoptotic keratinocyte death in paraneoplastic pemphigus

Paraneoplastic pemphigus (PP) is an autoimmune disease, which is frequently associated with non-Hodgkin's lymphoma. Autoantibodies against components of the cytoplasmic plaque of epithelial desmosomes are usually present in the sera and are believed to play a major pathogenic part in acantholysis and suprabasal epidermal blistering. However, another typical histological feature of PP, interface dermatitis with keratinocyte dyskeratosis, is shared with skin diseases that involve epithelial damage mediated by T cells. Here, we present the detailed characterization of the cutaneous T-cell response in a patient with PP and demonstrate a selective epidermal accumulation of activated CD8+ T cells together with an increased local production of interferon-gamma and tumour necrosis factor-alpha, and a strong expression of HLA-DR and ICAM-1 on keratinocytes. Apoptosis was identified as a key mechanism of keratinocyte death, and appeared independent of the FAS/FAS ligand (FAS-L) pathway, as epidermal expression of FAS was not increased compared with normal skin, and FAS-L was undetectable on the protein and mRNA level. Triple therapy with high-dose corticosteroids, cyclophosphamide and intravenous immunoglobulins reduced levels of pemphigus-like autoantibodies and reversed the cutaneous inflammatory reaction leading to long-standing clinical remission. Our findings support the concept of a major contribution of cytotoxic T lymphocytes to the immunopathology of paraneoplastic pemphigus.

Paraneoplastic pemphigus with fatal pulmonary involvement in a woman with a mesenteric Castleman tumour

A 42-year-old woman presented with oral and labial erosions, conjunctivitis, facial rash and lichenoid erythematous papules on the trunk. Paraneoplastic pemphigus (PNP) was suspected, and a search for a neoplasm revealed an intra-abdominal Castleman tumour sized 7 x 5 x 6 cm. After removal of the Castleman tumour, the skin and mucosal inflammation gradually subsided over the next 12 months. However, due to irreversible pulmonary involvement the patient died of intractable respiratory distress 2 years after the onset of the disease. Systemic corticosteroids, azathioprine, cyclophosphamide, high-dose intravenous immunoglobulins and thalidomide were ineffective. The diagnosis of PNP was confirmed by keratinocyte antigen immunoprecipitation with the patient's serum.

Paraneoplastic pemphigus with a pemphigus vegetans-like plaque as the only cutaneous manifestation

Paraneoplastic pemphigus (PNP) is a recently recognized autoimmune mucocutaneous disease associated with a few unusual lymphoreticular neoplasms. Intractable stomatitis is the most constant clinical feature but the cutaneous presentations are characteristically variable. We describe a patient with PNP associated with chronic lymphocytic leukemia who presented with severe oral, laryngeal, and pharyngeal involvement. The only cutaneous finding was a pemphigus vegetans-like plaque, a previously undescribed manifestation. The plaque evolved from a flaccid blister that formed at a prior intravenous catheter site. The mucosal biopsy specimen demonstrated faint intercellular staining with IgG, whereas results for the cutaneous plaque were negative. Indirect immunofluorescence testing was positive on both monkey esophagus and rat bladder epithelium. Immunoprecipitation (IP) studies demonstrated a complex of 4 proteins with molecular weights of 250, 230, 210, and 190 kd, confirming the diagnosis of PNP.

Paraneoplastic pemphigus as the presenting symptom of a lymphoma of the tongue

A patient is described who initially presented with an acrovesicular eczema which subsequently developed into erythema multiforme with histopathological features of bullous pemphigoid. Although the various laboratory studies pointed to the diagnosis of paraneoplastic pemphigus (PNP), the underlying neoplasm was not detected until 6 months later, when the biopsies of an oral lesion showed the presence of an underlying non-Hodgkin lymphoma.

Recurrent pemphigus vulgaris limited to the surgical area after mastectomy

A 45-year-old Japanese female presented with bullae and erosions on the trunk in December 1987. The histologic findings revealed a suprabasal cleft and acantholytic cells. Immunofluorescence staining showed IgG autoantibodies in the intercellular spaces. With a working diagnosis of pemphigus vulgaris, she was treated successfully with low dosage prednisolone. Adenocarcinoma of the right breast was found in March 1994, and she received a mastectomy followed by breast reconstruction that used a transverse rectus abdominis muscle flap. Six months later, vesicobullous eruptions developed and were limited to the surgical area (right chest and abdomen). The histopathologic and direct immunofluorescence findings were consistent with pemphigus vulgaris. Although these skin lesions improved with high dosages of prednisolone, she died of multiple metastases due to the breast cancer.

Molecular biological aspects of acquired bullous diseases

Bullous diseases of the oral mucosa and skin were originally classified on the basis of clinical and histological criteria. The discovery of autoantibodies in some of these patients and the introduction of molecular biology have resulted in a new understanding of the pathological mechanisms of many of the bullous lesions. In this article, updated topics of the immune-mediated bullous lesions which involve oral mucosa and skin are reviewed. Pemphigus antigens, which are desmosomal-associated proteins and belong to the cadherin superfamily of cell adhesion proteins, have been isolated, and their genes have been cloned. The antigens which react with autoantibodies from patients with bullous pemphigoid, cicatricial pemphigoid, acquired epidermolysis bullosa, and linear IgA disease are all proteins of the hemidesmosome basement membrane complex. Interestingly, most of the antigens also appear to be the target for mutations seen in patients with the inherited type of epidermolysis bullosa in which bullous lesions are a prominent clinical feature.

Localized mucosal involvement and severe pulmonary involvement in a young patient with paraneoplastic pemphigus associated with Castleman's tumour

We describe a 19-year-old female patient who developed recurrent ulcerations limited to the orogenital mucosa for the last 3 years. She also developed dyspnoea 5 months after the onset of the orogenital lesions. Castleman's tumour of the retroperitoneum was found incidentally during routine physical examination. The diagnosis of paraneoplastic pemphigus (PNP) was made by pathological and immunological studies. The orogenital ulceration responded well to corticosteroid therapy, but severe bronchiolitis obliterans progressed despite intensive care. The patient eventually died from respiratory failure. This case demonstrates the diversity of clinical features of paraneoplastic pemphigus.

Paraneoplastic pemphigus: report of a case

A 56-year-old male with chronic lymphocytic leukemia developed extensive erosive mucocutaneous lesions with histologic acantholysis. Immunopathologic studies showed IgG deposition at the intercellular space, C3 deposition at both the intercellular space and the dermo-epidermal junction, and reactivity of the serum to rat urinary bladder epithelium. Autoantibodies in the serum to human epidermal proteins of 210 kD and 190 kD were shown by Western blotting and to proteins of 250 kD, 210 kD, and 190 kD by immunoprecipitation. All these data suggest the diagnosis of paraneoplastic pemphigus. Repeated plasmapheresis resulted in re-epithelialization of the mucocutaneous lesions and reduction in antibody titer from 1:1280 to 1:20. Although this mucocutaneous disease was established as a new autoimmune bullous disease by Anhalt et al. (1990), cases have rarely been reported from Japan. The present patient demonstrates the major characteristics of paraneoplastic pemphigus.

Vesiculobullous disease of the oral cavity

This article reviews the clinical features of vesiculobullous diseases with oral manifestations. Oral vesiculobullous diseases may be viral, immunologically mediated, drug induced, hereditary, or traumatic in origin. A general approach to the diagnosis is outlined, including immunofluorescent testing of suspected vesiculobullous disease. Recommendations for treatment of oral vesiculobullous diseases are included.

[Paraneoplastic pemphigus: review of the literature, apropos of a case associated with chronic lymphoid leukemia]

In 1990, Anhalt et al described a newly autoimmune bullous disease: paraneoplastic pemphigus, in five patients. It was characterized by a distinct set of circulating autoantibodies from those in the sera of patients with pemphigus vulgaris and superficial pemphigus. We report a 71 year-old man with chronic lymphocytic leukemia of 4 years duration who developed a severe mucocutaneous eruption with clinical and immunofluorescence findings of pemphigus vulgaris evolving into an oral bullous lichen planus presentation. Evaluation of his serum confirmed the presence of autoantibodies specific for paraneoplastic pemphigus by indirect immunofluorescence on rat-bladder and immunoprecipitation. Subsequently, additional cases have been reported in the literature. All occurred in patients with various neoplastic conditions. These patients present with polymorphous skin lesions and severe erosive oral disease. Histologic examination shows interface dermatitis and keratinocyte necrosis in addition to acantolysis. Direct immunofluorescence may reveal deposition of immunoglobulin and/or complement at the basement membrane as well as deposition on epithelial cell surfaces. Circulating IgG anti-cell-surface antibodies are detectable with both stratified and stratified epithelia as substrates. These antibodies immunoprecipitate a complex of four desmosomal proteins, including desmoplakin I (250 kDa), the bullous pemphigoid antigen (230 kDa), desmoplakin II (210 kDa) and a 190 kDa antigen.

Mucocutaneous paraneoplastic manifestations of hematologic malignancies

PURPOSE

To review the clinical manifestations, pathophysiology, and oncologic implications of the major mucocutaneous paraneoplastic syndromes that can appear in patients with hematologic malignancies.

METHODS

A comprehensive search of the medical literature was conducted.

RESULTS

In vesiculobullous conditions, although the primary lesions are blisters, observed abnormalities may include large, flaccid bullae (pemphigus vulgaris), superficial crusted erosions (pemphigus foliaceus), or erythema multiforme-like lesions (paraneoplastic pemphigus). Paraneoplastic neutrophilic dermatoses include Sweet's syndrome and pyoderma gangrenosum. In both of these conditions, the skin lesions are characterized by a dermal infiltrate of mature neutrophils. Vascular dermatoses include vasculitis and erythromelagia. Papulosquamous conditions are characterized by small (papules) or large (plaques) raised skin lesions and are usually associated with solid tumors. Amyloidosis is a malignancy-related condition that probably stems from immune dysregulation.

RECOMMENDATIONS

Continued surveillance of patients with potential cutaneous paraneoplastic syndromes is necessary, since the malignancy may not be immediately detectable. Some of the cutaneous paraneoplastic syndromes will respond to specific measures, such as systemic corticosteroid therapy, but for the most part, successful resolution requires eradication of the underlying malignancy.

Accuracy of indirect immunofluorescence testing in the diagnosis of paraneoplastic pemphigus

BACKGROUND

Paraneoplastic pemphigus (PNP) is an autoimmune disease defined in part by autoantibodies with unique specificity. Initial reports suggested that indirect immunofluorescence with rodent bladder epithelium was highly reliable in detecting these autoantibodies.

OBJECTIVE

We compared the sensitivity and the specificity of indirect immunofluorescence in the diagnosis of PNP in a large number of cases.

METHODS

Indirect immunofluorescence was performed on stratified squamous epithelium of monkey esophagus and mouse tongue, bladder, liver, and myocardium. Sera were obtained from 28 patients with PNP and from 29 control subjects with autoimmune blistering diseases.

RESULTS

The sensitivity of murine bladder as a substrate was 75%, with a specificity of 83%. Indirect immunofluorescence on liver was specific (96.5%) but insensitive (43%). Sensitivity and specificity with myocardium were intermediate.

CONCLUSION

Indirect immunofluorescence on murine bladder epithelium is an adequate screening test for PNP but is negative or indeterminate in as many as one fourth of patients. Negative indirect immunofluorescence does not exclude the diagnosis of PNP, and immunochemical techniques such as immunoprecipitation must be performed.

Paraneoplastic pemphigus: a case of prolonged survival

OBJECTIVE

To describe a patient with severe, recalcitrant mucous membrane erosions and chronic lymphocytic leukemia.

DESIGN

We present a case report and a literature review of paraneoplastic pemphigus.

MATERIAL AND METHODS

Immunofluorescence studies and immunoprecipitation confirmed the presence of autoantibodies characteristic of paraneoplastic pemphigus in the patient's serum.

RESULTS

Our patient lived almost 8 years after the onset of paraneoplastic pemphigus, the longest time that anyone with this disease is known to have survived.

CONCLUSION

The clinical course of paraneoplastic pemphigus tends to be rapid and fatal despite immunosuppressive therapy. Long-term survival is uncommon.

Paraneoplastic pemphigus: a case with high titer of circulating anti-basement membrane zone autoantibodies

Multiple flaccid bullae, erosions, and tense bullae developed in a 67-year-old man with chronic lymphocytic leukemia. A biopsy specimen revealed features of typical pemphigus vulgaris (suprabasilar clefting with acantholysis), paraneoplastic pemphigus (necrotic keratinocytes and hydropic degeneration in addition to acantholysis), and bullous pemphigoid (subepidermal separation and epidermal regeneration). Direct and indirect immunofluorescence studies revealed deposits of immunoglobulins and C3 within the intercellular substance and basement membrane zone in some specimens. Immunoprecipitation of serum revealed four polypeptides with molecular weights of 250, 230, 210, and 190 kd.

Pemphigus vulgaris associated with spindle cell thymoma

This paper describes the occurrence of fatal pemphigus vulgaris in an 89 year old female, in whom a benign spindle cell thymoma was found at autopsy. The histological appearances of the skin biopsies, thymic tumour and immunofluorescence findings are described. The association between pemphigus and neoplasia is discussed, and the difference between classical pemphigus vulgaris and paraneoplastic pemphigus are evaluated.