Cases Of Bullous Pemphigoid Research Articles

Direct Immunofluorescence in Cutaneous Vesiculobullous Lesions: A Cross-sectional Study in a Tertiary Care Center

Introduction: Cutaneous noninfectious autoimmune vesiculobullous diseases are a wide variety of lesion. They can show clinical and histopathological overlap, posing diagnostic challenges. Clinically, vesiculobullous lesions might not present with typical morphology and distribution in all cases. The specific histomorphological changes are observed only in an early and intact bulla. Immunofluorescence (IF) is a histochemical staining technique which detects antibodies in the tissue and body fluids. IF an adjuvant to histopathology is considered as gold standard in the diagnosis of vesiculobullous diseases. Methodology: A two-year retrospective cross-sectional descriptive study was conducted in the department of pathology, in a tertiary care center from January 2018 to December 2019. Paraffin embedded hematoxylin and eosin slides were retrieved from the archives and analyzed. Biopsies received in Michel’s medium were utilized for immunofluorescence study. Results: A total of 67 cases with Vesiculobullous lesions were analysed. The most common lesion diagnosed was Bullous Pemphigoid (BP) (29 cases -46.7%), followed by Pemphigus Vulgaris (PV) (19 cases- 30.6%). The highest number of cases were noted in the 7th decade, with a slight female preponderance. Sixteen out of 19 cases of pemphigus vulgaris and 28 out of 29 cases of bullous pemphigoid showed positive histomorphological correlation with IF. The PPV for pemphigus vulgaris was 100% and sensitivity was 84.2%, and in bullous pemphigoid, both the PPV and sensitivity was 96.5%. Higher concordance was noted between Histopathology and IF diagnosis in cases of BP in comparison to PV. Conclusion: Vesiculobullous lesions are heterogeneous in nature and can have clinical and histopathological overlap, posing diagnostic challenges. IF is considered gold standard and is necessary for the diagnosis in every case. A combined clinical, histopathological and IF examination is the best approach to accurate diagnosis. Keywords Bullous, Pemphigus, Vesiculobullous, Direct Immunofluorescence

Role of C4d immunohistochemical marker in the diagnosis of bullous pemphigoid: A cross-sectional study.

Objective To determine the diagnostic utility of C4d immunohistochemical marker in cases of bullous pemphigoid by calculating the sensitivity, specificity, positive predictive value and negative predictive value. Methods We conducted an exploratory study (retrospectively and prospectively) from January 2017 to June 2022. All direct immunofluorescence proven cases of bullous pemphigoid were included in the study while cases with inadequate tissue for immunohistochemistry studies were excluded. Results Among the 57 cases of bullous pemphigoid, 49 showed positivity for C4d marker. All the ten control cases of inflammatory dermatoses were negative for C4d staining. A sensitivity of 86%, a specificity of 100%, a positive predictive value of 100% and a negative predictive value of 55.56% were calculated with a confidence interval of 95%. Limitation It is a single centre study. Selection bias may come into play. Conclusion Direct immunofluorescence on fresh or frozen skin tissue remains the gold standard. But in circumstances where direct immunofluorescence facilities are not available, C4d immunohistochemistry marker staining on formalin-fixed paraffin-embedded material submitted for standard microscopic investigation can, in most cases, confirm the diagnosis of bullous pemphigoid, obviating the need for a second biopsy.

P32 Bullous Pemphigoid in Childhood and Infancy. A case of a 4-months old post vaccination

Abstract The first case of bullous pemphigoid was reported in 1970, however, this remains a mystery. Two peaks of incidences of BP in childhood have been reported in the first year of life (infantile BP) and around the age of 8 years old. Bullous pemphigoid is characterized by circulating autoantibodies that attack basal skin membrane antigens. Increasing numbers of cases have recently increased the suspicion around the link to immunization. We present the case of a 4-month-old male born at full term with no family history of skin diseases and progressive blistering disease manifesting as a papulovesicular eruption on the face, acral sites, and the trunk while sparing the back, who also recently received a 12-week vaccination. He was treated with Steroids, Intravenous immunoglobulin, and Erythromycin. However, management has been challenging due to limited evidence regarding treatment. He responded well with no relapse. Resources: Medline, Embase, and Google

Epidemiological Study of Autoimmune Bullous Dermatoses in Northeastern Romania.

Autoimmune bullous diseases (ABDs) are a rare but significant group of dermatoses that pose great challenges to the treating dermatologist. ABDs are characterized by the presence of tissue-bound and circulating autoantibodies directed against disease-specific target antigens of the skin. Most epidemiological studies have focused on a single ABD. More than that, there are few data about the incidence and prevalence of autoimmune blistering diseases in Romania. In this study, between 2015 and 2019, we retrospectively investigated a total of 225 patients with autoimmune bullous diseases from the northeastern region of Romania. The diagnosis was based on the clinical and histo- and immunohistological findings. Pemphigus was the most frequently encountered ABD, with an incidence of 8.16/1,000,000 inhabitants, representing 58.7% (132 cases), followed by 24% cases of bullous pemphigoid (54 cases), 15.4% of patients were diagnosed with dermatitis herpetiformis (37 cases), and 0.9% other subepidermal autoimmune bullous dermatoses. The average age of onset of pemphigus vulgaris was 59.4 years, the majority of patients being male, while the average age of patients diagnosed with bullous pemphigoid was 73.8 years, the majority being female. Pemphigus vulgaris is the most frequently encountered ABDs in the northeast of Romania, with a higher incidence than in Western European countries, and this may be due to specific peculiarities of the geographical area, as well as to a genetic susceptibility of the population in this region.

Claudin-4 Upregulation in Acantholytic and Autoimmune-Mediated Bullous Disorders.

Claudin-4 is a key component of tight junctions, which play an important role in the formation of the epidermal barrier by forming a circumferential network in the granular layer that serves as a gatekeeper of the paracellular pathway. The aim of this study is to illustrate claudin-4 immunohistochemical staining patterns of different blistering disorders. We collected 35 cases, including two Hailey-Hailey disease, one Darier disease, three Grover disease, one acantholytic acanthoma, two warty dyskeratoma, 11 pemphigus vulgaris (PV) including six mucosal PV, and two pemphigus foliaceus. For comparison, we included five cases of normal skin, five eczema, and three bullous pemphigoid cases. Claudin-4 demonstrated weak-to-moderate expression in keratinocytes located in the stratum granulosum, keratinocytes surrounding hair follicles, and adnexal glands. Further, claudin-4 exhibited moderate-to-strong membranous staining in disrupted keratinocytes surrounding and within the acantholytic and bullous areas in 16/22 of the acantholytic cases (not seen in the six cases of mucosal PV) and all three bullous pemphigoids. This finding suggests that claudin-4 is upregulated in these conditions, which may be a compensatory response to the disrupted barrier function. This finding could shed light on the molecular mechanisms underlying disrupted barrier function in blistering disorders, independent of the specific underlying disease mechanism.

A case of bullous pemphigoid in a psoriatic patient treated with etanercept

The prevalence of Bullous Pemphigoid (BP) as a most common autoimmune bullous skin disease has increased in recent years. Drug-induced BP is an uncommon form of BP. A 25-year-old psoriatic woman was admitted to Imam Khomeini hospital complex affiliated to the Tehran University of Medical Science with a chief complaint of generalized blistering lesions.

A case of bullous pemphigoid and renal disease after dipeptidyl peptidase 4 inhibitor administration

A 62-year-old man with type 2 diabetes was admitted because of a decrease in estimated glomerular filtration rate from 72 to 17.5 mL/min/1.73 m2 in 10 years and development of widespread bullous skin lesions. His hemoglobin A1c level had been maintained at 6.0–7.0% for 10 years with a dipeptidyl peptidase (DPP)-4 inhibitor. Skin biopsy showed typical bullous pemphigoid, and kidney biopsy showed tubulointerstitial nephritis with eosinophilic infiltration and glomerular endothelial cell proliferation. After discontinuing the DPP-4 inhibitor, skin lesions improved, and renal decline slowed. This case indicates that DPP-4 inhibitors can cause not only skin lesions but also renal disease.

5 A case of bullous pemphigoid associated with membranous nephropathy

5 A case of bullous pemphigoid associated with membranous nephropathy

Accuracy of serration pattern analysis by direct immunofluorescence in subepidermal autoimmune blistering diseases.

Background Direct immunofluorescence (DIF) is essential for the diagnosis of sub-epidermal immunobullous diseases (SIBD). Bullous pemphigoid (BP), a sub-epidermal immunobullous disease, shows linear IgG and C3 deposition along the dermo-epidermal junction by DIF. However, similar histological and DIF findings are also seen in epidermolysis bullosa acquisita (EBA). High-power examination of antibody deposition by DIF in a "u" or "n" serrated pattern can help differentiate these two entities. Aims/Objectives The aim of this study was to determine the diagnostic accuracy of serration patterns in IgG-mediated sub-epidermal immunobullous disease. Methods All cases of IgG-mediated sub-epidermal immunobullous disease diagnosed over the past 2 years and 9 months period and confirmed serologically, were included. Examination of the serration pattern in DIF was assessed on oil emersion. Salt split skin indirect immunofluorescence (SSS IIF), BP180 enzyme-linked immunosorbent assay (ELISA), profile ELISA and BIOCHIP mosaic were performed, wherever available. Results This study included 74 cases of bullous pemphigoid, eight cases of mucus membrane pemphigoid (MMP) and one case of epidermolysis bullosa acquisita. The characteristic zigzag "n" pattern was visualised in 66 out of 82 cases (80.5%) of the pemphigoid group (BP + MMP); the single epidermolysis bullosa acquisita case showed the "u" serrated pattern. No statistical correlation was seen between serration pattern and BP180 positivity by ELISA (P = 0.05). Limitations The study is limited by the single case of epidermolysis bullosa acquisita (which could be due to rarity of this disease in north Indian population due to genetic variation), lack of detailed serological investigations and immunoblot in all cases. Conclusion Serration pattern analysis is an easy-to-interpret and highly useful technique for characterisation of sub-epidermal immunobullous diseases.

Use of IgG4 Immunohistochemistry as a Diagnostic Tool for Pemphigus

Pemphigus belongs to the group of antibody mediated autoimmune vesiculobullous disease (AIBD) of skin and mucous membranes. Antibodies are directed against the desmosomal adhesion proteins and IgG4 is the predominant subclass. It is a rare disease associated with significant mortality and morbidity. DIF is the gold standard test for AIBD. It requires fresh frozen section which is a major technical issue in most centres. The aim of this research was to study the diagnostic accuracy of IgG4 immunohistochemistry in pemphigus. The study was conducted as a diagnostic test evaluation in a tertiary care hospital. Paraffin blocks of histopathologically diagnosed AIBD were used for doing immunohistochemistry. The findings were compared with DIF findings. Statistical analysis was performed using SPSS, version 20.0. 48 paraffin blocks of AIBD were selected, DIF of all cases were already done from outside centre. There were 21 cases of pemphigus, 25 cases of bullous pemphigoid and one case each of epidermolysis bullosa acquisita and dermatitis herpetiformis. The sensitivity of IgG4 IHC was found to be 85.7%, specificity 96.3%, positive predictive value of 94.7% and negative predictive value 89.7%. So, we conclude that IgG4 IHC done on paraffin sections can be used as a diagnostic tool for pemphigus.

A case of bullous pemphigoid with correlation to serum levels of anti‐BP180‐NC16a antibodies and thymus and activation‐regulated chemokine

A case of bullous pemphigoid with correlation to serum levels of anti‐<scp>BP180‐NC16a</scp> antibodies and thymus and activation‐regulated chemokine

A case of bullous pemphigoid developing under treatment with benralizumab for bronchial asthma.

Bullous pemphigoid (BP) is an autoimmune disease characterized by itchy erythema and tense blisters on the whole body. Recent reports have unveiled the pathogenic roles of eosinophils in BP (e.g., dermal-epidermal separation, generation of pruritus). Thus, eosinophils are considered a therapeutic target. Benralizumab is an anti-IL-5 receptor alpha (IL-5Rα) monoclonal antibody (mAb) that is widely used to treat severe eosinophilic asthma. By affecting IL-5Rα, benralizumab depletes eosinophils and basophils due to apoptosis through antibody-dependent cell-mediated cytotoxicity. The efficacies of benralizumab and other biologics, including bertilimumab (anti-eotaxin-1 mAb) and mepolizumab (anti-IL-5 mAb), were evaluated in several clinical trials. Also, reslizumab, an anti-IL-5 mAb, was reported as a successful treatment option in a case of BP. We present a case of severe asthma treated with benralizumab at 8-week intervals for 3 years before BP developed. Histologically, subepidermal blisters without eosinophilic infiltration were observed. Methylprednisolone pulse therapy followed by 40 mg/day (1 mg/kg/day) of oral prednisolone (PSL) was initiated, but the skin lesions worsened. Additional intravenous immunoglobulin and oral azathioprine enabled the oral PSL to be tapered. The benralizumab was discontinued after the onset of BP because the asthma did not worsen. To the best of our knowledge, there have been no reports of BP developing during anti-eosinophil therapy. BP may occur paradoxically via various pathways during treatment with drugs that are typically effective against BP.

Bullous Pemphigoid in a 37-Year Old Female: A Case Report and Literature Review

Bullous pemphigoid is a blistering disorder which mainly affects the geriatric population predominantly older than 70 years. It is caused by an autoimmune reaction to the hemidesmosomal proteins in basal keratinocytes, causing an inflammatory cascade and subsequent bullae formation. It is rarely encountered in infants, children, and middle-aged adults. Herein, a case of Bullous pemphigoid in a 37-year old female patient is reported. The patient presented with a three-month history of multiple serous fluid-filled tense blisters on the face, neck, trunk, flexor and extensor surfaces of the extremities up to the lower thigh, with areas of excoriation, peeling, erosion and crusting. No involvement of the mucous membranes noted. The lesions were associated with intense pruritus and pain upon rupture. Patient had no other subjective complaints and had an unremarkable past medical history. Patient was initially treated with antibiotics but noted no improvement in her condition. Histologic evaluation of the skin was done and revealed a subepidermal vesicular dermatitis with prominent neutrophilic infiltrates. No hyphae or spores were seen. With these findings, patient was admitted and treated with systemic steroids, antibiotics, and antipruritic medications. Direct Immunofluorescence was done and yielded findings consistent with the diagnosis of Bullous Pemphigoid. The overall response of the patient to therapy was satisfactory. The differentiation of Bullous pemphigoid from other subepidermal bullous diseases is important due to the potential of systemic manifestations and complications of the other diseases. The importance of clinical, histopathologic and immunologic findings in confirming the diagnosis of Bullous Pemphigoid is highlighted in this case report.

伴脑卒中的大疱性类天疱疮74例临床分析

伴脑卒中的大疱性类天疱疮74例临床分析

Cutaneous metastases at the sites of pembrolizumab-induced bullous pemphigoid lesions in a patient with melanoma.

The authors report a case of bullous pemphigoid (BP) that occurred during pembrolizumab therapy in a 67-year-old male patient with advanced melanoma. Following regression of BP blisters, they reintroduced anti-PD-1 treatment. Due to the flare-up of BP, immunotherapy was discontinued again and corticosteroid was restarted. As the BP lesions regressed, interestingly, new skin metastases developed, exactly where the blisters were. One year after discontinuation of anti-PD-1 treatment, considering the significant tumor progression, pembrolizumab was restarted. This induced tumor remission, while the added low-dose corticosteroid was able to prevent the recurrence of BP. The patient carries the BP-predisposing HLA-DQB1*03:01 allele. In conclusion, anti-PD-1 rechallenge may be considered in metastatic melanoma, even if restarting anti-PD-1 has previously caused the flare-up of BP symptoms.

Case of bullous pemphigoid refractory to corticosteroids by antiepileptic drug-induced CYP3A4.

The most common treatment option for patients with bullous pemphigoid is systemic corticosteroids. CYP3A4, a drug-metabolizing enzyme in the liver, metabolizes synthetic steroids to a varying degree. Although there are many CYP3A4-inducing drugs, several antiepileptic drugs, such as phenytoin and phenobarbital, strongly induce CYP3A4, thereby reducing the effects of corticosteroids. Here, we report a case of refractory bullous pemphigoid that rapidly improved after the discontinuation of phenytoin and phenobarbital. To achieve adequate pharmacological effects of corticosteroids, we must always ensure that patients who require corticosteroids for treatment are not medicated with CYP3A4-inducing agents.

Bullous pemphigoid and the associated co-morbidities: A prospective study at a tertiary-care center

Background: Bullous pemphigoid is an autoimmune blistering disorder of the skin. Recent studies have shown that there are various associated co-morbidities existing even before the diagnosis of the condition. Objectives: The aim was to study the association of co-morbidities in bullous pemphigoid at a tertiary-care center. Methodology: This was a hospital-based prospective study of forty cases of bullous pemphigoid conducted over a period of thirty months at a tertiary-care center. Results: The mean age of the participants was 73. There was a male preponderance, with a male-to-female ratio of 1.8:1. Bullous pemphigoid was significantly associated with hypertension in 80% (32) of the patients, followed by diabetes mellitus in 75% (30), cerebrovascular accidents in 35% (14), coronary artery disease in 27.5% (11), depression in 12.5% (5), hypothyroidism in 12.5 % (5), and chronic kidney disease in 5% (2). Conclusion: Screening for co-morbid health conditions is paramount in patients with bullous pemphigoid for an optimal outcome since treatment options have an impact on the control of comorbidities and vice versa. It should be a multidisciplinary approach for optimal management and the improvement of the quality of life, thus reducing the number of hospital visits and medications to reduce the economic burden and morbidity, hence improving the quality of life.

A case of bullous pemphigoid associated with metastatic bilio-pancreatic cancer

A case of bullous pemphigoid associated with metastatic bilio-pancreatic cancer

Vaxzevria COVID-19 aşısı sonrasında gelişen şiddetli büllöz pemfigoid

Bullous pemphigoid has been described in a small number of cases secondary to the Pfizer and Moderna COVID-19 vaccinations. This is the first reported case of bullous pemphigoid triggered by the Oxford-AstraZeneca Vaxzevria COVID-19 vaccination. His first symptoms occurred four weeks after his first dose, and were confirmed on direct immunofluorescence and with positive BP180 antibodies.

Clinical features of dipeptidyl peptidase-4 inhibitor-associated bullous pemphigoid in Japan: A nationwide retrospective observational study.

Many cases of bullous pemphigoid (BP) have been reported in patients taking dipeptidyl peptidase-4 inhibitors (DPP-4i), which are the most widely used antidiabetic drug for type 2 diabetes mellitus. However, no large-scale survey has been conducted in Japan. This retrospective study investigated the incidence, clinical presentation, and clinical course of DPP-4i-associated BP (DPP-4i-BP) using epidemiological data from a nationwide registry for BP. In 2016, 713 new BP patients at 94 dermatological institutes were registered, 243 (34.1%) with DPP-4i-BP and 461 (64.7%) with non-DPP-4i-BP. The male-to-female ratio was 1.9 and 0.84, respectively. Patients with DPP-4i-BP were predominantly male. Non-inflammatory BP was more common in DPP-4i-BP (33.3%) than in non-DPP-4i-BP (14.6%), while inflammatory BP was common in both. No specific subtype or difference in disease severity was evident in DPP-4i-BP. The most common gliptins administered to DPP-4i-BP patients were vildagliptin (37.2%) and linagliptin (23.8%). DPP-4i intake was discontinued in 79.9% of cases after diagnosis. Some DPP-4i-BP patients (17.6%) achieved spontaneous remission after discontinuing DPP-4i without requiring the use of systemic corticosteroids and/or adjuvant therapy. Mean duration to achieve disease control was 2.87months. The odds ratio for non-inflammatory BP requiring systemic corticosteroids and/or adjuvant therapy was low (0.52), suggesting that remission was achieved easily with supportive care in that phenotype. Non-inflammatory and mild cases of DPP-4i-BP may resolve spontaneously with supportive care, including the discontinuation of DPP-4i and no oral corticosteroid therapy.