Fixation of pemphigus vulgaris and foliaceus antibodies in shedding snake epidermis

The fixation of pemphigus antibodies was revealed by indirect immunofluorescence in shedding grass snake epidermis. The antibodies of patients with pemphigus vulgaris (PV) were specifically binding to the antigenic substance which appears in the snake epidermis at the initial stage of integument change. At the peak of shedding, the fixation of PV antibodies was observed only in the upper layers of the 'old' epidermis, although the intensity of fluorescent staining was considerably reduced. At the same stage of shedding, there was marked fixation of antibodies of patients suffering from pemphigus foliaceus (PF). The specific binding of PF antibodies was noted predominantly on the cell membranes of the 'old' keratinocytes, localized in the upper layers of the epidermis. In contrast to bullous pemphigoid antibodies, PV and PF antibodies failed to fix in the skin of the snake prior to or after physiologic shedding. The data obtained suggest that pemphigus may have an atavistic origin.     

Distinct types of IgG and IgA anti-intercellular autoantibodies from patients with pemphigus and vesiculopustular dermatosis

The pattern of binding of two different types of IgA class pemphigus-like antibodies was compared with that of the true IgG class pemphigus antibody. The IgG antibodies from pemphigus vulgaris (PV) and pemphigus foliaceus (PF) sera bound to the intercellular spaces in normal human epidermis, whereas only the PV antibody reacted with monolayers of keratinocytes derived from human foreskin. Both IgG and IgA antibodies from a patient with PF were found in the intercellular spaces of the epidermis and only the IgA antibody reacted with the cultured keratinocytes. The IgA antibody from a patient with a vesiculopustular eruption and whose serum contained IgA intercellular space antibody alone, bound to the upper epidermis but not to the monolayers of keratinocytes. These findings indicate that PV but not PF antigens can be expressed by monolayers of cultured human keratinocytes and that there are at least two distinct types of IgA intercellular antibodies.     

Internalization of constitutive desmogleins with the subsequent induction of desmoglein 2 in pemphigus lesions

Acantholytic blisters in pemphigus vulgaris (PV) and pemphigus foliaceus (PF) are caused by a dissociation of desmosomes mediated by autoantibodies against desmoglein (Dsg) 3 and Dsg 1, respectively. The blistering occurs at the suprabasilar level in PV and at the subcorneal level in PF, which corresponds to the distribution of target antigens in the epidermis: there is a more prominent expression of Dsg 1 in the upper layer, whereas Dsg 3 is more prominent in the lower layer. To elucidate the histogenesis of acantholysis, we studied the alterations of the desmosomal components and the expression pattern of Dsg isoforms in the lesional and perilesional epidermis of pemphigus patients. The results demonstrated an internalization of the desmosomes in the lower epidermis of PV, PF and pemphigus vegetans. A similar phenomenon was induced in monolayers of keratinocytes cultured with PV sera. However, little change was observed in E-cadherin expression until acantholysis became manifest. This internalization occurred prior to overt acantholysis, and was frequently associated with the induction of Dsg 2 expression in the basilar or lower layers of the epidermis. These findings indicate an alteration of Dsg isoform expression in subclinical pemphigus lesions, which might be related to the characteristic acantholytic patterns: the suprabasilar layer in PV and the upper epidermis in PF.     

用免疫荧光技术观察表皮与血清中天疱疮自身抗体

对11名落叶型(PF),8名寻常型天疱疮(PV)进行了免疫荧光法检查.全部PF与PV表皮ICS在DIF检查中均出现IgG与C₃沉积,其中84.6%患者血清中天疱疮抗体(PAb)阳性,多数滴度为1:40-1:1280,45.4%PF患者在DIF染色中其IgG主要或仅只沉积在表皮浅层ICS部位,而PV则否.著者在讨论中提出:(1)在DIF检查中表皮ICS有IgG沉积即可确诊为天疱疮;(2)若此沉积在表皮浅层之强度较深层伪强,超过一个“+”时可确定为PF;(3)在大疱性皮肤病患者血清中,若PAb滴度较高时(>1:40),可以确定为天疱疮的诊断.     

Pemphigus with features of both vulgaris and foliaceus variants localized to the nose

We report the case of a 74‐year‐old man affected by an unusual variant of pemphigus. He presented with a crusty and scaly lesion of the nose. We performed reflectance confocal microscopy and optical coherence tomography on the lesion, which suggested an unexpected diagnosis of pemphigus. Therefore, to confirm our diagnostic suspicions, we executed indirect immunofluorescence and two biopsies, one for histopathological examination and one for direct immunofluorescence. Histopathological evaluation showed acantholysis with formation of clefts in the granular and spinous layers of the epidermis. Direct immunofluorescence revealed immunoglobulin G and C3 deposit to the full thickness of the epidermis. Indirect immunofluorescence showed intercellular antibodies at a titer of 1:40 in the suprabasal epidermis. The immunoblot analysis using epidermal extract revealed the presence of circulating antibodies directed to 130‐ and 160‐kDa antigens in the patient's serum. These two antigens were evidenced from nitrocellulose membrane with colorimetric AP systems, which highlighted the presence of autoantibodies against desmoglein (Dsg)1 and Dsg3 (sodium dodecylsulfate polyacrylamide gel electrophoresis). We also performed an enzyme‐linked immunoassay. All these findings suggested that this patient's pemphigus had features of both vulgaris and foliaceus variants.     

Pemphigus foliaceus with prominent neutrophilic pustules

We describe four patients with generalized scaly and pustular skin lesions showing extensive neutrophilic infiltration in the subcorneal region of the epidermis. Immunofluorescence, immunoblot and enzyme-linked immunosorbent assay analyses detected IgG antibodies reacting exclusively with desmoglein 1, the pemphigus foliaceus antigen. This study indicates that pemphigus foliaceus may show prominent neutrophilic pustular skin lesions.     

天疱疮抗体结合靶抗原的定位研究

目的 研究天疱疮抗体铺皮细胞间抗原在超微结构水平的部位。方法 采用ＬＲＷｈｉｔｅ树脂为包埋剂,用金标记包一直接和间接免疫电镜技术,观察天疱疮患者皮损中ＩｇＧ的沉积部位和患者血清中ＩｇＧ型自身抗体结构正常人皮肤的部位。结果 寻常型天疱疮和落叶型天疱疮的直接和间接免疫电镜均在表皮细胞间的桥粒部位觅金颗粒沉积,在非桥数部位的角质形成细胞间未金颗粒沉积。结论寻常型天疱疮和落叶型天疱疮的靶抗原均是桥粒成分,     

Desmosomal antigens are not recognized by the majority of pemphigus autoimmune sera

Sera from 7 patients with pemphigus vulgaris and both mouse and rabbit antisera against bovine epidermal desmosomes contained antibodies that bound to cell surface components of the spinous layer of bovine epidermis. The antidesmosomal sera showed significant binding to purified desmosomal proteins in an enzyme-linked immunosorbent assay (ELISA). Two of 7 pemphigus sera bound to desmosomal protein-coated microtiter plates at low dilution titers. Two of 6 normal human sera also bound to desmosomal protein-coated microtiter plates at titers comparable to those of the pemphigus sera. Indirect immunofluorescent labeling of frozen sections of monkey esophagus revealed striking differences in the distribution of pemphigus antigens and desmosomal constituents. Pemphigus antisera produced rather uniform fluorescence around the borders of spinous cells of the esophageal epithelium, while anti-desmosomal antibodies bound in a punctate pattern. Anti-desmosomal antibodies labeled cells of the basal layer in a strongly punctate pattern. Only 1 pemphigus serum appreciably labeled basal cells. Two of 3 anti-desmosomal antisera bound avidly in the upper differentiating layers of the epithelium. Pemphigus antibodies did not. Pemphigus sera that reacted with desmosomal proteins in ELISA were absorbed by affinity chromatography on immobilized desmosomal proteins. This treatment did not alter the immunofluorescent labeling patterns produced by these sera. From these results we conclude that the pemphigus autoantibodies studied here bind to epithelial cell surface antigens which are distinguishable from the structural components of desmosomes.     

South American pemphigus foliaceus: electron microscopy and immunoelectron localization of bound immunoglobulin in the skin and oral mucosa

Five skin and two oral biopsies from patients with South American pemphigus foliaceus (SAPF) were studied by electron and immunoelectron microscopy for the ultrastructural localization of bound immunoglobulin in epidermal and oral lesions. Electron microscopy showed the tonofilament-desmosome complex to be preserved in the various layers of the epidermis. Immunoglobulin was bound over the plasma membrane and permeated the desmosomal junctions both in the skin and oral mucosa, thus suggesting that pemphigus antibodies are attached to the glycocalyx. It appears that the initial injury in SAPF acantholysis involves the glycocalyx and that it might be caused by interaction with intercellular antibodies present in the patient's serum.     

An immunofluorescence study of light chain in pemphigus

Immunofluorescence studies were made on light (L) chain of immunoglobulins in patients with pemphigus. These patients fell into two groups: a subcorneal bulla group, consisting of 10 patients with Senear-Usher syndrome, and one with pemphigus foliaceus, and a suprabasal bulla group consisting of 8 patients with pemphigus vulgaris. In the former group there was deposition of L chains of either type alone in the intercellular spaces of the upper epidermis: kappa type alone in 9 and lambda type alone in 2 patients. Deposition of L chains of both types was observed in the intercellular spaces of the lower epidermis in all patients of the latter group. No significant difference existed between groups as to the titre of circulating intercellular antibodies of either type. Some comments are made on the significance of the L chain of immunoglobulins in a pemphigus.     

Pemphigus foliaceus successfully treated with mycophenolate mofetil as a steroid-sparing agent

Pemphigus foliaceus is an autoimmune blistering disease of unknown origin with antibodies produced against desmoglein 1, an adhesive protein found in the desmosomal cell junction in the suprabasal layers of the epidermis. The disease is primarily treated with corticosteroids and corticosteroid-sparing immunosuppressive agents. We report a case of pemphigus foliaceus successfully treated with mycophenolate mofetil. It remains to be seen whether this agent has a significant effect on the course of the disease and remission induction.     

IgA pemphigus foliaceus. Report of two cases and a review of the literature

The cases of two patients with vesiculobullous lesions were diagnosed clinically and histopathologically as pemphigus foliaceus; unexpectedly, both revealed intercellular IgA, but not IgG, in the upper epidermis by direct immunofluorescence. Such histologic and immunofluorescence findings have been reported in eight other cases. In our cases no circulating IgA or IgG intercellular antibodies could be detected; in four of eight other reported cases IgA antibodies showed intercellular staining like that of pemphigus antibodies. Subcorneal acantholytic lesions occurred in both our cases; of the other cases reported, five had essentially identical histopathologic findings. The clinical and histopathologic features of pemphigus, as well as the recent findings of circulating IgA intercellular antibodies alone or with IgG antibodies, appear to place this disease into the spectrum of pemphigus. The 10 IgA pemphigus cases reported to date fall into one of two groups, the IgA pemphigus foliaceus (including our two cases) and IgA pemphigus of the intraepidermal neutrophilic type, which seems to be less common.     

Pemphigus controlled by dapsone

Three uncomplicated cases of pemphigus were clinically controlled by dapsone. Improvement was associated with decreasing titres of circulating intercellular antibodies. Interestingly, the sera from one case of pemphigus foliaceus contained intercellular antibodies found in the Malpighian and basal cell layers using the fluorescent technique and in the granular layer using the peroxidase technique. These findings suggest that the intercellular antibodies in pemphigus vulgaris and pemphigus foliaceus are similar but bind at different anatomical site     

Regional variation in the expression of pemphigus foliaceus, pemphigus erythematosus, and pemphigus vulgaris antigens in human skin

The expression of the pemphigus foliaceus (PF), pemphigus erythematosus (PE), and pemphigus vulgaris (PV) antigens in 16 different regions of normal human skin was evaluated by indirect immunofluorescence by using sera with a high titer of PF, PE, and PV antibodies. Regional variations were observed in the expression of all these antigens. The expression of the PF and PE antigens, as measured by endpoint titer of antibody reactivity, was highest in skin specimens obtained from the upper torso, and lowest in those from the buccal mucosa, lower torso, and scalp. This distribution pattern differed from that of PV antigen, whose expression was highest in buccal mucosa and scalp. These patterns correlate with, and may provide a partial explanation for, the different distribution of skin lesions in these different forms of pemphigus.     

IgA pemphigus

Pemphigus is a life-threatening autoimmune blistering disease. Pemphigus is divided into 4 major types; pemphigus vulgaris, pemphigus foliaceus, paraneoplastic pemphigus, and IgA pemphigus. Among them, IgA pemphigus is characterized by tissue-bound and circulating IgA antibodies targeting desmosomal or nondesmosomal cell surface components in the epidermis. Histopathologically, slight epidermal acantholysis and extensive neutrophilic infiltration in either the upper part or all layers of the epidermis were observed. IgA pemphigus is subdivided into intraepidermal neutrophilic IgA dermatosis-type (IEN-type), whose target antigen is still unknown (probably nondesmosomal cell surface protein), and subcorneal pustular dermatosis-type (SPD-type), whose target antigen is desmocollin 1 (Dsc1). We summarize reported cases of IgA pemphigus and describe current knowledge including epidemiology, clinical manifestations, pathology, laboratory tests, pathophysiology, associated diseases, prognosis and treatment, and future perspectives of IgA pemphigus.     

Pemphigus with features of both vulgaris and foliaceus variants, associated with antibodies to 160 and 130 kDa antigens

We report an unusual variant of pemphigus in a 44-year-old man. He presented with scaly and crusted erosions associated with pruritic vesicles and erythema mainly on the chest, abdomen, back and face. Histology showed acantholysis with neutrophilic spongiosis in the granular layer and subcorneal region of the epidermis. Intercellular IgG in the epidermis was positive on direct immunofluorescence. Indirect immunofluorescence showed intercellular antibodies at a titre of 1 : 2 in the suprabasal epidermis. Circulating autoantibodies to 130 kDa and 160 kDa antigens were detected in the patient's serum by immunoblot analysis using epidermal extracts. These two antibodies eluted from individual nitrocellulose membranes reacted with the intercellular space in the epidermis on indirect immunofluorescence. This observation suggests that these antibodies correspond to desmogleins 3 and 1, respectively. The clinical symptoms almost completely disappeared after 28 days treatment with oral prednisolone (30 mg/day), leaving brown pigmented flecks on the lesional sites. These findings suggest that this patient's pemphigus has features of both the vulgaris and foliaceus variants, with antibodies against desmogleins 3 and 1.     

Comparative study of pemphigus vulgaris and pemphigus foliaceus in Singapore

This is a retrospective study of all patients diagnosed to have pemphigus in our centre over a 3 year period. The case records of all patients with pemphigus from January 1995 to December 1997 were analysed. Fifty patients were diagnosed to have pemphigus during the study period. The diagnoses were pemphigus vulgaris in 31 patients, pemphigus foliaceus in 16, paraneoplastic pemphigus in two and IgA pemphigus in one. The average titre of anti-intercellular antibodies in patients with pemphigus vulgaris (1:96) was higher than the titre in patients with pemphigus foliaceus (1:69). The average initial dose of prednisolone required for disease control in patients with pemphigus vulgaris (62 mg/day) was significantly higher than that required for patients with pemphigus foliaceus (44 mg/day). In our study population, pemphigus vulgaris is a more severe and chronic disease than pemphigus foliaceus, as reflected in the higher titre of anti-intercellular antibodies, higher dose of systemic corticosteroids required for control of the disease, the longer duration to achieve complete remission and longer follow-up period.     

71例天疱疮的棘层松解位置分析

目的 探讨天疱疮的棘层松解位置,为天疱疮出现不同位置棘层松解的表现提供解释.方法 收集43例寻常型天疱疮和28例落叶型天疱疮患者的临床资料、组织病理、免疫病理、天疱疮抗体指标值进行分析.结果 寻常型天疱疮中有35例棘层松解的位置发生在基底层上方,8例发生在表皮中上部,落叶型天疱疮中有25例棘层松解的位置发生在颗粒层、棘层上方,3例发生在表皮中下部,落叶型天疱疮患者抗Dsg1抗体指标较寻常型天疱疮患者显著升高(P=0.047),寻常型天疱疮棘层松解的位置发生在表皮中上部的患者抗Dsg1、3抗体指标值与棘层松解发生在基底层上方的患者相比有差异,但无统计学意义.结论 寻常型天疱疮及落叶型天疱疮患者组织病理中,棘层松解的位置可发生于表皮中上部、表皮中下部.棘层松解的位置可能与抗Dsg1抗体和抗Dsg3抗体指标值等相关.     

Effects of pemphigus antibody on the regeneration of cell-cell contact in keratinocyte cultures grown in low to normal Ca++ concentration

Pemphigus is an autoimmune blistering disease of epidermal cells in which autoantibodies to the surface develop. The present study was performed to determine whether the binding of pemphigus antibodies to the surface of keratinocytes can inhibit the regeneration of cell-cell contact induced by altering from low to normal Ca++ concentration medium. Human keratinocytes (a cell line of squamous cell carcinoma, DJM-1 cell) were grown in low Ca++ medium for 4 days, then the cells were incubated in normal Ca++ medium containing 10% pemphigus (4 patients with pemphigus vulgaris and 4 patients with pemphigus foliaceus) or normal serum (treated at 56 degrees C, for 30 min) for various incubation periods (2, 6, 12, 24 h). The cells were fixed and stained with antikeratin antibody by the indirect immunofluorescence method so that the detachment of cell-cell contact was able to be clearly visualized by observing the cytoskeletal arrays of keratin filaments. The cells grown in normal Ca++ medium showed detachments of cell-cell contact 24-36 h after addition of any one of the pemphigus sera used in this study. The cells grown in low Ca++ medium formed no cell-cell contacts and expressed no pemphigus antigens. However, re-formation of cell-cell contacts and reexpression of the antigens were confirmed by immunofluorescence microscopy 30 min after the addition of Ca++ to the medium. The addition of any pemphigus vulgaris and foliaceus sera with Ca++ did not inhibit the regeneration of cell-cell contact and exerted no effects on the contact during the subsequent 12 h. However, after 24 h, these cells again lost the contact. These results indicate that pemphigus antibody and antigen reaction on the cell surface did not directly inhibit the Ca++-induced re-formation of cell-cell contact.     

Autoantigens for IgA anti-intercellular antibodies of intercellular IgA vesiculopustular dermatosis

A new disease characterized by the presence of in vivo bound and/or circulating IgA anti-intercellular (IC) antibodies has recently been identified. We propose the term intercellular IgA vesiculopustular dermatosis (IAVPD) for this entity, which seems to be divided clinicopathologically into at least two distinct subtypes: intraepidermal neutrophilic IgA dermatosis (IEN type) and subcorneal pustular dermatosis-like cases (SPD type). Using immunoblot technique, we examined the antigen substances for the IgA anti-IC antibodies in the sera from one Japanese patient with IEN type of IAVPD and three Japanese patients with SPD type. A serum from a patient with IEN type reacted exclusively with a 120-kD protein in both the normal human skin extract and the bovine desmosome sample. Sera from three patients with SPD type reacted specifically with a doublet of 115-kD and 105-kD proteins, which appeared to be identical to desmocollins I and II, well known desmosomal core proteins, in the bovine desmosome sample. IgA antibody from our patients with IAVPD bound to neither pemphigus vulgaris antigen nor pemphigus foliaceus antigen. From these results, we suggest that IAVPD is different from pemphigus and is heterogeneous in terms of the antigens to which IgA autoantibodies bind.