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Kartan S, Shi VY, Clark AK, Chan LS. Paraneoplastic Pemphigus and Autoimmune Blistering Diseases Associated with Neoplasm: Characteristics, Diagnosis, Associated Neoplasms, Proposed Pathogenesis, Treatment. Am J Clin Dermatol 2017; 18:105-126. [PMID: 27878477 DOI: 10.1007/s40257-016-0235-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Autoimmune paraneoplastic and neoplasm-associated skin syndromes are characterized by autoimmune-mediated cutaneous lesions in the presence of a neoplasm. The identification of these syndromes provides information about the underlying tumor, systemic symptoms, and debilitating complications. The recognition of these syndromes is particularly helpful in cases of skin lesions presenting as the first sign of the malignancy, and the underlying malignancy can be treated in a timely manner. Autoimmune paraneoplastic and neoplasm-associated bullous skin syndromes are characterized by blister formation due to an autoimmune response to components of the epidermis or basement membrane in the context of a neoplasm. The clinical manifestations, histopathology and immunopathology findings, target antigens, associated neoplasm, current diagnostic criteria, current understanding of pathogenesis, and treatment options for a selection of four diseases are reviewed. Paraneoplastic pemphigus manifests with clinically distinct painful mucosal erosions and polymorphic cutaneous lesions, and is often associated with lymphoproliferative neoplasm. In contrast, bullous pemphigoid associated with neoplasm presents with large tense subepidermal bullae of the skin, and mild mucosal involvement, but without unique clinical features. Mucous membrane pemphigoid associated with neoplasm is a disorder of chronic subepithelial blisters that evolve into erosions and ulcerations that heal with scarring, and involves stratified squamous mucosal surfaces. Linear IgA dermatosis associated with neoplasm is characterized by annularly grouped pruritic papules, vesicles, and bullae along the extensor surfaces of elbows, knees, and buttocks. Physicians should be aware that these autoimmune paraneoplastic and neoplasm-associated syndromes can manifest distinct or similar clinical features as compared with the non-neoplastic counterparts.
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Vassileva S, Drenovska K, Manuelyan K. Autoimmune blistering dermatoses as systemic diseases. Clin Dermatol 2014; 32:364-75. [DOI: 10.1016/j.clindermatol.2013.11.003] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Abstract
The presence of one autoimmune disorder helps lead to the discovery of other autoimmune conditions. It is thought that diseases in which autoimmunity is a feature tend to be associated together more often than one can ascribe to chance. A variety of diseases have been implicated in the onset of intraepidermal and subepidermal autoimmune diseases. The presence of one autoimmune disease should alert the physician to watch for a second immunologic disorder. A list of autoimmune bullous diseases associations includes autoimmune bullous diseases, pemphigus, pemphigoid, epidermolysis bullosa acquisita, dermatitis herpetiformis (Duhring), linear immunoglobulin A disease, and multiple autoimmune syndrome.
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Affiliation(s)
- Suzana Ljubojevic
- University Department of Dermatology and Venereology, University Hospital Center Zagreb, School of Medicine,University of Zagreb, Croatia.
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Abstract
Linear immunoglobulin A (IgA) bullous dermatosis, also known as linear IgA disease, is an autoimmune mucocutaneous disorder characterized by subepithelial bullae, with IgA autoantibodies directed against several different antigens in the basement membrane zone. Its immunopathologic characteristic resides in the presence of a continuous linear IgA deposit along the basement membrane zone, which is clearly visible on direct immunofluorescence. This disorder shows different clinical features and distribution when adult-onset of linear IgA disease is compared with childhood-onset. Diagnosis is achieved via clinical, histopathologic, and immunopathologic examinations. Two common therapies are dapsone and sulfapyridine, which reduce the inflammatory response and achieve disease remission in a variable period of time.
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Affiliation(s)
- Giulio Fortuna
- Department of Dermatology, Program in Epithelial Biology, Stanford University School of Medicine, CA 94305, USA
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Celiac disease in the elderly. ACTA ACUST UNITED AC 2008; 5:697-706. [DOI: 10.1038/ncpgasthep1281] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2008] [Accepted: 09/22/2008] [Indexed: 12/16/2022]
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Coban S, Palabiyikoğlu M, Ensari A, Idilman R, Köklü S, Yolcu OF, Ormeci N. Intestinal B cell lymphoma associated with chronic hepatitis C and celiac disease. Dig Dis Sci 2005; 50:2359-61. [PMID: 16416190 DOI: 10.1007/s10620-005-3063-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2004] [Accepted: 11/03/2004] [Indexed: 12/20/2022]
MESH Headings
- Abdomen, Acute/diagnosis
- Abdomen, Acute/surgery
- Aged
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Biopsy, Needle
- Celiac Disease/complications
- Celiac Disease/diagnosis
- Celiac Disease/therapy
- Colonic Diseases/complications
- Colonic Diseases/diagnosis
- Colonic Diseases/surgery
- Follow-Up Studies
- Hepatitis C, Chronic/complications
- Hepatitis C, Chronic/diagnosis
- Hepatitis C, Chronic/drug therapy
- Humans
- Immunohistochemistry
- Laparotomy
- Lymphoma, B-Cell/complications
- Lymphoma, B-Cell/diagnosis
- Lymphoma, B-Cell/drug therapy
- Lymphoma, Non-Hodgkin/complications
- Lymphoma, Non-Hodgkin/diagnosis
- Lymphoma, Non-Hodgkin/drug therapy
- Male
- Risk Assessment
- Severity of Illness Index
- Treatment Outcome
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Affiliation(s)
- Sahin Coban
- Department of Gastroenterology, Ankara University Medical School, Ankara, Turkey.
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Salmhofer W, Soyer HP, Wolf P, Födinger D, Hödl S, Kerl H. UV light–induced linear IgA dermatosis. J Am Acad Dermatol 2004; 50:109-15. [PMID: 14699378 DOI: 10.1016/s0190-9622(03)02120-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Various exogenous factors (eg, drugs, dietary antigens, trauma, infections, radiographs, and UV radiation) are known to induce or aggravate skin diseases. UV radiation in particular is known to induce or aggravate the autoimmune bullous diseases of pemphigus foliaceus, pemphigus vulgaris, and bullous pemphigoid. Its role in linear IgA dermatosis, however, is not well recognized. We report the second case of linear IgA dermatosis induced by intense sun exposure in which blistering was induced by UVA radiation. Furthermore, a review of the literature on photoinduced autoimmune bullous diseases and the wavelengths responsible for the induction of blistering is presented and several proposed mechanisms of action for the blister induction, including release or unmasking of antigens, promotion of antibody fixation by UV radiation, and launching of an inflammatory process, are discussed. We conclude that linear IgA dermatosis should be added to the list of autoimmune bullous diseases induced and/or aggravated by UV radiation.
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Varadarajulu S, Lewin D. Enteropathy-associated T-cell lymphoma involving the colon and extraintestinal B-cell lymphoma in celiac disease. Dig Dis Sci 2003; 48:1298-302. [PMID: 12870786 DOI: 10.1023/a:1024103108527] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Shyam Varadarajulu
- The Digestive Disease Center, Suite 210 CSB, Medical University of South Carolina, 96 Jonathan Lucas Street, Charleston, South Carolina 29425, USA
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Keller AS, Bouldin MB, Drage LA, Hauser SC, Davis MDP. Linear IgA bullous dermatosis: an association with ulcerative colitis versus renal cell carcinoma. Dig Dis Sci 2003; 48:783-9. [PMID: 12741472 DOI: 10.1023/a:1022805329847] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
MESH Headings
- Biopsy
- Carcinoma, Renal Cell/diagnosis
- Carcinoma, Renal Cell/immunology
- Carcinoma, Renal Cell/pathology
- Colitis, Ulcerative/diagnosis
- Colitis, Ulcerative/immunology
- Colitis, Ulcerative/pathology
- Diagnosis, Differential
- Humans
- Immunoglobulin A/blood
- Kidney Neoplasms/diagnosis
- Kidney Neoplasms/immunology
- Kidney Neoplasms/pathology
- Male
- Microscopy, Fluorescence
- Middle Aged
- Paraneoplastic Syndromes/diagnosis
- Paraneoplastic Syndromes/immunology
- Paraneoplastic Syndromes/pathology
- Skin/immunology
- Skin/pathology
- Skin Diseases, Vesiculobullous/diagnosis
- Skin Diseases, Vesiculobullous/immunology
- Skin Diseases, Vesiculobullous/pathology
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Affiliation(s)
- A Scott Keller
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota, USA
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Holló P, Preisz K, Nemes L, Bíró J, Kárpáti S, Horváth A. Linear IgA dermatosis associated with chronic clonal myeloproliferative disease. Int J Dermatol 2003; 42:143-6. [PMID: 12709006 DOI: 10.1046/j.1365-4362.2003.01438_2.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- P Holló
- Department Dermato-Venerology, Semmelweis University, Budapest, Hungary.
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Abstract
Coeliac disease is characterized by gluten intolerance and immunologically mediated damage to small intestinal mucosa. Patients classically present with gastrointestinal symptoms including chronic diarrhoea, steatorrhoea, weight loss, anorexia and abdominal distension. In a substantial proportion of cases however, gastrointestinal symptoms are minor or absent, and cutaneous manifestations may provide an early clue to diagnosis. Early recognition of coeliac disease, with appropriate implementation of a gluten-free diet, may reduce the incidence of benign and malignant complications associated with this condition.
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Affiliation(s)
- E Poon
- Monash Medical Centre, Melbourne, Victoria, Australia.
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Abstract
Coeliac disease is an inflammatory disorder of the small intestine induced by dietary gluten. This frequently results in malabsorption of a range of important nutrients including iron, folic acid, calcium and fat-soluble vitamins. Coeliac disease in now considered to be a common disorder, possibly affecting 1:300 of the general population. Many patients present in adulthood, have minimal symptoms, and gastrointestinal manifestations are frequently absent. The diagnosis and screening for coeliac disease has been dramatically facilitated by testing for endomysial autoantibodies, although biopsy and demonstration of a characteristic histological lesion remains the definitive diagnostic investigation. Treatment with a gluten-free diet is effective but requires good patient compliance and monitoring to succeed.
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Affiliation(s)
- N P Kennedy
- Department of Clinical Medicine, Trinity College, Dublin, Ireland
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Affiliation(s)
- C A Egan
- Medicine Service, Section of Dermatology, Salt Lake City Veterans Affairs Medical Center, Utah, USA
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Swensson O, Stüber E, Nickel T, Sticherling M, Ghohestani RF, Nitsche R, Christophers E. Linear IgA disease associated with lymphocytic colitis. Br J Dermatol 1999; 140:317-21. [PMID: 10233230 DOI: 10.1046/j.1365-2133.1999.02670.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
A 66-year-old woman presented with a bullous skin eruption and chronic diarrhoea. Lesional skin showed subepidermal blistering, and direct immunofluorescence of perilesional skin revealed linear deposits of IgA at the dermoepidermal junction, establishing a diagnosis of linear IgA disease (LAD). Chronic watery diarrhoea complicated by substantial loss of body weight preceded the skin eruption for several months. On endoscopy, the colon appeared macroscopically normal. On histology, the colon mucosa showed increased numbers of intraepithelial lymphocytes and infiltrates of mononuclear cells in the lamina propria, indicative of lymphocytic colitis. Treatment with methylprednisolone and dapsone led to complete clearing of the bullous skin eruption and marked improvement of the patient's diarrhoea. Gastrointestinal disorders such as lymphocytic colitis have rarely been reported in patients with LAD. Whether the simultaneous occurrence of these two diseases is coincidental or due to related pathogenetic mechanisms remains to be seen.
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Affiliation(s)
- O Swensson
- Departments of Dermatology and Internal Medicine, University of Kiel, Schittenhelmstr., 24105 Kiel, Germany
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Abstract
A 63-year-old man presented with an intensely pruritic vesiculo-bullous eruption on the limbs and was subsequently found to have an IgA kappa multiple myeloma. The eruption clinically and histologically was suggestive of linear IgA disease (LAD), dermatitis herpetiformis (DH), epidermolysis bullosa acquisita (EBA), or bullous lupus erythematosus (LE), with the skin biopsy revealing subepidermal bullae and dermal papillary micro-abscesses. However, direct immunofluorescence showed a unique pattern of diffuse dermal IgA staining. Although chemotherapy produced a dramatic resolution of the lesions, which paralleled the fall in serum IgA paraprotein level, the myeloma later became progressive and the resulting paraprotein increase was accompanied by recurrence of the eruption. We propose that this patient's rash was the presenting manifestation of his multiple myeloma, and was a consequence of transudation of IgA paraprotein into the dermis.
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Affiliation(s)
- D A Wong
- Department of Dermatology, Westmead Hospital, Sydney, New South Wales, Australia
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Chiou AG, Florakis GJ, Kazim M. Management of conjunctival cicatrizing diseases and severe ocular surface dysfunction. Surv Ophthalmol 1998; 43:19-46. [PMID: 9716191 DOI: 10.1016/s0039-6257(98)00005-8] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Physical or chemical injuries, infections, immunologic oculocutaneous disorders, drugs, and various systemic disorders may cause scarring of the conjunctiva and disturbances of the ocular surface. Trichiasis, lid margin malposition, and dry eye may result in persistent ocular irritation. The cornea may be primarily or secondarily involved. If severe, disturbances of the ocular surface may lead to significant visual impairment. Thorough evaluation of patients and of the underlying disease process is required for optimal management. Treatment may be challenging and should be comprehensive, combining medical measures and surgical correction of structural changes. Suppression of exogenous irritants, treatment of dry eye, antiinflammatory therapy, and immunosuppressants are paramount to control the underlying disease and allow optimal surgical results. Surgical correction of trichiasis and lid margin malposition, conjunctival grafting, mucous membrane transplantation, limbal stem cell transplantation, amniotic membrane transplantation, and penetrating keratoplasty help reestablish a physiologic ocular surface. Severe cases may require keratoprosthetics for visual rehabilitation. Corneal ulceration or perforation requires prompt attention to maintain ocular integrity. Special measures should be considered for patients who require cataract or glaucoma surgery.
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Affiliation(s)
- A G Chiou
- Edward S. Harkness Eye Institute, Columbia Presbyterian Medical Center, New York, New York 10032, USA
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Abstract
The increased incidence of lymphoma in celiac sprue (CS) is well documented, and the risk of developing this malignancy is 40-100-fold greater than in the general population. The author believes that gluten may also be at the root of lymphomas in asymptomatic and latent celiac sprue, as well. Among the 20-30% of the population which has the HLA factors most common in celiac, increased intestinal permeability leads to absorption of macromolecular peptides with opioid activity, which derive from pepsin digests of wheat. The presence, in the bloodstream, of these peptides may increase the risk of lymphomas for the entire hereditary group, which includes CS. Several processes contribute to the effect that is herein hypothesized, including opioid attachment at the hypothalamic-pituitary-adrenal axis (HPA), and subsequent downregulation of production of natural killer cells. This may offer an explanation for our longstanding awareness that there is an 'impaired lymphocyte reactivity against tumor cells in patients with coeliac disease' which may also apply to first-degree relatives with the same HLA markers.
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