Genotyping of HLA-I and HLA-II alleles in Chinese patients with paraneoplastic pemphigus

BACKGROUND: Class I and class II HLA genes are thought to play a role in the immunopathogenesis of bullous dermatoses such as pemphigus vulgaris and pemphigus foliaceus, but we know little about the genetic background of paraneoplastic pemphigus (PNP) in Chinese patients. OBJECTIVES: To identify class I and class II HLA alleles by genotyping in Chinese patients with PNP, and to find out the possible association between HLA alleles and disease susceptibility. METHODS: Nineteen Chinese patients with PNP were enrolled in this study. HLA-A, B, C, DRB1 and DQB1 alleles were typed by polymerase chain reaction and a colour-coded sequence-specific oligonucleotide probes method. RESULTS: The frequencies of HLA-B*4002/B*4004, B*51, B*52, Cw*14, DQB1*0301, DRB1*08 and DRB1*11 were relatively prevalent in Chinese Han patients with PNP in comparison with normal controls. After correction for multiple comparisons, Cw*14 remained statistically significant, and the other alleles were unremarkable in these patients. CONCLUSIONS: The genetic background predisposing to PNP may be different in patients from various races and areas. HLA-Cw*14 may be the predisposing allele to PNP in Chinese patients, which is different from the predisposing allele in French patients with PNP and the alleles predisposing to pemphigus vulgaris and pemphigus foliaceus.     

Association of human leukocyte antigen class I antigens in Iranian patients with pemphigus vulgaris

There are a limited number of reports indicating the role of human leukocyte antigen (HLA) class I alleles in pemphigus vulgaris. This study was designed to highlight the association of HLA class I alleles with pemphigus vulgaris in Iran. Fifty patients with pemphigus vulgaris, diagnosed based on clinical, histological and direct immunofluorescence findings were enrolled into this study. The control group consisted of 50 healthy, age‐ and sex‐matched individuals. HLA typing of class I (A, B and C alleles) was carried out using polymerase chain reaction based on the sequence‐specific primer method. This study showed the higher frequency of HLA‐B*44:02 (P = 0.007), ‐C*04:01 (P < 0.001), ‐C*15:02 (P < 0.001) and ‐C*16:01 (P = 0.027) in the patient group, compared to the controls, while the frequency of HLA‐C*06:02 (P < 0.001) and ‐C*18:01 (P = 0.008) in the patients with pemphigus vulgaris was significantly lower than the controls. Regarding the linkage disequilibrium between HLA class I alleles, the HLA‐A*03:01, ‐B*51:01, ‐C*16:02 haplotype (4% vs 0%, P = 0.04) is suggested to be a predisposing factor, whereas HLA‐A*26:01, ‐B*38, ‐C*12:03 haplotype (0% vs 6%, P = 0.01) is suggested to be a protective factor. In conclusion, it is suggested that HLA‐B*44:02, ‐C*04:01, ‐C*15:02 alleles and HLA‐A*03:01, ‐B*51:01, ‐C*16:02 haplotype are susceptibility factors for development of pemphigus vulgaris in the Iranian population, while HLA‐C*06:02, ‐C*18:01 alleles and HLA‐A*26:01, ‐B*38, ‐C*12:03 haplotype may be considered as protective alleles.     

Direct immunofluorescence of the outer root sheath in anagen and telogen hair in pemphigus vulgaris and pemphigus foliaceus

Direct immunofluorescence of peri‐lesional skin is the gold standard in the diagnosis of pemphigus. A specific immunofluorescence pattern may also be demonstrated in the outer root sheath of anagen and telogen hair. We demonstrated an intercellular reticular deposition of immunoglobulin G in the outer root sheath of plucked anagen and telogen hair in all pemphigus vulgaris patients with active disease and for the first time in all patients with active pemphigus foliaceus. Moreover, we demonstrated for the first time that plucked hair samples may be kept at ?20°C for at least 2 weeks before immunofluorescent staining and analysis.     

The transition of pemphigus vulgaris into pemphigus foliaceus: a reflection of changing desmoglein 1 and 3 autoantibody levels in pemphigus vulgaris

The transition of pemphigus vulgaris (PV) into pemphigus foliaceus (PF) is rare and the immunological changes underlying this event are not well understood. We report a 44-year-old woman who presented with oral and cutaneous erosions typical of PV. Over a 9-year period, the clinical features evolved into those of PF. To examine whether quantitative changes in desmoglein (Dsg) antibodies were associated with this transition, Dsg1 and Dsg3 antibody levels were measured by enzyme-linked immunosorbent assay in 82 sequential serum samples collected over this period. At presentation, when the phenotype was PV with oral and cutaneous erosions, antibodies to both Dsg1 and Dsg3 were detected. The disappearance of oral involvement was associated with a decline in Dsg3 antibodies, which are now undetectable, while the development of more severe skin involvement was associated with rising Dsg1 antibody levels. These data strongly suggest that the change in clinical features is a reflection of qualitative and quantitative changes in antibody profile. It is not known whether the transition to PF is permanent or whether disease relapses in the future may be associated with the re-emergence of Dsg3 antibodies, oral ulceration and a PV phenotype.     

Comparison of desmoglein ELISA and indirect immunofluorescence using two substrates (monkey oesophagus and normal human skin) in the diagnosis of pemphigus

A prospective study was performed to assess the usefulness of desmoglein enzyme-linked immunosorbent assay testing compared with indirect immunofluorescence in the diagnosis of new cases of pemphigus, as well as to compare the relative sensitivities of monkey oesophagus and normal human skin as substrates for indirect immunofluorescence. These tests were performed on the sera of 29 consecutive new cases of pemphigus diagnosed over a 2-year period based on clinical, histological and direct immunofluorescence findings. Desmoglein enzyme-linked immunosorbent assay was positive in all patients whereas indirect immunofluorescence was positive in only 25 of 29 patients. All four patients with negative indirect immunofluorescence had positive antinuclear antibodies or cytoplasmic fluorescence that could have masked the anti-intercellular antibodies. Desmoglein enzyme-linked immunosorbent assay appeared to reflect the disease activity better than indirect immunofluorescence in a few patients who had active disease of recent onset. Monkey oesophagus was found to be superior or equal to human skin as a substrate for indirect immunofluorescence in both pemphigus vulgaris and foliaceus.     

The clinical transition between pemphigus foliaceus and pemphigus vulgaris correlates well with the changes in autoantibody profile assessed by an enzyme-linked immunosorbent assay

BACKGROUND: There are a number of reports of pemphigus with clinical shifting between pemphigus foliaceus (PF) and pemphigus vulgaris (PV). On the other hand, a novel enzyme-linked immunosorbent assay (ELISA) against recombinant baculoproteins of desmoglein 1 (Dsg1) (PF antigen) and Dsg3 (PV antigen) has been established and found to be extremely sensitive and specific. OBJECTIVES: To characterize the change in the antibody profiles in a series of pemphigus cases with mixed features of PF and PV by various methods, including the novel ELISA. Patients/methods Sera were obtained from eight cases undergoing a shift between PF and PV and three cases of coexistent PF and PV. The autoantigens were analysed by ELISA, as well as by immunofluorescence using normal human skin sections and immunoblotting using normal human epidermal extracts. RESULTS: The results of the ELISA, immunofluorescence and immunoblotting studies showed that the transition between PF and PV correlates well with the changes of autoantibodies against either Dsg1 or Dsg3. CONCLUSIONS: The clinical phenotype at each stage is defined by the anti-Dsg antibody profile in the serum of these pemphigus patients showing mixed features of PF and PV. In addition, ELISA using recombinant baculoproteins was particularly useful in distinguishing PF and PV.     

A 6‐year treatment experience for pemphigus: retrospective study of 69 Chinese patients

There is a lack of data on treatment and prognosis of pemphigus in China. The aim of this study was to evaluate long‐term follow‐up and prognosis of pemphigus. Forty‐seven inpatients with pemphigus vulgaris (PV) and 22 with pemphigus foliaceus (PF) were recruited in this retrospective study. The average age at onset was 51.6 and 54.9 years in PV and PF, respectively. High‐dose systemic steroids were administered in 47 PV and 21 PF, of which 18 PV and 8 PF with adjuvant therapies. CD4 lymphocytopenia was found in 5 PV and 2 PF patients at admission and successfully treated by intravenous thymopentin daily. During a mean follow‐up of 37.1 months, 41 PV and 19 PF reached remission, 30 PV and 9 PF relapsed, 4 PV and 2 PF died. Major causes of death were relapse of pemphigus due to discontinuation of oral steroids by the patients themselves (four cases) and severe infections (two cases, one with severe CD4 lymphocytopenia). The 1‐year mortality rate of PV and PF was 8.5% and 4.5%, respectively. Cox regression analysis indicated that age at onset of pemphigus was an independent risk factor related to the elevated mortality. Our report confirmed the high mortality rate of pemphigus in a Chinese population and stressed that patient education was urgently needed to prevent relapses and deaths.     

Analysis of current data on the use of methotrexate in the treatment of pemphigus and pemphigoid

Methotrexate (MTX) is primarily used in the treatment of malignancies. It has also been used as an immunosuppressive agent in the treatment of pemphigus and pemphigoid. The objective of this study was to determine the role of MTX in the treatment of pemphigus and pemphigoid based on an analysis of the available literature. A retrospective analysis of the English language literature was conducted. The studies included in this analysis were required to fulfil the following inclusion criteria: English language; diagnosis based on histology and immunopathology; minimum of five patients in each series; and data for efficacy, spectrum of responses and follow-up. A total of 136 patients with pemphigus were reported in seven studies. One hundred and eleven of the 136 patients (82%) showed clinical improvement with MTX. A total of 79 patients with pemphigoid were reported in six studies. Overall, 74 of the 79 patients (94%) showed clinical improvement. Nausea and infection were the most common side-effects. Death due to MTX resulted in seven of 215 patients (3%). There is a lack of randomized controlled trials. In many studies in this review there was insufficient information on clinical follow-up post-therapy and on serological correlations. Analysis of the data suggests that MTX may be useful and effective in patients with pemphigus vulgaris, who are corticosteroid dependent or who develop significant complications in relation to corticosteroids. MTX is likely to be more beneficial in patients with pemphigoid, particularly in bullous pemphigoid, than in patients with pemphigus. Given the limitations of the available data, it appears that when there is a need for adjuvant therapy, MTX may be considered early in the management of moderate to moderately severe disease.     

中国北方汉族人寻常型天疱疮与HLA-A、B单倍型的相关性研究

目的:探讨HLA-A、B单倍型与中国东北地区汉族人寻常型天疱疮的相关性。方法:采用标准微量淋巴细胞毒试验方法对寻常型天疱疮患者组及正常对照组进行HLA-I类抗原分型并计算单倍型频率进行比较。结果:与对照组比较,寻常型天疱疮患者组中单倍型HLA-A2、B5,HLA-A2、B13,HLA-A3、B40,HLA-A3、B13,HLA-A3、B16,HLA-A3、B5和HLA-A10、B40的频率明显增高(P<0.05),而单倍型HLA-A2、B46在患者组中未发现。结论:特异单倍型可能是决定寻常型天疱疮发生的重要因素。     

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.     

Autoreactive T cells in the immune pathogenesis of pemphigus vulgaris

Pemphigus vulgaris is a life‐threatening autoimmune blistering disease caused by anti‐desmoglein IgG autoantibodies that finally lead to acantholysis presenting clinically as progressive blistering. Whilst the production of pathogenic antibodies is key to the development of pemphigus vulgaris, many immunological steps are required prior to autoantibody induction. We review advances in the understanding of these immunologic processes with a focus on human leucocyte antigen polymorphisms and antigen recognition, epitope spreading, central and peripheral tolerance, T helper differentiation, induction of pro‐ and anti‐inflammatory cytokines and T‐cell regulation of B cells. Targeting autoaggressive T cells as regulators and stimulators of B‐cell antibody production should allow for more specific therapeutic immune interventions, avoiding the global immunosuppression seen with many commonly used immunosuppressants in pemphigus vulgaris.     

寻常型天疱疮患者疱液及血清白介素-10的检测及其临床意义

目的：探讨白细胞介素10(IL-10)在寻常型天疱疮患者的表达及其临床意义。方法：采用ELISA方法检测36例寻常型天疱疮患者活动期血清、疱液和缓解期血清中IL—10的水平。结果：寻常型天疱疮患者活动期血清中IL—10水平明显高于健康对照者血清中的水平，病情缓解后血清中IL—10的水平明显下降，活动期疱液IL-10水平明显高于活动期血清中的水平。结论：IL—10可能在寻常型天疱疮的发病起重要作用，并且与病情的活动性有关。     

寻常型天疱疮患者血清白介素-4和白介素-13的检测

目的 :　探讨白介素 - 4 (IL - 4 )和白介素 - 13(IL- 13)在寻常型天疱疮 (PV)发病机制中的作用。方法 :　采用流式细胞仪检测 33例PV患者血清中IL - 4和IL - 13水平。结果 :　寻常型天疱疮患者血清中IL - 4和IL- 13水平显著高于对照组 (P <0 .0 0 1)。结论 :　IL - 4和IL - 13可能在寻常型天疱疮的发病中起一定的作用     

Desmoglein 1 and 3 enzyme-linked immunosorbent assay in Iranian patients with pemphigus vulgaris: correlation with phenotype, severity, and disease activity

BACKGROUND: Pemphigus vulgaris (PV) is a chronic autoimmune blistering disorder of the skin and mucosa characterized by the presence of autoantibodies against desmoglein3 (Dsg3). Some patients also have antibodies against desmoglein1 (Dsg1). The aims of this study were to evaluate the diagnostic value of Dsg enzyme-linked immunosorbent assay (ELISA) in Iranian PV patients, to assess its correlation with the clinical phenotype and severity of disease and to investigate the changes of these antibodies after treatment. METHODS: Seventy-three patients with PV (29 men, 44 women) presenting to the Pemphigus Research Unit at Razi Hospital, Tehran, Iran were enrolled. ELISAs were used to detect IgG autoantibodies reactive with the ectodomains of Dsg1 and Dsg3, and the correlation of antibodies with the clinical phenotype as well as oral and skin disease severity was assessed. In addition, the tests were repeated in 18 patients after treatment and the resulting remission. RESULTS: Anti-Dsg1 and anti-Dsg3 were detected in 56 (76.7%) and 69 (94.5%) patients, respectively. Anti-Dsg1 and anti-Dsg3 antibodies were present in 48 (94.1%) and 50 (98%) patients with mucocutaneous type, in 2 (12.5%) and 15 (93.7%) patients with mucosal type, and in 6 (100%) and 4 (66.7%) patients with cutaneous PV, respectively. The mean anti-Dsg1 index values were significantly higher in cutaneous and mucocutaneous phenotypes than mucosal PV (P < 0.001). The mean anti-Dsg3 index values were significantly lower in cutaneous and mucosal phenotypes than mucocutaneous PV (P < 0.01). The severity of skin lesions (but not oral lesions) was correlated with anti-Dsg1 antibody level (P < 0.001); on the other hand, the severity of oral lesions (P < 0.01) as well as skin lesions (P < 0.001) was significantly correlated with anti-Dsg3 antibody levels. Both anti-Dsg1 and anti-Dsg3 levels were significantly reduced after treatment and clinical remission (P < 0.001). CONCLUSION: Dsg ELISA is not only a sensitive tool for the diagnosis of PV, it can also serve as a predictive means for assessing the severity as well as for monitoring the disease activity. Although, in general, the clinical phenotype is related to the antibody profile, there are occasional cases with discordant phenotype and antibody profile. These discrepancies might be explained by genetic variations or the presence of possible minor antigens involved in the pathogenesis of pemphigus.     

Association of HLA class I and class II alleles with bullous pemphigoid in Chinese Hans

Background

Bullous pemphigoid (BP) is one of the most common autoimmune skin diseases. Associations of genes, especially human leukocyte antigen (HLA)-DQ alleles, with BP indicate that genetic predisposition contributes to the disease.

Infective endocarditis in two patients with pemphigus vulgaris under multiagent immunosuppressive drug therapy: A rare entity to remember in the differential diagnosis of fever of unknown origin

Pemphigus vulgaris (PV) is an autoimmune blistering skin disease that may require multiagent immunosuppressive drug therapies in severe cases. In addition to the well‐established corticosteroid sparing agents azathioprine, mycophenolate mofetil, and methotrexate, rituximab is being increasingly used alone or in combination in the management of PV. Due to the chronic course of the disease, the cumulative effects of these therapy agents over long follow‐up periods may result in various adverse reactions, including bacterial and viral infections. Infective endocarditis (IE) is one of the rarest complications of PV treatment with only a few reported cases. In the present study, the present authors discuss two PV patients without prior histories of cardiovascular disease, complicated with native aortic valve IE, which led to death in one of the patients. Because determining the origin of fever is difficult in patients under immunosuppressive therapy, it is particularly challenging to diagnose IE coupled with a fever of unknown origin. Therefore, dermatologists must be vigilant for the dermatological signs of IE and use a multidisciplinary approach to the differential diagnosis of fever of unknown origin.     

Development of oesophageal involvement in a subject with pemphigus vulgaris: a case report and review of the literature

We present the case of a 50-year-old-man with pemphigus vulgaris involving the oropharyngolaryngeal mucosa and oesophagus. Oesophageal involvement of pemphigus vulgaris is relatively uncommon, especially in subjects in clinical remission, and has been rarely described in the literature. Endoscopic examination should be performed to avoid inappropriate therapy due to misdiagnosis of steroid-induced oesophagitis and peptic ulcers.