Efficacy and safety of adjuvant immunoadsorption in pemphigus vulgaris and pemphigus foliaceus (IA-Pem Study): a multicentre randomized controlled trial

BACKGROUND

Pemphigus vulgaris (PV) and pemphigus foliaceus (PF) are potentially life-threatening autoimmune blistering diseases. Treatment is based on long-term immunosuppression with high doses of glucocorticosteroids in combination with potentially corticosteroid-sparing agents and/or rituximab. Immunoadsorption (IA) has emerged as a fast-acting adjuvant treatment option.

OBJECTIVES

To assess the clinical efficacy of IA in addition to best medical treatment (BMT).

METHODS

We conducted a multicentre (26 centres from Germany and Austria) randomized controlled trial in 72 patients with newly diagnosed, relapsed or chronic active PV or PF (34 female patients and 38 male patients, aged 42-72 years) comparing BMT (prednisolone 1.0 mg kg-1 per day plus azathioprine or mycophenolate) with adjuvant IA (BMT + IA). Central 1 : 1 randomization was done at the coordinating centre for clinical trials (KKS Marburg). The primary endpoint was analysed using Kaplan-Meier and Cox regression methods.

RESULTS

The study was ended prematurely owing to safety concerns after random allocation of 72 patients to BMT + IA (n = 34) or BMT (n = 38). The primary endpoint, time to complete remission on therapy, was not significantly different for the two groups [hazard ratio (HR) 1.35, 95% confidence interval (CI) 0.68-2.69; P = 0.39]. The cumulative dose of prednisolone was significantly lower in the BMT + IA group compared with BMT alone (difference -1214, 95% CI -2225 to -70; P = 0.03). In a post hoc analysis, patients with more extensive PV/PF showed a tendency towards a shorter time to remission in the BMT + IA group compared with the BMT group (HR 1.87, P = 0.17 in patients with baseline Pemphigus Disease Area Index ≥ 15). While more adverse events were observed in patients in the BMT group (29 vs. 25), severe adverse events were more frequent in patients in the BMT + IA group (17 events in 10 patients vs. 11 events in 8 patients).

CONCLUSIONS

In this study, adjuvant IA did not demonstrate a shorter time to clinical remission, but a corticosteroid-sparing effect was observed. In patients with extensive PV/PF, post hoc analysis suggests that adjuvant IA may lead to earlier remission, but potential adverse events must be carefully weighed against the expected benefits.

Serum reactivity in dermatitis herpetiformis: an international multicentre study

BACKGROUND

Dermatitis herpetiformis (DH) is a rare gluten-induced skin disorder characterized predominantly by IgA autoantibodies against endomysium, tissue transglutaminase (TG2/tTG), epidermal transglutaminase (TG3/eTG) and deamidated gliadin. To date, circulating autoantibody reactivity has not been systematically described.

OBJECTIVES

Characterization of serum reactivities in DH.

METHODS

This multicentre international study analysed sera from 242 patients with DH taken at the time of initial diagnosis. DH-specific IgA and IgG serum autoantibodies were analysed by indirect immunofluorescence (IF) on monkey oesophagus, and by enzyme-linked immunosorbent assay (ELISA) based on recombinant TG2/tTG, TG3/eTG and deamidated gliadin (GAF3X).

RESULTS

IgA indirect IF microscopy on monkey oesophagus revealed the highest reactivity (84.3%; specificity 100%) followed by IgA TG2/tTG ELISA (78.5%, specificity 99.0%), IgA TG3/eTG ELISA (72.7%, specificity 95.0%) and IgA GAF3X ELISA (69.0%, specificity 98.5%).

CONCLUSIONS

Serum IgA and IgG autoantibodies against endomysium, TG2/tTG, TG3/eTG and deamidated gliadin are highly prevalent in DH. Indirect IF microscopy on monkey oesophagus (IgA) provides the highest diagnostic accuracy that can be further enhanced by 4.5% when combined with IgA TG2/tTG ELISA.

Divergent in situ expression of IL-31 and IL-31RA between bullous pemphigoid and pemphigus vulgaris

Bullous pemphigoid (BP) and pemphigus vulgaris (PV) are two major autoimmune blistering skin diseases. Unlike PV, BP is accompanied by intense pruritus, suggesting possible involvement of the pruritogenic cytokine IL-31. However, the underlying mechanisms of the clinical difference between BP and PV in terms of pruritus are not fully understood. To compare the expression levels of IL-31 and its receptor IL-31RA in the lesional skin, including peripheral nerves in BP and PV patients, immunohistochemical staining for IL-31 and IL-31RA was performed in skin samples of BP and PV patients and healthy controls (HC). The IL-31RA-expressing area in epidermis and peripheral nerves was analysed using ImageJ and the percentage of positive cells for IL-31/IL-31RA in dermal infiltrating cells was manually quantified. Quantitative analyses revealed that IL-31/IL-31RA expressions in the epidermis and dermal infiltrate were significantly increased in BP compared to PV and HC. The difference between BP and PV became more obvious when advanced bullous lesions were compared. Peripheral nerves in BP lesions presented significantly higher IL-31RA expression compared to PV lesions. In conclusion, we found significantly augmented expressions of IL-31/IL-31RA in BP lesions, including peripheral nerves, in comparison to PV. These results suggest a possible contribution of IL-31/IL-31RA signalling to the difference between BP and PV in the facilitation of pruritus and local skin inflammation, raising the possibility of therapeutic targeting of the IL-31/IL-31RA pathway in BP patients.

Serum autoantibody reactivity in bullous pemphigoid is associated with neuropsychiatric disorders and the use of antidiabetics and antipsychotics: a large prospective cohort study

BACKGROUND

Bullous pemphigoid (BP), the by far most frequent autoimmune blistering skin disease (AIBD), is immunopathologically characterized by autoantibodies against the two hemidesmosomal proteins BP180 (collagen type XVII) and BP230 (BPAG1 or dystonin). Several comorbidities and potentially disease-inducing medication have been described in BP, yet, a systematic analysis of these clinically relevant findings and autoantibody reactivities has not been performed.

OBJECTIVE

To determine associations of autoantibody reactivities with comorbidities and concomitant medication.

METHODS

In this prospective multicenter study, 499 patients diagnosed with BP in sixteen European referral centers were included. The relation between anti-BP180 NC16A and anti-BP230 IgG ELISA values at the time of diagnosis as well as comorbidities and concomitant medication collected by a standardized form were analyzed.

RESULTS

An association between higher serum anti-BP180 reactivity and neuropsychiatric but not atopic and metabolic disorders was observed as well as with the use of insulin or antipsychotics but not with dipeptidyl peptidase-4 (DPP4) inhibitors, inhibitors of platelet aggregation and L-thyroxine. The use of DPP4 inhibitors was associated with less anti-BP180 and anti-BP230 reactivity compared to BP patients without these drugs. This finding was even more pronounced when compared with diabetic BP patients without DPP4 inhibitors. Associations between anti-BP180 and anti-BP230 reactivities were also found in patients using insulin and antipsychotics, respectively, compared with patients without this medication, but not for the use of inhibitors of platelet aggregation, and L-thyroxine.

CONCLUSION

Taken together, these data imply a relation between autoantibody reactivities at the time of diagnosis and both neuropsychiatric comorbidities as well as distinct concomitant medication suggesting a link between the pathological immune mechanisms and clinical conditions that precede the clinically overt AIBD.

[Reality of inpatient vasoactive treatment with prostacyclin derivatives in patients with acral circulation disorders due to systemic sclerosis in Germany]

Hintergrund

Das Raynaud-Phänomen und die damit häufig einhergehenden digitalen Ulzerationen stellen für Patienten mit systemischer Sklerose (Sklerodermie [SSc]) ein frühes und sehr belastendes Symptom mit bedeutenden Einschränkungen der Arbeitsfähigkeit und Lebensqualität dar. Der Einsatz vasoaktiver Medikamente (insbesondere intravenöser Prostazyklinderivate) soll helfen, das Risiko hypoxischer Gewebeschäden bis hin zum Verlust der Finger zu reduzieren.

Methoden

Um Aufschluss über die aktuelle Versorgung von Patienten mit Prostazyklinderivaten im klinischen Alltag in Deutschland zu erhalten, führten wir eine Umfrage unter den im Deutschen Netzwerk für systemische Sklerodermie (DNSS) zusammengeschlossenen Kliniken durch. Zusätzlich erfolgte eine separate Patientenbefragung über die Sklerodermie Selbsthilfe e. V., die sich nur auf die Symptome „Raynaud-Phänomen“ und „Digitale Ulzera“ und den Einsatz intravenöser Prostazyklinderivate bezog.

Ergebnisse

Von den befragten 433 Patienten gaben 56 % an, dass sie bereits aufgrund ihrer Erkrankung und Symptome mit Prostazyklinderivaten behandelt wurden. Insgesamt 61 % erhielten die Therapie aufgrund starker Raynaud-Symptomatik und 39 % aufgrund digitaler Ulzerationen. Die meisten Befragten erfuhren durch die Therapie nicht nur eine Verbesserung des Raynaud-Phänomens und der digitalen Ulzera, sondern auch eine wesentliche Verbesserung von Einschränkungen im Alltag. Sie gaben zudem an, wesentlich weniger fremde Hilfe in Anspruch genommen sowie wesentlich weniger Fehlzeiten bei der Arbeit gehabt zu haben.

Schlussfolgerung

Die Patienten empfanden durchweg einen positiven Effekt der Therapie mit Prostazyklinderivaten auf das Raynaud-Phänomen, ihre digitalen Ulzerationen, Schmerzen und Alltagseinschränkung und fühlten sich durch die stationäre Therapie gut und sicher betreut. Diese positiven Effekte in der Patientenwahrnehmung sind eine eindrückliche Stütze und bestätigen nachdrücklich die auf europäischer und internationaler Ebene erarbeiteten Therapieempfehlungen.

Zusatzmaterial online

Die Online-Version dieses Beitrags (10.1007/s00393-019-00743-9) enthält die 2 Fragebögen, die für die Befragung verwendet wurden. Beitrag und Zusatzmaterial stehen Ihnen auf www.springermedizin.de zur Verfügung. Bitte geben Sie dort den Beitragstitel in die Suche ein, das Zusatzmaterial finden Sie beim Beitrag unter „Ergänzende Inhalte“.

Factors associated with serious intent to die among suicide attempters in Hungary

As suicide attempts pose major risk for future suicide death, understanding the underlying factors of suicide attempts and suicidal behaviour is an important mental health imperative. The aim of this study was to examine suicide attempts with a special focus on the intention. A total of 2540 discharge summaries were collected between 2009 and 2011 in Miskolc, Hungary, and a content analysis was conducted. Data regarding the method, the reason for suicide attempts, the amount, the source, and the type of the medication taken were examined. Deliberate self-poisoning was the most frequent method (73.8%) committed with more than 200 different types of drugs. 40.5% of the patients attempted suicide with an intent to die, whilst 35.6% of the patients wanted to escape from an unbearable situation. Older age groups, greater amount of taken pills, and affective disorders were associated with self-reported serious intention to die. Our findings should be taken into consideration when monitoring drugs for older patients with depressive disorders.

Effects of Short-Term Moisturizer Application in Different Ethnic Skin Types: Noninvasive Assessment with Optical Coherence Tomography and Reflectance Confocal Microscopy

BACKGROUND/AIMS

Ethnic skin types are known to differ in their morphological and physiological features. Thus, treatment responses may vary among different races. We aimed to assess skin morphology of different ethnicities and to compare the effect of short-term moisturizer application using optical coherence tomography (OCT) and reflectance confocal microscopy (RCM).

METHODS

Thirty healthy female subjects of European, Asian and Black ethnicity at 30-45 years of age were included in the study. OCT and RCM imaging was performed on the cheek to compare morphology. Following the 2-week application of a moisturizer cream (Sebamed® lotion) on one forearm, imaging was performed on both forearms to assess and compare treatment responses.

RESULTS

Epidermal thickness and morphology of pores varied between the three ethnic groups, with Black subjects displaying the thickest epidermis and largest skin pores. On the treated forearm, OCT measurements revealed a significantly thicker epidermis in all groups as compared to the untreated forearm. Width of skin folds on the treated forearm was measured by RCM to be significantly lower in all ethnic groups as compared to the untreated forearm.

CONCLUSION

Different ethnic skin types showed variations in skin morphology and treatment response to short-term moisturizer application. OCT and RCM were useful methods for noninvasive, real-time, repeated assessment of ethnic skin.

Different signaling patterns contribute to loss of keratinocyte cohesion dependent on autoantibody profile in pemphigus

Pemphigus is an autoimmune blistering skin disease caused primarily by autoantibodies against desmoglein (Dsg)1 and 3. Here, we characterized the mechanisms engaged by pemphigus IgG from patients with different clinical phenotypes and autoantibody profiles. All pemphigus vulgaris (PV) and pemphigus foliaceus (PF) IgG and AK23, a monoclonal mouse antibody against Dsg3, caused loss of cell cohesion, cytokeratin retraction and p38MAPK activation. Strong alterations in Dsg3 distribution were caused by mucosal (aDsg3 antibodies), mucocutaneous (aDsg1 + aDsg3) as well as atypical (aDsg3) PV-IgG. All PV-IgG fractions and AK23 compromised Dsg3 but not Dsg1 binding and enhanced Src activity. In contrast, rapid Ca²⁺ influx and Erk activation were induced by mucocutaneous PV-IgG and pemphigus foliaceus (PF) IgG (aDsg1) whereas cAMP was increased by mucosal and mucocutaneous PV-IgG only. Selective inhibition of p38MAPK, Src or PKC blocked loss of keratinocyte cohesion in response to all autoantibody fractions whereas Erk inhibition was protective against mucocutaneous PV-IgG and PF-IgG only. These results demonstrate that signaling patterns parallel the clinical phenotype as some mechanisms involved in loss of cell cohesion are caused by antibodies targeting Dsg3 whereas others correlate with autoantibodies against Dsg1. The concept of key desmosome regulators may explain observations from several experimental models of pemphigus.

Diagnostic Value of Linear Fluorescence Along the Basement Membrane of Sweat Gland Ducts in Bullous Pemphigoid

Linear IgG deposits along the basement membrane of adnexa has been proposed to be useful in the diagnosis of bullous pemphigoid (BP), but no controlled studies have been performed. This study evaluated linear IgG fluorescence of the basement membrane of sweat gland ducts (SGD) and other adnexa in perilesional biopsies from patients with BP (n = 64) and controls (n = 82), using direct immunofluorescence microscopy. Fluorescence intensity was graded semi-quantitatively. Positive SGDs were found in 58 (90.6%) patients with BP and 44 (53.7%) controls, a statistically significant difference (p < 0.0001). The sensitivity of positive SGDs for BP was high (90.6%), but the specificity was low (46.3%). Only strong fluorescence intensity was associated with high specificity. In conclusion, positive SGDs in direct immunofluorescence microscopy are highly sensitive for BP; however, only strong fluorescence has acceptable specificity. Weak positivity of SGDs without linear fluorescence of the epidermal basement membrane may not be sufficiently specific for BP.

[Inflammatory diseases of oral mucous membranes]

BACKGROUND

Mucous membranes are involved in many different inflammatory disorders.

METHODS

We describe the clinical features, diagnostic workup, and therapy of inflammatory diseases of mucous membranes.

RESULTS

The diagnostic workup is based on medical history, clinical manifestations, histopathology, and serology. Inadequate dental hygiene is one of the main pathogenetic factors. Treatment options depend on the diagnosis, underlying cause, and disease severity. Both local and systemic immunosuppressive or immunomodulatory strategies may be effective.

CONCLUSIONS

The diagnostic and therapeutic management of inflammatory mucous membrane disorders is usually more difficult than that of skin diseases and requires interdisciplinary cooperation.

Complement Fixation Test: An Update of an Old Method for Diagnosis of Bullous Pemphigoid

The complement fixation test (CFT) is a method traditionally used for diagnosis of gestational pemphigoid. Its performance in diagnosis of bullous pemphigoid (BP) has not been investigated in a large patient cohort. The aim of this single-centre, retrospective, serological case-control study of 300 patients with BP and 136 control patients was to analyse its operating characteristics. CFT was found to have a sensitivity of 71.7% and a specificity of 100%. Furthermore, CFT diagnosed 20 of 46 patients with BP (43.5%) who were negative for both BP180 and BP230 enzyme-linked immunoassays (ELISAs), 31 of 66 patients (47.0%) who were negative for indirect immunofluorescence of the oesophagus, 5 of 14 patients (35.7%) who were serologically negative for all investigated serological assays, and 7 of 18 patients (38.9%) in whom direct immunofluorescence was negative. Combination of CFT with all other serological assays resulted in a sensitivity of 95.3%. In conclusion, CFT is suitable for the diagnosis of BP, and can help to diagnose serologically challenging cases.

Diagnostic performance of the "MESACUP anti-Skin profile TEST"

BACKGROUND

The "MESACUP anti-Skin profile TEST" is a new, commercially available ELISA kit to detect circulating IgG autoantibodies against desmoglein 1, desmoglein 3, BP180, BP230, and type VII collagen, both simultaneously and more rapidly than previous assays.

OBJECTIVES

The aim of this study was to evaluate the diagnostic accuracy of this kit for the diagnosis of pemphigus foliaceus, pemphigus vulgaris, bullous pemphigoid and epidermolysis bullosa acquisita.

MATERIALS & METHODS

Dual-centre retrospective study in which 138 patients with autoimmune blistering diseases were compared to 40 controls

RESULTS

Using the MESACUP anti-Skin profile TEST, both sensitivities and specificities for desmoglein 1, desmoglein 3, BP180, BP230, and type VII collagen autoantibodies were similar to those obtained using previous, specific ELISA systems and 88% of the results were concordant without any significant difference.

CONCLUSION

The MESACUP anti-Skin profile TEST had a similar performance to previously produced ELISA systems. The novel kit can be used for rapid diagnosis of most common autoimmune blistering diseases and is especially suitable for identifying overlapping disorders.