Tag Archives: immunofluorescent

A 14-year-old male presented with seven years history of recurrent episodes of fluid filled, itchy and eroded lesions over the body not responding to oral corticosteroids and azathioprine. Dermatological examination revealed crusted plaques and erosions in a seborrheic distribution. Histopathology of skin lesions and direct immunofluorescence were characteristic of pemphigus foliaceus. He was treated with dexamethasone pulse therapy with inadequate response. However, relapsing skin lesions revealed a circinate arrangement with a predilection to trunk and flexures. In view of clinical features suggestive of IgA pemphigus, he was started on dapsone, to which he responded dramatically in four weeks. However, repeat biopsy continued to reveal features of pemphigus foliaceus and ELISA for anti- desmoglein 1 antibodies was positive.

Bullous pemphigoid (BP) is an autoimmune blistering skin disease. Autoantibodies to BP180 and BP230 can be detected by indirect immunofluorescence (IIF) on different substrates (oesophagus, salt-split-skin, BP180-antigen dots, BP230-transfected cells) and ELISA. Here, we compared test characteristics of these test systems. We analysed sera from BP patients (n=60) in whom the clinical diagnosis had been confirmed histopathologically. The control cohort comprised sera from patients with other autoimmune-associated (n=22) or inflammatory (n=35) skin diseases. All samples were tested by IIF (EUROIMMUN™ Dermatology Mosaic) and ELISA (EUROIMMUN and MBL). Anti-BP180 is best detected with BP180-antigen dots by IIF (sensitivity: 88%; specificity: 97%). As

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compared to IIF, the differences with both BP180 ELISA techniques are small though. Likelihood ratios (LRs) for positive and negative test results are >10 and between 0.1 and 0.2, respectively, for all test systems. Detection of anti-BP230 is highly variable (sensitivity range 38-60%; specificity range 83-98%). Only the IIF test reveals a LR for positive test results >10. Since the LRs for a negative test are all ~0.5, negative test results for anti-BP230 antibodies do not help to exclude BP. In conclusion, the multi-parameter IIF test reveals a good diagnostic performance in BP. Since this test simultaneously allows for the detection of anti-Dsg1 and anti-Dsg3 antibodies, involved in pemphigus foliaceus and vulgaris, a single test-incubation may be sufficient to differentiate between the most frequent autoimmune blistering diseases.

In conclusion, the multi-parameter IIF test reveals a good diagnostic performance in BP. Since this test simultaneously allows for the detection of anti-Dsg1 and anti-Dsg3 antibodies, involved in pemphigus foliaceus and vulgaris, a single test-incubation may be sufficient to differentiate between the most frequent autoimmune blistering diseases. PMID: 22580378 [PubMed – in process] (Source: Journal of Immunological Methods)
from MedWorm: Pemphigus http://www.medworm.com/index.php?rid=6304089&cid=c_297_3_f&fid=33859&url=http%3A%2F%2Fwww.ncbi.nlm.nih.gov%2FPubMed%2F22580378%3Fdopt%3DAbstract

by Edward Tenner, M.D.

INTRODUCTION

The autoimmune bullous skin diseases, pemphigus (with major subsets pemphigus vulgaris, pemphigus foliaceus and paraneoplastic pemphigus) and the more common bullous pemphigoid (with variant disease phenotypes of cicatricial pemphigoid and gestational pemphigoid) each may have ocular manifestations.

By Robert Jordon, M.D.
Professor and Chairman, Department of Dermatology,
University of Texas
Houston, Texas

Historical Perspective

The term pemphigus was most likely in use in the ancient world, but the first recorded instance was by Hippocrates (460-370 BC) who described pemphigoid fever as “pemphigodes pyertoi.” Galen (AD 13 1-201) named a pustular disease of the mouth as “febris pemphigodes.” In 1637, Zacutus again uses the term “febris pemphigodes” to describe patients with blisters of short duration. DeSauvages (1760) described patients with high fever and blisters of short duration as having “pemphigus maior.” None of the above conditions is considered to be true pemphigus, as their disease was of short duration and all patients recovered.

 

By Professor Martin M Black, MD

Pemphigus and its variants are rare autoimmune disorders characterized by loss of cell to cell cohesion between keratinocytes leading to intra-epidermal blistering. In all types of pemphigus, antibodies are directed against antigens in the intercellular substance between keratinocytes and in a substantial number of active cases, these pemphigus antibodies can be detected in the general blood circulation.

Pempigus vulgaris (PV) is characterized by flaccid blistering and erosions of the skin and mucous membranes. Involvement within the mouth may often precede the skin erosions and may persist even long after skin lesions subside. It is therefore important to remember that involvement of the oral cavity may take the patient to see dental surgeon, rather than a dermatologist in the first instance. However, in pemphigus foliaceus (PF) the blistering tends to be more superficial than in the vulgaris form of pemphigus and the mucous membrane areas are not involved.

For many years, London, one of the largest cities in the world, has been truly international, with large populations of different ethnic groups living together within a 50 mile radius. This multi ethnicity provides an ideal opportunity to study the epidemiology of pemphigus and provide information on ethnic groups and numbers of involvement. We have recently surveyed our 140 patients of pemphigus who attend our St. John’s Institute for Diseases of the Skin. In our group, the male to female ratio was 1:1.12 (77 F, 63 M) and the mean age of disease onset was 44 years. This of course, is in the prime of adult life and has important economic consequences for patient sufferers, particularly if the disease is severe and the treatment likely to be longstanding. In our patients, the ethnic break-up of our group was British 51 (36.4%), Asian (Indian subcontinent) 46 (32.8%). This is quite a high figure and corroborates other evidence that pemphigus is much more common in patients living in the Indian subcontinent countries. Of Afro-caribbean countries, 15 (10.7%) had pemphigus, Middle-East 12 (8.5%) and curiously, Jewish 9 (6.4%) is rather low, as all the text books state that pemphigus is much more common in those of Jewish ancestry. Others of mixed ethnicity are fewer in number and comprise 2 Greeks and 2 Chinese. This evidence certainly would indicate the genetic factors and have an important role in predisposing individuals to developing pemphigus. It is therefore an opportunity for us to develop this theme further and we will be doing this over the next few years, looking at the genetic haplo types.

For over 25 years, our immunodermatopathological laboratory at our Institute has specialized in diagnosis of auto-immune bullous diseases. We have developed considerable experience with immunofluoresence techniques to detect the presence of antibodies in the skin by the direct method and in the serum by indirect methods. It is now well known that the PF antigen is a transmembrane glycoprotein called desmoglein 1 (Dsg1) and the PV angiten is termed desmoglein 3 (Dsg3). These desmogleins are adhesion molecules belonging to the cadherin family of cell adhesion substances and are very important in keeping the covering of our skin together.

A recent innovation has been the introduction of an antigen specific ELISA test in the diagnosis of pemphigus. The patient’s serum is tested on ELISA plates pre-coated with recombinant proteins of the ectodomain of Dsg1 or Dsg3 antigens (Medical and Biological laboratories Co, Ltd, Nagoya, Japan). Thus specific antibodies directed against Dsg1 or Dsg3 antigens can be detected by this technique.

It was seen that 61% of patients with PV have antibodies to Dsg 1 in addition to Dsg3, and presence of both the antibody types was associated with severe cutaneous and mucosal involvement, while presence of only Dsg3 autoantibodies was associated with pemphigus limited to mucosal surfaces (mainly oral). The proportion of Dsg1 positive PV patients was higher in the Asian ethnic group when compared to their British counterparts. The severity of the skin and oral disease is influenced by the quantities of Dsg1 and Dsg3 antibodies present in a patient.

Conclusion

Whether ELISA plate techniques will eventually overtake immunofluoresence in the diagnosis of pemphigus and related diseases is too early to say, but they are an important advance and enable large numbers of samples to be read quite quickly. I am sure those of you who are interested in pemphigus will see much more on this in the future about diagnostic techniques. Clearly, accurate diagnosis will ultimately lead to the potential of good targeted therapies.

By Jean-Claude Bystryn, M.D.
Professor of Dermatology
Director of Immunofluorescence Laboratory
The Ronald O. Perelman
Department of Dermatology
New York University Medical Center

Pemphigus vulgaris (PV) can enter into remissions in which all manifestations of the disease disappear and all therapy can be discontinued. How often, and when this occurs is unclear. Review of all major studies of PV conducted during the past four decades describes remissions as occurring in less than one-third of patients.1 However, a problem with these studies is that the incidence of remissions is usually provided at only a single time point. Thus, it is unclear how long it takes for remissions to appear, how long they last and what happens when therapy is discontinued. Further complicating interpretations of the results is that the meaning of remission is often unclear. The criteria used by different investigators to define this event differ and/or are not provided. The practical outcome of this incomplete information is uncertainty about the management of pemphigus. It is unclear whether treatment simply suppresses the manifestations of the disease and must be continued permanently, or whether complete and durable remissions can be induced that permit therapy to be safely discontinued.

by Thierry Olivry, DrVet, PhD, DipACVD, DipECVD,
Associate Professor of Dermatology, Department of Clinical Sciences,
College of Veterinary Medicine, NC State University,
Raleigh, North Carolina,
and Adjunct Clinical Associate Professor of Dermatology, Department of Dermatology,
School of Medicine, University of North Carolina,
Chapel Hill, North Carolina

Autoimmune blistering skin diseases first were identified in companion animals twenty five years ago, with the description of two dogs affected with pemphigus vulgaris (PV). Two years later, the first cases of pemphigus foliaceus (PF) were recognized in canine patients. These two diseases represent the main forms of animal pemphigus being diagnosed by veterinarians.

Surprisingly, whereas the main form of pemphigus affecting human individuals is pemphigus vulgaris (PV), this entity is extremely rare in dogs with less than 50 cases being reported in veterinary medical journals. This deep pemphigus variant also has been recognized, albeit very sporadically, in rare cats and horses.

by Luis A. Diaz, M.D.
Professor and Chairman Department of Dermatology Medical College of Wisconsin
Milwaukee, Wisconsin

Pemphigus foliaceous (PF) one of the major clinical variants of pemphigus, is characterized by superficial blisters and anti-epidermal autoantibodies. The epidermal antigen with which PF autoantibodies react is a desmosomal protein designated desmoglein 1 (dsg1). There are two forms of PF-a sporadic form which has worldwide distribution, and an endemic form, which has only been observed in certain rural areas of Brazil, Columbia and Tunisia.

By Sergei A. Grando, M.D., Ph.D., D.Sci.
Professor of Dermatology
University of California Davis
NPF Advisory Board Member

The goal of my research is to develop a safer and more rational treatment for pemphigus. I am deeply concerned that we, as physicians caring for patients with pemphigus, have to accept the risk of severe side effects related to the use of long term, high dose corticosteroid therapy.

Despite recent progress in developing nonhormonal therapy for other autoimmune conditions, the treatment of pemphigus remains largely dependent on corticosteroid hormones. The lack of progress in developing new therapies for pemphigus is ironic because we thought we understood the basic mechanisms responsible for the development of this disease. But, perhaps our understanding was wrong and possibly this misunderstanding has hampered advancement in treatment.

 

Grant J. Anhalt, MD Head, Dermatoimmunology Department Johns Hopkins University Baltimore, Maryland Vice President in charge of Scientific Affairs, The International Pemphigus Foundation

 

Prior to the introduction of an effective therapy with oral corticosteroids in the 1950s, the disease had a dismal natural course with a 50% mortality rate at 2 years and 100%