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Demonstration of pemphigus specific immunofluorescence pattern by direct immunofluorescence of plucked hair
P1503
P1505
Demonstration of pemphigus specific immunofluorescence pattern by direct immunofluorescence of plucked hair Raghavendra Rao, MBBS, MD, Manipal, India; Shruthi Shenoi, Kasturba Medical College, Manipal, India; Balachandran Nair, MBBS, MD, Kasturba Medical College, Manipal, Manipal, India
The role of collagen IV immunomapping in the evaluation of cutaneous autoimmune subepidermal blistering disorders Carmen Rinaldi, MD, Mayo Clinic Rochester, Rochester, MN, United States; Michael Camilleri, MD, Mayo Clinic Rochester, Rochester, MN, United States
Background: Direct immunofluorescence (DIF) of perilesional skin is the gold standard in the diagnosis of pemphigus. It characteristically shows the deposition of IgG antibodies against the cell surface of keratinocytes. Because the outer root sheath (ORS) of anagen hair is structurally analogous to epidermal keratinocytes, pemphigus specific immunofluorescence pattern may be present in the ORS. Objective: To study the DIF of plucked hair in pemphigus. Materials and methods: Twenty consecutive patients with pemphigus attending skin clinic for the first time were enrolled in the study, irrespective of any other inclusion or exclusion criteria. Hairs were plucked in a similar fashion to that of trichogram. Approximately 5 anagen hairs were selected, processed, and stained with fluorescein isothiocyanate (FITC) conjugates. DIF of perilesional skin and indirect immunofluorescence (IIF) were carried out in all patients simultaneously. The fluorescence microscope examination was performed on stained sections. DIF of hair was also done in equal numbers of controls with other dermatoses. Results: Intercellular deposition of IgG was seen in the ORS of anagen hair in 85% of patients (n ¼ 17). This is, in contrast to DIF of perilesional skin (100%; 20 patients) and IIF (95%; 19 patients). The test was positive in all patients who had scalp lesions (n ¼ 11); however, it was also positive in 7 patients (77.7%) who did not have scalp lesions. The test was negative in 3 patients; two of whom were elderly and had sparse scalp hair. The other patient only had mucosal lesion. The test was negative in the control group. Conclusion: DIF of hair is a simple, noninvasive test, the specificity of which is comparable to that of skin. The test may be positive even in the absence of scalp lesion. In the future, it may alleviate the need for skin biopsies in patients with pemphigus. Commercial support: None identified.
Background: Cutaneous autoimmune subepidermal blistering disorders (CASBD) include bullous pemphigoid (BP), mucous membrane pemphigoid (MMP), other pemphigoid variants, linear IgA bullous dermatosis (LABD), epidermolysis bullosa acquisita (EBA), and bullous systemic lupus erythematosus (BSLE). The diagnosis of these disorders is based on clinical presentation, histologic and immunopathologic findings. Although an accurate diagnosis is aided by the staining pattern of a circulating antibasement membrane antibody on human salt split skin, this is absent in a number of patients. Patients who have serum that illustrate an epidermal pattern on HSSS (BP, some MMP, and some LABD) should have collagen IV present in the floor of their blisters. Conversely, patients who have serum that illustrate a dermal pattern on HSSS (EBA, BSLE, some MMP, and some LABD) should have collagen IV present in the roof of their blisters. The purpose of this study is to determine whether collagen IV immunomapping of a blister from cutaneous biopsies in patients with CASBD, is a useful adjuvant test in the classification of these cutaneous disorders. Methods: Thirty-nine patients with the diagnosis of a CASBD and a subepidermal blister on histopathology were included in this study. Sections of paraffin-embedded tissue of these patients were stained with collagen IV immunoperoxidase antibody and the pattern was noted. Results: Thirty-eight of 39 patients had serum tested for a circulating autoantibody using HSSS as a substrate. Twenty-six of these 38 patients had an antibody on HSS. Detectable collagen IV staining was noted in 33 of 39 patient biopsies. All cases with an epidermal pattern on HSSS and detectable collagen IV staining (16 patients) showed collagen IV deposition in the floor of the blister. Four of 5 cases with a dermal pattern on HSSS and detectable collagen IV staining, showed collagen IV deposition in the roof of the blister. In the 12 cases with a negative antibody on HSSS, 9 showed collagen IV staining. There were a total of 6 with indeterminate collagen IV staining. Conclusions: Collagen IV immunomapping of cutaneous blister is a useful tool in the diagnosis of CASBD. This may be particularly helpful in patients with a negative circulating autoantibody, combined epidermal and dermal pattern on human saltesplit skin, or as a confirmatory test in atypical presentations. Commercial support: None identified.
P1504 Magnetic resonance imaging for the diagnosis of subcutaneous involvement in patients with chronic graft-versus-host disease Jason A. Clark, National Institutes of Health, Bethesda, MD, United States; Lawrence Yao, MD, Department of Diagnostic Radiology, Bethesda, MD, United States; Maria L. Turner, MD, Dermatology Branch, Bethesda, MD, United States; Edward W. Cowen, MD, MHS, Dermatology Branch, Bethesda, MD, United States Background: Chronic graft-versus-host disease (cGVHD) is a common complication of allogenic hematopoietic stem cell transplantation (HSCT). Cutaneous cGVHD may present with sclerosis at any level of the skin or underlying tissue, and may result in significant morbidity arising from joint range-of-motion limitation and contractures. Identification of fascial involvement may be delayed as the overlying skin changes may be subtle or absent. At present, diagnosis requires deep biopsy.
P1506
Methods: Sixty-two patients with a history of cGVHD following allogeneic HSCT were evaluated. Forty-four patients had clinical evidence of cutaneous cGVHD and 28 had dermal or subcutaneous sclerosis or fasciitis based on physical examination. Seventeen of the 44 patients underwent MRI. MRI was performed at 1.5 Tesla (T) and 3T and imaging included T1 spin echo, short tau inversion recovery (STIR) and pre- and postcontrast 3D gradient echo. Results: Seventeen MRI scans (100%) showed thickening of the subcutaneous fibrous septa, 16 cases (94%) showed subcutaneous edema. Fourteen of 17 MRI scans (82%) showed evidence of fasciitis or fascial thickening, 6 (35%) showed evidence of concomitant myositis, and 6 (35%) showed evidence of epimysial inflammation or edema. Nine cases (53%) showed skin thickening. STIR imaging surpassed contrast enhanced MRI in demonstrating these findings. Three patients underwent repeat MRI assessments several months apart. In each case, the MRI findings remained consistent over time. Overall, imaging was concordant with cutaneous findings on clinical examination. Limitations: The study population was a referral group of patients with multisystem cGVHD and is not representative of all patients who develop cGVHD. Although the MRI findings of fascial inflammation corresponded closely with the clinical findings indicative of fasciitis, fascial biopsies were not performed to confirm this diagnosis. Conclusions: STIR MRI is a promising diagnostic modality for the diagnosis of cutaneous cGVHD with subcutaneous and fascial involvement.
Pemphigus vulgaris: Still a difficult disease to treat Nuno Menezes, MD, Servic¸o de Dermatologia do Centro Hospitalar de VN de Gaia, VN Gaia, AA, Portugal; Ineˆs Leite, MD, Centro Hospitalar de VN Gaia, VN Gaia, Portugal; Paulo Varela, MD, Centro Hospitalar de VN Gaia, VN Gaia, Portugal; Armando Baptista, MD, Centro Hospitalar de VN Gaia, VN Gaia, Portugal Pemphigus vulgaris (PV) is a potentially fatal autoimmune mucocutaneous blistering disease. Long-term systemic corticosteroids, with or without the addition of immunosuppressive or antiinflammatory adjuvant agents, remains the mainstay of therapy for PV, although this increases the risk for severe side effects like infections and malignancies. These side effects lead to the use of biologic agents, namely immunoglobulins and the anti-CD20 monoclonal antibody rituximab, apparently with good results. We present the case of a 43-year-old male that was referred to our clinic with bullae and crusts of different sizes located on the upper part of the trunk. He also had erosions on the mouth. The diagnosis of PV was histologically confirmed and antibodies against desmoglein 1 and 3 were present. Treatment with high doses of prednisolone (maximum 2 mg/kg/day) together with high doses of immunosuppressive drugs (azathioprine, cyclosporine, and mycophenolate mofetil) were tried without sustained response and occurrence of side-effects namely opportunistic infections and liver alterations. Therefore treatment with intravenous immunoglobulin was started (2 g/kg over 3 days) and after 6 sessions a partial response was obtained (50% clearance) but with rapid relapse. It was decided to initiate rituximab 375 mg/m2 and 1 month after the 4 weekly doses, was possible to observe marked improvement of the lesions without the appearance of new ones. A rapid decrease in antidesmoglein 3 antibodies also occurred, with a slower reduction in antidesmoglein 1 titre. With this case we intend to emphasise that, despite all therapeutic armamentarium to treat bullous diseases, they can still be very difficult to manage, even in the new era of biologic therapy.
Commercial support: None identified.
Commercial support: None identified.
Objective: To study the utility of MRI in evaluating subcutaneous disease activity in patients with cutaneous cGVHD.
FEBRUARY 2008
J AM ACAD DERMATOL
AB85
P1505
Demonstration of pemphigus specific immunofluorescence pattern by direct immunofluorescence of plucked hair Raghavendra Rao, MBBS, MD, Manipal, India; Shruthi Shenoi, Kasturba Medical College, Manipal, India; Balachandran Nair, MBBS, MD, Kasturba Medical College, Manipal, Manipal, India
The role of collagen IV immunomapping in the evaluation of cutaneous autoimmune subepidermal blistering disorders Carmen Rinaldi, MD, Mayo Clinic Rochester, Rochester, MN, United States; Michael Camilleri, MD, Mayo Clinic Rochester, Rochester, MN, United States
Background: Direct immunofluorescence (DIF) of perilesional skin is the gold standard in the diagnosis of pemphigus. It characteristically shows the deposition of IgG antibodies against the cell surface of keratinocytes. Because the outer root sheath (ORS) of anagen hair is structurally analogous to epidermal keratinocytes, pemphigus specific immunofluorescence pattern may be present in the ORS. Objective: To study the DIF of plucked hair in pemphigus. Materials and methods: Twenty consecutive patients with pemphigus attending skin clinic for the first time were enrolled in the study, irrespective of any other inclusion or exclusion criteria. Hairs were plucked in a similar fashion to that of trichogram. Approximately 5 anagen hairs were selected, processed, and stained with fluorescein isothiocyanate (FITC) conjugates. DIF of perilesional skin and indirect immunofluorescence (IIF) were carried out in all patients simultaneously. The fluorescence microscope examination was performed on stained sections. DIF of hair was also done in equal numbers of controls with other dermatoses. Results: Intercellular deposition of IgG was seen in the ORS of anagen hair in 85% of patients (n ¼ 17). This is, in contrast to DIF of perilesional skin (100%; 20 patients) and IIF (95%; 19 patients). The test was positive in all patients who had scalp lesions (n ¼ 11); however, it was also positive in 7 patients (77.7%) who did not have scalp lesions. The test was negative in 3 patients; two of whom were elderly and had sparse scalp hair. The other patient only had mucosal lesion. The test was negative in the control group. Conclusion: DIF of hair is a simple, noninvasive test, the specificity of which is comparable to that of skin. The test may be positive even in the absence of scalp lesion. In the future, it may alleviate the need for skin biopsies in patients with pemphigus. Commercial support: None identified.
Background: Cutaneous autoimmune subepidermal blistering disorders (CASBD) include bullous pemphigoid (BP), mucous membrane pemphigoid (MMP), other pemphigoid variants, linear IgA bullous dermatosis (LABD), epidermolysis bullosa acquisita (EBA), and bullous systemic lupus erythematosus (BSLE). The diagnosis of these disorders is based on clinical presentation, histologic and immunopathologic findings. Although an accurate diagnosis is aided by the staining pattern of a circulating antibasement membrane antibody on human salt split skin, this is absent in a number of patients. Patients who have serum that illustrate an epidermal pattern on HSSS (BP, some MMP, and some LABD) should have collagen IV present in the floor of their blisters. Conversely, patients who have serum that illustrate a dermal pattern on HSSS (EBA, BSLE, some MMP, and some LABD) should have collagen IV present in the roof of their blisters. The purpose of this study is to determine whether collagen IV immunomapping of a blister from cutaneous biopsies in patients with CASBD, is a useful adjuvant test in the classification of these cutaneous disorders. Methods: Thirty-nine patients with the diagnosis of a CASBD and a subepidermal blister on histopathology were included in this study. Sections of paraffin-embedded tissue of these patients were stained with collagen IV immunoperoxidase antibody and the pattern was noted. Results: Thirty-eight of 39 patients had serum tested for a circulating autoantibody using HSSS as a substrate. Twenty-six of these 38 patients had an antibody on HSS. Detectable collagen IV staining was noted in 33 of 39 patient biopsies. All cases with an epidermal pattern on HSSS and detectable collagen IV staining (16 patients) showed collagen IV deposition in the floor of the blister. Four of 5 cases with a dermal pattern on HSSS and detectable collagen IV staining, showed collagen IV deposition in the roof of the blister. In the 12 cases with a negative antibody on HSSS, 9 showed collagen IV staining. There were a total of 6 with indeterminate collagen IV staining. Conclusions: Collagen IV immunomapping of cutaneous blister is a useful tool in the diagnosis of CASBD. This may be particularly helpful in patients with a negative circulating autoantibody, combined epidermal and dermal pattern on human saltesplit skin, or as a confirmatory test in atypical presentations. Commercial support: None identified.
P1504 Magnetic resonance imaging for the diagnosis of subcutaneous involvement in patients with chronic graft-versus-host disease Jason A. Clark, National Institutes of Health, Bethesda, MD, United States; Lawrence Yao, MD, Department of Diagnostic Radiology, Bethesda, MD, United States; Maria L. Turner, MD, Dermatology Branch, Bethesda, MD, United States; Edward W. Cowen, MD, MHS, Dermatology Branch, Bethesda, MD, United States Background: Chronic graft-versus-host disease (cGVHD) is a common complication of allogenic hematopoietic stem cell transplantation (HSCT). Cutaneous cGVHD may present with sclerosis at any level of the skin or underlying tissue, and may result in significant morbidity arising from joint range-of-motion limitation and contractures. Identification of fascial involvement may be delayed as the overlying skin changes may be subtle or absent. At present, diagnosis requires deep biopsy.
P1506
Methods: Sixty-two patients with a history of cGVHD following allogeneic HSCT were evaluated. Forty-four patients had clinical evidence of cutaneous cGVHD and 28 had dermal or subcutaneous sclerosis or fasciitis based on physical examination. Seventeen of the 44 patients underwent MRI. MRI was performed at 1.5 Tesla (T) and 3T and imaging included T1 spin echo, short tau inversion recovery (STIR) and pre- and postcontrast 3D gradient echo. Results: Seventeen MRI scans (100%) showed thickening of the subcutaneous fibrous septa, 16 cases (94%) showed subcutaneous edema. Fourteen of 17 MRI scans (82%) showed evidence of fasciitis or fascial thickening, 6 (35%) showed evidence of concomitant myositis, and 6 (35%) showed evidence of epimysial inflammation or edema. Nine cases (53%) showed skin thickening. STIR imaging surpassed contrast enhanced MRI in demonstrating these findings. Three patients underwent repeat MRI assessments several months apart. In each case, the MRI findings remained consistent over time. Overall, imaging was concordant with cutaneous findings on clinical examination. Limitations: The study population was a referral group of patients with multisystem cGVHD and is not representative of all patients who develop cGVHD. Although the MRI findings of fascial inflammation corresponded closely with the clinical findings indicative of fasciitis, fascial biopsies were not performed to confirm this diagnosis. Conclusions: STIR MRI is a promising diagnostic modality for the diagnosis of cutaneous cGVHD with subcutaneous and fascial involvement.
Pemphigus vulgaris: Still a difficult disease to treat Nuno Menezes, MD, Servic¸o de Dermatologia do Centro Hospitalar de VN de Gaia, VN Gaia, AA, Portugal; Ineˆs Leite, MD, Centro Hospitalar de VN Gaia, VN Gaia, Portugal; Paulo Varela, MD, Centro Hospitalar de VN Gaia, VN Gaia, Portugal; Armando Baptista, MD, Centro Hospitalar de VN Gaia, VN Gaia, Portugal Pemphigus vulgaris (PV) is a potentially fatal autoimmune mucocutaneous blistering disease. Long-term systemic corticosteroids, with or without the addition of immunosuppressive or antiinflammatory adjuvant agents, remains the mainstay of therapy for PV, although this increases the risk for severe side effects like infections and malignancies. These side effects lead to the use of biologic agents, namely immunoglobulins and the anti-CD20 monoclonal antibody rituximab, apparently with good results. We present the case of a 43-year-old male that was referred to our clinic with bullae and crusts of different sizes located on the upper part of the trunk. He also had erosions on the mouth. The diagnosis of PV was histologically confirmed and antibodies against desmoglein 1 and 3 were present. Treatment with high doses of prednisolone (maximum 2 mg/kg/day) together with high doses of immunosuppressive drugs (azathioprine, cyclosporine, and mycophenolate mofetil) were tried without sustained response and occurrence of side-effects namely opportunistic infections and liver alterations. Therefore treatment with intravenous immunoglobulin was started (2 g/kg over 3 days) and after 6 sessions a partial response was obtained (50% clearance) but with rapid relapse. It was decided to initiate rituximab 375 mg/m2 and 1 month after the 4 weekly doses, was possible to observe marked improvement of the lesions without the appearance of new ones. A rapid decrease in antidesmoglein 3 antibodies also occurred, with a slower reduction in antidesmoglein 1 titre. With this case we intend to emphasise that, despite all therapeutic armamentarium to treat bullous diseases, they can still be very difficult to manage, even in the new era of biologic therapy.
Commercial support: None identified.
Commercial support: None identified.
Objective: To study the utility of MRI in evaluating subcutaneous disease activity in patients with cutaneous cGVHD.
FEBRUARY 2008
J AM ACAD DERMATOL
AB85