Childhood ocular mucous membrane pemphigoid successfully treated with rituximab

Challenges and advances in ocular mucous membrane pemphigoid (OMMP); from pathogenesis to treatment strategies

PURPOSE

Mucous membrane pemphigoid (MMP) is a systemic autoimmune condition characterized by blistering and cicatrization, predominantly affecting mucous membranes, including those lining the esophagus, oropharynx, nasal cavity, trachea, conjunctiva, and genitalia. Ocular mucous membrane pemphigoid (OMMP) is observed in approximately 70% of MMP cases. This study aims to review the pathophysiology, clinical manifestations, diagnosis, treatment, and complications of OMMP.

METHODS

A literature search was conducted using MEDLINE and EMBASE databases.

RESULTS

OMMP is characterized by the deposition of autoantibodies along the basement membrane zone of mucous membranes, particularly affecting the conjunctival epithelium. OMMP manifests as chronic ocular discomfort, inflammation, conjunctival scarring, eyelid abnormalities, and visual impairment. Given the extensive range of similar conditions, including drug-induced pseudo-pemphigoid and paraneoplastic conjunctival cicatrization, challenges in differential diagnosis may arise. The clinical diagnosis of OMMP is supported by confirmatory biopsy with histopathology and immunofluorescence studies. The mainstay of management includes systemic immunomodulatory medications and anti-inflammatory agents, tailored to disease severity. Surgical interventions may be necessary, although caution is warranted due to the risk of exacerbating OMMP. Prompt diagnosis and treatment are essential to halt disease progression and prevent vision loss. Complications of OMMP include corneal disorders, lid disorders, and vision disturbances. A comprehensive understanding of OMMP aids in timely intervention and improved patient outcomes.

CONCLUSION

OMMP is a bilateral, chronic, progressive, relapsing-remitting condition. Early diagnosis and treatment of OMMP are necessary to prevent disease progression. The management of OMMP varies according to the severity of the disease, but often involves both medical control of the underlying inflammatory process and subsequent surgical correction of residual anatomical changes.

Ocular involvement in autoimmune bullous diseases

Autoimmune bullous diseases represent a heterogenous group of disorders caused by autoantibodies against adhesion molecules; the location of the target protein determines the level of cleft formation. The spectrum of ocular lesions in autoimmune bullous diseases can range from mild symptoms to severe involvement with sight impairment and even, in some cases, blindness. In pemphigus vulgaris, the prevalence of ocular involvement has been reported to be between 7% and 26%. The most common clinical sign of ocular pemphigus vulgaris is bilateral conjunctivitis with hyperemia. Ocular involvement also occurs in 41% to 70% of patients with paraneoplastic pemphigus. The main ocular manifestations are bilateral cicatrizing conjunctivitis with symblepharon formation, and shortening of the fornices. In mucous membrane pemphigoid, ocular involvement is seen in 61% to 70% of patients; the most frequent ocular finding is cicatricial conjunctivitis. Patients with autoimmune bullous diseases having common ocular involvement should be assessed by an ophthalmologist to avoid serious complications. Diagnostic procedures and treatment require multidisciplinary care based on the close cooperation between dermatologists and ophthalmologists.

[Clinical aspects of ocular mucosal pemphigoid]

Mucosal pemphigoid is a rare chronic autoimmune disease that also affects the eyes in more than two thirds of all cases. Especially in the early phase of the ocular manifestation, the findings are subtle and the disease is often not recognized. The aim of this article is to provide the clinical aspects of ocular mucosal pemphigoid so that timely diagnostics can be initiated when this disease is suspected.

Surgical Management of Ocular Cicatricial Pemphigoid in a Pediatric Patient

PURPOSE

The purpose of the report was to describe the first successful tarsal fracture surgery in a 1-year-old boy diagnosed with cicatricial ocular pemphigoid whose visual and psychomotor development were notably limited.

METHODS

We present the case of a 1-year-old boy diagnosed with mucous membrane pemphigoid by biopsy who was treated with rituximab (375 mg/m 2 intravenous infusion at 2-week interval administered twice) and stable with oral dapsone (2 mg·kg -1 ·d -1 ). His eyelid cicatricial entropion and trichiasis in both eyes prevented him from opening his eyes, impeding visual development. After 1 year of clinical stability, we performed a tarsal fracture procedure in both eyes to restore eyelid anatomy and functionality, with the aim to prevent an inflammatory reaction, administrating intravenous dexamethasone before and after surgery.

RESULTS

The intervention was successfully performed without postoperative complications. Excellent anatomic and functional results allowed him to develop normally in his daily life the first week after surgery. He is currently taking oral dapsone (2 mg·kg -1 ·d -1 ) as a maintenance treatment to stop the progression of the disease.

CONCLUSIONS

Tarsal fracture surgery may be considered part of the treatment in pediatric patients with stable ocular cicatricial pemphigoid presenting with severe entropion and trichiasis.

Use of rituximab in the treatment of mucous membrane pemphigoid: An analytic review

Mucous Membrane Pemphigoid (MMP) is a potentially fatal mucocutaneous autoimmune blistering disease. Autoantibodies are produced against various components of the dermo-epidermal or mucosal-submucosal junction are referred to as basement membrane zone (BMZ). The hallmark is deposition of of Ig and C3 on the perilesional tissues and in some patients detection of anti-BMZ autoantibodies. A unique characteristic of MMP is that as the blisters or erosions heal, they leave irreversible scarring. This scarring results in serious and catastrophic sequelae that affect the quality of life. Conventional therapy consists of anti-inflammatory and immunosuppressive agents (ISA). In patients who fail conventional therapy or develop significant side effects to them, rituximab (RTX) has been used off label. In this review, the clinical outcomes of patients with MMP treated with RTX were studied. 124 patients were identified, 47.58% being male. 72 patients were treated by the Lymphoma Protocol and 51 by Rheumatoid Arthritis (RA) protocol. Follow up for the entire cohort was 36 months (range 0.5-72). On follow-up 64 patients (51.61%) achieved complete clinical remission (CR) off therapy, 25 patients (20.16%) were in CR on therapy, 5 patients (4.03%) were non-responders, and 9 patients (7.25%) were failures. 52 patients (41.93%) experienced a relapse, after 36 months follow-up. Duration between last RTX infusion and relapse was 10.5 months (range 1-30). Most patients with relapses were treated with additional RTX. A statistically significant better outcome was observed in patients treated with RTX as monotherapy compared to those who received RTX with ISA. Clinical outcomes in patients treated with Lymphoma protocol were better than RA protocol at a statistically significant level. Data on CD20+ B cell depletion and repopulation was limited. Interestingly relapses were seen in patients with CD20+ B cell depletion and after repopulation. In the final analysis, 89 patients (71.77%) were in complete remission. Data in this review indicated that RTX was a useful agent to treat MMP. While a randomized control trial may not be practically possible, better and disease specific protocols need to be developed. When publishing, authors should attempt to provide complete and detailed information. In doing so, they will benefit their colleagues and the patients with MMP they treat with RTX.

Ocular mucous membrane pemphigoid: novel treatment strategies

PURPOSE OF REVIEW

To describe current treatments of ocular mucous membrane pemphigoid (OMMP), including conventional systemic immunosuppression (CIST) and novel biologic agents.

RECENT FINDINGS

CIST remains the main stay therapy for the management of OMMP. The choice of agents is tailored to disease severity - mild disease is treated with dapsone, whereas moderately severe cases are often treated with mycophenolate mofetil or sulfa-based drugs and severe cases are treated with cyclophosphamide. In recalcitrant disease newer biologics such as Rituximab, intravenous immunoglobins and tumour necrosis alpha antagonists have proven to be effective in disease control. Control of inflammation with topical therapy and halting conjunctival fibrosis remain as areas of unmet clinical needs.

SUMMARY

OMMP is largely treated with CIST. The recent introduction of new biologic agents could shape the way the disease is treated in the near future.

A rare case of childhood mucous membrane pemphigoid involving the oral and genital mucosa

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.

Laryngeal mucous membrane pemphigoid serves as a prognostic factor for poor response to treatment with rituximab

Mucous membrane pemphigoid (MMP) is an autoimmune blistering, scarring and occasionally mutilating disease that may progress to blindness or airway obstruction. Over the past few years, rituximab (RTX) has emerged as a potential therapeutic solution for MMP; however, the literature regarding its efficacy in the treatment of severe MMP is sparse. We studied four patients with recalcitrant MMP who were treated with RTX. Three of these had recalcitrant laryngeal disease; two were unresponsive to RTX, while the third patient achieved complete remission (CR) but relapsed twice. The fourth patient, who had oral and ocular disease, also achieved CR. In addition, we reviewed 143 cases of MMP treated with RTX reported in the literature to date. Of these, 120 had late observation endpoints, of whom 81 (67.5%) achieved CR, 24 (20%) received partial remission and 15 (12.5%) had no remission. Based on this study, the presence of laryngeal MMP seems to predict refractoriness to RTX treatment. In conclusion, we found that RTX can ameliorate the MMP course and that laryngeal involvement, which is known to be a prognostic factor for severe MMP, may also predict poor response to RTX.

Disease Relapse After Drug-Free Remission in Ocular Mucous Membrane Pemphigoid

PURPOSE

To quantitate the risk of relapse of ocular and extraocular disease among patients with mucous membrane pemphigoid (MMP) who had undergone drug-free remission.

DESIGN

Retrospective, comparative, interventional case series.

METHODS

There were 167 patients with biopsy-proven MMP who were seen at the Wilmer Eye Institute between November 1984 and December 2019. Among the 167 patients, 119 patients had ocular involvement and 103 of those patients received systemic treatment for MMP. The main outcome measures were the incidence of ocular remission, incidence rate of disease relapse after remission, and risk factors for disease relapse.

RESULTS

Over a median follow-up time of 7 years, 74 of 103 treated patients (71.8%) experienced drug-free remission (incidence rate = 0.28/person-year [PY], 95% confidence interval [CI] 0.22-0.35/PY). Most patients (80/103, 77.7%) received cyclophosphamide therapy. Thirteen of the 74 patients (17.6%) had disease relapse after remission: 4 with ocular disease only, 4 with extraocular disease only, and 5 with both. The rate relapse of ocular MMP was 0.020/PY (95% CI 0.009-0.038/PY), and the rate of relapse of MMP at any site (ocular or extraocular site) was 0.029/PY (95% CI 0.015-0.050/PY). The use of cyclophosphamide was associated with a greater chance of remission (hazard ratio [HR] = 3.84, P < .0001) and a lower risk of relapse (HR = 0.32, P = .05) compared with other immunosuppressive drugs except for rituximab. Five patients experienced drug-free remission after rituximab therapy and none of them had relapse (median follow-up after remission = 3.6 years). When use of cyclophosphamide or rituximab was compared with all other treatments, the risk of MMP relapse at any site (HR = 0.17, P = .02) and of ocular MMP (HR = 0.11, P = .007) were significantly lower.

CONCLUSIONS

Rates of relapse of MMP after drug-free remission are low but not zero; therefore, monitoring of patients remains necessary. Relapses were not observed among those patients treated with rituximab who had remission; however, follow-up duration in those patients was shorter than the whole MMP cohort and the sample size was small.