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Pemphigus herpetiformis with IgA and IgG antibodies to desmoglein 1 and IgG antibodies to desmocollin 3
CASE
REPORTS
Pemphigus herpetiformis with IgA and IgG antibodies to desmoglein 1 and IgG antibodies to desmocollin 3 A. Kozlowska, MD,a T. Hashimoto, MD,b M. Jarzabek-Chorzelska, PhD,a A. Amagai, MD,c Y. Nagata, MD,b Z. Strasz, PhD,a and S. Jablonska, MDa Warsaw, Poland, and Fukuoka and Tokyo, Japan We describe a case with clinical and histologic features of pemphigus herpetiformis associated with IgG and IgA anti-keratinocyte cell surface antibodies to desmoglein 1 (Dsg1) and exclusively IgG antibodies to desmocollin 3 (Dsc3). The clinical presentation was somewhat similar to IgA pemphigus; the main difference was the prevailing association with IgG antibodies to Dsg1. The presence of IgA anti-Dsg1 antibodies was confirmed by IgA enzyme-linked immunosorbent assay and IgG anti-Dsc3 antibodies were detected by a novel enzyme-linked immunosorbent assay with the use of baculovirus expressing recombinant Dscs for IgG and IgA. The reactivity of IgG antibodies with Dsc3 was confirmed by COS-7 cell cDNA transfection method using cDNA of human Dsc1 to Dsc3. We discuss the differentiation of pemphigus herpetiformis, associated with both IgG and IgA antibodies, from IgA pemphigus, particularly in regard to the autoimmune reaction with Dsgs and Dscs. (J Am Acad Dermatol 2003;48:117-22.)
P
emphigus herpetiformis (PH) is considered a variant of pemphigus displaying clinical features similar to dermatitis herpetiformis and a diverse histopathologic pattern with intraepidermal and subcorneal microabscesses, eosinophilic spongiosis, or superficial bullae with usually scant acantholytic cells.1,2 The clinical picture is variable, often with coalescent annular or gyrate vesiculopustular lesions. The diagnosis is based on detection of IgG antikeratinocyte cell surface antibodies, both bound in vivo and in circulation. The target antigen for PH antibodies is most often desmoglein 1 (Dsg1),3 and the clinical and immunologic findings are closer to pemphigus foliaceus (PF). In some cases the autoantibodies are directed to multiple epidermal antigens4 or to Dsg3, the pemphigus vulgaris (PV) antigen.5 However, the study of a large series of patients with PH showed that the main target autoantigen is Dsg1, and that Dsg3 is detected in fewer cases.3 From the Department of Dermatology, Warsaw School of Medicine, Warsawa; Kurume University School of Medicine, Fukuokab; and Keio University School of Medicine, Tokyo.c Funding sources: None. Conflict of interest: None identified. Reprint requests: Stefania Jablonska, MD, Department of Dermatology, Warsaw School of Medicine, 02-008 Warsaw, Koszykowa 82a str, Poland. E-mail: [email protected]. Copyright © 2003 by the American Academy of Dermatology, Inc. 0190-9622/2003/$30.00 ⫹ 0 doi:10.1067/mjd.2003.23
Abbreviations used: Dsc3: Dsg1: ELISA: PF: PH: PV:
desmocollin 3 desmoglein 1 enzyme-linked immunosorbent assay pemphigus foliaceus pemphigus herpetiformis pemphigus vulgaris
Of special interest are PH cases with coexistent IgG and IgA antibodies and their relationship with a heterogeneous group of IgA pemphigus cases.6-10 Only some cases are positive for anti-Dsg1 IgA antibodies,9,10 and only a single case was found positive for anti-Dsg3 IgA antibodies.9 Similar cases have also been reported in children, recognized as a vesiculopustular dermatosis with pemphigus-like IgA deposits11 or with IgA antibodies not directed to Dsg.12 One such case has been described as IgA PH,13 and a case of PH with IgG antibodies was found to have predominant neutrophilic infiltrates.14 We describe a patient with PH associated with both IgG and IgA circulating and in vitro bound anti-cell surface antibodies. The important finding is the confirmation of the IgA anti-Dsg1 antibodies by a new IgA enzyme-linked immunosorbent assay (ELISA) technique10 and detection of IgG anti-desmocollin 3 (Dsc3) antibodies. 117
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Fig 1. Vesicular and pustular eruption on the thorax. Some larger pustular lesions are more erythematous and partly covered with crusts.
CASE REPORT In December 2000, a 42-year-old Polish man presented with a 4-month history of vesicular and pustular eruption, localized mainly on the thorax and gradually spreading to the neck, face, and scalp. The eruption consisted of irregularly disseminated small blisters, partly pustular, irregular erythematous plaques with desquamation and crusts, and in some places coalescent (Fig 1). Erosions, seborrheic crusts, and hyperpigmentations prevailed on the back. No oral mucosal lesions were present. After the histopathologic and immunopathologic studies confirmed the diagnosis of PH, treatment with antimalarial (Plaquenil) and nicotinamide was started; however, this therapy proved to be unsatisfactory, and prednisolone (40 mg/d) was introduced in April 2001. From May to June 2001, the patient developed sepsis with kidney complications, followed by thrombosis of the lower extremity and pulmonary embolism. The patient was treated with various antibiotics, antithrombotic compounds, intravenous IgG, and blood transfusions. During his severe ill-
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ness, prednisolone (25-40 mg) was continued, but this did not prevent repeated relapses of cutaneous eruption. His general condition improved considerably in July 2001. His main complaint at this time, in addition to pruritic eruption, was arthralgia, which preceded the skin disease for 2 years. The cutaneous involvement was as mentioned previously: papular, pustular, and erythematous eruptions on the trunk and face, with erosions, crusts, and desquamation predominantly on the back and seborrheic crusts on the scalp. The lesions in some areas were arranged in annular pattern. Oral mucosa was not involved. The general condition of the patient was satisfactory. The results of laboratory tests were within normal limits except for increased levels of triglycerides 248 mg/dL (normal range, 45-150 mg/dL) and cholesterol 254 mg/dL (normal range, 120-200 mg/dL). The abnormal findings also included strongly positive lupus anticoagulant IgM 176.4 U/mL (positive ⬎26) and increased anticardiolipin antibody level 50.43 GPL U/mL (strongly positive ⬎50). Antinuclear antibodies were repeatedly negative. There were no laboratory findings or clinical manifestations characteristic of systemic lupus erythematosus: normal serum immunoglobulins and complement components, normal complete blood cell count, thrombocytes, urinalysis, and x-rays of joints and bones. Lupus band test in sun-exposed and nonexposed skin was negative. Capillaroscopic study did not disclose Raynaud’s loops, and the capillaries were thin, tortuous, and of spastic type. Histologic examination of the skin specimen revealed intraepidermal vesicles filled with neutrophils (Fig 2, A) and numerous eosinophils, and scant (single) acantholytic cells (Fig 2, B). Immunologic studies Direct immunofluorescence showed cell surface IgG and IgA deposits (Fig 3, A and B). Indirect immunofluorescence was negative for the first 2 months; after that, on the substrate of guinea pig esophagus, it showed IgG anti-cell surface antibodies at a titer of 640 (Fig 4, A) and IgA anti-cell surface antibodies at a titer of 160 (Fig 4, B). Indirect immunofluorescence of human skin sections showed IgG and IgA anti-cell surface antibodies at a titer of more than 160. Both the IgG and IgA antibodies reacted stronger in the upper epidermis, with a staining pattern compatible with the distribution of Dsg1. Repeated immunofluorescence studies showed some fluctuations of the antibody titers reflecting the disease activity. By immunoblotting of human epidermal extracts (Fig 5),15 IgG antibodies in the patient’s serum did not react with either the 130-kd Dsg3 or the 160-kd
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Fig 3. Direct immunofluorescence. A, IgG cell surface deposits throughout the whole epidermis. B, IgA intercellular deposits in the epidermis in the same location.
Fig 2. Histopathologic features. A, Intraepidermal bulla filled with neutrophils and numerous eosinophils. Single acantholytic cells are seen. B, Intraepidermal bulla filled with neutrophils and eosinophils, characteristic of eosinophilic spongiosis.
Dsg1. However, IgG antibodies showed a clear doublet of the 110- kd and 100- kd protein bands, which showed exactly the same migration as the “a” form and “b” form of Dsc shown by monoclonal antibody specific to Dsc1 to Dsc3 (Fig 5). No specific reactivity was shown by IgA antibodies. IgG ELISA using baculovirus-expressing human
Dsg1 and Dsg3,3 in which the cut-off value was index value 20, showed high titer anti-Dsg1 antibodies (index value 188.32), but negative anti-Dsg3 (index value 4.02). IgA ELISA,10 in which the cut off value was OD490 0.1, showed high titer anti-Dsg1 antibodies (OD490 2.571), but very weak or negative anti-Dsg3 antibodies (OD490 0.120). In addition, we performed a novel ELISA using baculovirus-expressing Dsc1 to Dsc3 recombinant proteins for both IgG and IgA (Nagata Y, manuscript in preparation). Preliminary data of the studies using the ELISA showed that classic types of pemphigus, such as PV and PF, do not have anti-Dsc antibodies, whereas autoantibodies to the Dsc1 to Dsc3 of both IgG and IgA classes were detected in some atypical pemphigus cases, particularly in cases showing anticell surface antibodies of both IgG and IgA classes. In this ELISA, we consider OD490 more than 0.2 as positive, OD490 0.1 to ⫺0.2 as the gray zone, and OD490 less than 0.1 negative. All of the 10 negative controls for these ELISAs showed OD490 less than 0.100. The ELISA for IgG antibodies showed a relatively high titer of anti-Dsc3 antibodies (OD490 0.246) and a weak reactivity with Dsc1 (OD490
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Fig 4. Indirect immunofluorescence on the substrate of guinea pig esophagus. A, Anti-IgG antibodies: staining stronger in the upper epidermis. Titer 640. B, Anti-IgA antibodies: staining stronger in the upper epidermis. Titer 160.
0.148). IgA ELISA showed no reactivity with any Dsc1 to Dsc3. We also performed COS-7 cell cDNA transfection method for both IgG and IgA antibodies using cDNAs of human Dsc1 to Dsc3 (see Hashimoto et al16 and Dmochowski et al17). In this assay, IgG antibodies reacted clearly with Dsc3 (Fig 6). Although this serum showed a considerable background reactivity as in the previous study,17 the characteristic spotted positive reactivity with Dsc3 was expressed on the cell surfaces of the COS-7 cells. No IgG reactivity with either Dsc1 or Dsc2 was seen. IgA antibodies of the patient serum did not react with any Dscs, although control subcorneal pustular dermatosis type IgA pemphigus sera clearly reacted with Dsc1. Course of the disease After treatment with Plaquenil and nicotinamide proved unsuccessful, administration of prednisolone (30-40 mg/d) was continued, with improvement. However, there were steady relapses of vesiculopustular eruptions that were not controlled by topical steroids. Because of a widespread relapse in early July 2001, we introduced sulfones (Disulone)
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Fig 5. Immunoblotting of normal human epidermal extracts. A control pemphigus vulgaris (PV) serum reacted with both the 160-kd Dsg1 and the 130-kd Dsg3 (lane 1, PV); a control paraneoplastic pemphigus sera reacted with both the 210-kd envoplakin and the 190-kd periplakin (lane 2, PNP); an anti-desmoplakin monoclonal antibody reacted with the 250-kd desmoplakin I and 210-kd desmoplakin II-5F (lane 3, DPL); and an anti-Dsc monoclonal antibody 52-3B reacted with the 110-kd “a” form and the 100-kd “b” form of Dscs, as well as weakly with Dsg1 and Dsg3 (lane 4, Dsc). The IgG antibodies of this patient’s serum reacted clearly with the doublet protein of Dscs (lane 5, Pt), whereas IgA antibodies did not show any positive reactivity.
100 mg per day, and this produced a dramatic improvement after 1 to 2 days and almost complete clearing after 5 days. The patient is presently under maintenance therapy, with no recurrences for some months. However, the disease is not fully controlled because the antibodies to keratinocyte cell surface are still present, and from time to time small blisters appear on the trunk.
DISCUSSION The reported case was clinically almost typical of PH but with some features compatible with intraepidermal neutrophilic dermatosis of IgA pemphigus type and/or PF. The histology was also characteristic of PH: intraepidermal vesicles filled with neutrophils and eosinophils, scant acantholysis, and eosinophilic spongiosis. Immunopathologic studies confirmed the diagnosis, revealing the presence of circulating and in vivo bound anti-cell surface antibodies. However,
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Fig 6. The results of cDNA transfection study for IgG antibodies. A, The IgG antibodies of the patient’s serum reacted with Dsc3 expressed on the cell surfaces of the COS-7 cells. B, Negative results on Dsc2- expressing cells
in addition to IgG anti-cell surface antibodies and IgG deposits, IgA anti-cell surface antibodies and IgA deposits characteristic of IgA pemphigus were also detected. IgA PF with a clinical presentation of PH also may display the histologic pattern of PH and presence of both IgA and IgG antibodies.18 Several cases with vesiculopustular eruption, neutrophilic abscesses, and anti-cell surface antibodies showed clinical and histologic similarity to PH.19,20 However, the main difference is the presence of IgG antibodies in PH, in contrast with the association of intraepidermal neutrophilic IgA dermatosis type IgA pemphigus with IgA antibodies or IgA deposits. In our case, both IgG and IgA anti-cell surface antibody titers were high. Specific IgG ELISA showed Dsg1 antibodies with a very high index of 188.32. In addition, IgA antibodies detected by a recently developed IgA ELISA10 were strongly positive for Dsg1, OD490 2.517 by a cutoff value of OD490 0.15. Thus, it has been confirmed that IgG and IgA antibodies are of PF type, as in the majority of PH cases.3 Antibodies to Dsg1 were also found in a case of PF with prominent neutrophilic pustules.21 Al-
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though differentiation between PH associated with IgG antibodies and the heterogeneous group of IgA pemphigus is based on immunopathology (IgG vs IgA antibodies), differentiation of PH from PF also associated with IgG antibodies may be difficult in very early stages and/or remission periods of PF when similarity to dermatitis herpetiformis may be even striking.1 It has been speculated that the phenotypic difference between PF and PH is due to other epitopes reacting with anti-Dsg antibodies, which in PH are unable to produce full acantholysis.3,21 Activation of complement system was regarded as an important factor for chemoattraction of neutrophils and induction of inflammation.3 In a proportion of our cases, complement (C3) was disclosed by direct immunofluorescence and/or indirect immunofluorescence.2 It is conceivable that complement activation is, in part, responsible for neutrophilic abscesses in PH, which in a majority of cases develop despite exclusive association with IgG antibodies.14 An important feature of our case is the presence (in addition to IgG antibodies) of IgA antibodies, which was confirmed by a novel IgA ELISA.10 A highly significant finding was the clear detection of IgG anti-Dsc3 antibodies, by Dsc ELISA and COS-7 cell cDNA transfection methods, and weak anti-Dsc1 IgG antibodies. Dsc1 is regarded as an autoantigen for the subcorneal pustular dermatosis IgA pemphigus type.16,22 The presence of IgA antiDsc antibodies have been indicated by immunoblotting of bovine desmosome.23 Although anti-Dsc antibodies were detected in various types of pemphigus, especially in Brazilian PF,17,23 and antibodies to Dsc in a case of PV were also reactive with Dsg3 and Dsg1,24 the presence of IgG antibodies to Dsc3 (and weak to Dsc1) associated with IgG and IgA anti-Dsg1 antibodies in our PH case seems to be especially significant. In an unusual case of atypical bullous dermatosis with pronounced acantholysis, pustule formation, and IgG and IgA keratinocyte cell surface deposits, the only detected antibodies were reactive with Dscs..25 Thus, Dscs are conceivably the target antigen for the heterogenous group of vesiculopustular dermatoses with cell surface IgA and IgG deposits. In the present PH case, the target for the autoimmune reaction with both IgG and IgA antibodies was Dsg1, and for IgG, Dsc3. This complex immunoreactivity may explain the presence of somewhat larger pustules in our patient and could also provide some explanation for the heterogeneity of PH and its possible relationship with IgA pemphigus.
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REFERENCES 1. Jablonska S, Chorzelski TP, Beutner EH, Jarzabek-Chorzelska M. Herpetiform pemphigus, a variable pattern of pemphigus. J Dermatol 1975;14:353-9. 2. Maciejowska E, Jablonska S, Chorzelski T. Is pemphigus herpetiformis an entity? J Dermatol 1987;26:571-7. 3. Ishii K, Amagai M, Komai A, Ebihara T, Chorzelski TP, Jablonska S, et al. Desmoglein 1 and desmoglein 3 are the target autoantigens in herpetiform pemphigus. Arch Dermatol 1999; 135: 943-7. 4. Shimizu K, Kikuchi A, Watanabe K, Hashimoto T, Nishikawa T. A case of herpetiform pemphigus associated with autoimmune hemolytic anemia: detection of autoantibodies against multiple epidermal antigens. Dermatology 1996;192:179-82. 5. Kubo A, Amagai M, Hashimoto T, Doi T, Higashiyama M, Hashimoto K, et al. A case of herpetiform pemphigus showing reactivity with pemphigus vulgaris antigen (desmoglein 3). Br J Dermatol 1997;137:109-13. 6. Hashimoto T, Inamoto N, Nakamura K, Nishikawa T. Intercellular IgA dermatosis with clinical features of subcorneal pustular dermatosis. Arch Dermatol 1987;123:1062-5. 7. Wallach D, Janssen F, Vignon-Pennamen MD, Lemarchand-Venencie F, Cottenot F. Atypical neutrophilic dermatosis with subcorneal IgA deposits. Arch Dermatol 1987;123:790-5. 8. Stolz W, Bieber T, Meurer M. Is the atypical neutrophilic dermatosis with subcorneal IgA deposits a variant of pemphigus foliaceus? Br J Dermatol 1989;121:276-9. 9. Prost C, Intrator L, Wechsler J, Lebbe C, Bagot M, Roujeau JC, et al. IgA autoantibodies bind to pemphigus vulgaris antigen in a case of intraepidermal neutrophilic IgA dermatosis. J Am Acad Dermatol 1991;25:846-8. 10. Hashimoto T, Komai A, Futei Y, Nishikawa T, Amagai M. Detection of IgA autoantibodies to desmogleins by an enzyme-linked immunosorbent assay. Arch Dermatol 2001;137:735-8. 11. Saurat JH, Merot Y, Salomon D, Didierjean L. Pemphigus-like IgA deposits and vesiculo-pustumlar dermatosis in a 10-year-old girl. Dermatologica 1987;175:96-100. 12. Cordoliani F, Rybojad M, Verola O, Dallot A, Flageul B, Didierjean L, et al. Pustulose intraepidermique a IgA chez un enfant. Ann Dermatol Venereol 1995;122:671-4. 13. Hodak E, David M, Ingber A, Rotem A, Hazaz B, Shamai-Lubowitz O, et al. The clinical and histopathological spectrum of IgA-pemphigus-report of two cases. Clin Exp Dermatol 1990;15:433-7. 14. O’Toole EA, Mak LL, Guitart J, Woodley DT, Hashimoto T, Amagai M, et al. Induction of keratinocyte interleukin-8 expression and secretion by IgG autoantibodies as a novel mechanism of epi-
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15.
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dermal neutrophil recruitment in a pemphigus variant. Clin Exp Immunol 2000;119:217-24. Ebihara T, Hashimoto T, Iwatsuki K, Takigawa M, Ando M, Ohkawam A, et al. Autoantigens for IgA anti-intercellular antibodies of intercellular IgA vesiculopustular dermatosis. J Invest Dermatol 1991;97:742-5. Hashimoto T, Kiyokawa C, Mori O, Miyasato M, Chidgey MA, Garrod DR, et al. Human desmocollin 1 (Dsc1) is an autoantigen for subcorneal pustular dermatosis type of IgA pemphigus. J Invest Dermatol 1997;109:127-31. Dmochowski M, Hashimoto T, Garrod DR, Nishikawa T. Desmocollins 1 and 2 are recognized by certain sera from patients with various types of pemphigus, particularly Brazilian pemphigus foliaceus. J Invest Dermatol 1993;100:380-4. Chorzelski TP, Beutner EH, Kowalewski C, Olszewska M, Maciejowska E, Seferowicz E, et al. IgA Pemphigus foliaceus with a clinical presentation of pemphigus herpetiformis. J Am Acad Dermatol 1991;24:839-44. Inazumi T, Kikuchi A, Hanyaku H, Hashimoto T, Nishikawa T. Intercellular IgA vesiculopustular dermatosis: an additional case and a review of the literature. Eur J Dermatol 1997;7: 503-7. Niimi Y, Kawana S, Kusunoki T. IgA pemphigus; a case report and its characteristic clinical features compared with subcorneal pustular dermatosis. J Am Acad Dermatol 2000;43:546-9. Matsuo K, Komai A, Ishii K, Futei Y, Amagai M, Deguchi H, et al. Pemphigus foliaceus with prominent neutrophilic pustules. Br J Dermatol 2001;145:132-6. Yasuda H, Kobayashi H, Hashimoto T, Itoh K, Yamane M, Nakamura J. Subcorneal pustular dermatosis type of IgA pemphigus: demonstration of autoantibodies to desmocollin-1 and clinical review. Br J Dermatol 2000;143:144-8. Dmochowski M, Nie Z, Kiyokawa C, Hashimoto T. Human desmocollin la expressed in cultured mammalian fibroblast-like cells is bound by IgG4 antibodies in a pemphigus foliaceus serum. J Dermatol Sci 1999;21:42-8. Hashimoto T, Amagai M, Watanabe K, Dmochowski M, Chidgey MA, Yue KKM, et al. A case of pemphigus vulgaris showing reactivity with pemphigus antigens (Dsgl and Dsg3) and desmocollins. J Invest Dermatol 1995;104:541-4. Chorzelski TP, Hashimoto T, Nishikawa T, Ebihara T, Dmochowski M, Ismail M, et al. Unusual acantholytic bullous dermatosis associated with neoplasia and IgG and IgA antibodies against bovine desmocollins I and II. J Am Acad Dermatol 1994; 31:351-5.
REPORTS
Pemphigus herpetiformis with IgA and IgG antibodies to desmoglein 1 and IgG antibodies to desmocollin 3 A. Kozlowska, MD,a T. Hashimoto, MD,b M. Jarzabek-Chorzelska, PhD,a A. Amagai, MD,c Y. Nagata, MD,b Z. Strasz, PhD,a and S. Jablonska, MDa Warsaw, Poland, and Fukuoka and Tokyo, Japan We describe a case with clinical and histologic features of pemphigus herpetiformis associated with IgG and IgA anti-keratinocyte cell surface antibodies to desmoglein 1 (Dsg1) and exclusively IgG antibodies to desmocollin 3 (Dsc3). The clinical presentation was somewhat similar to IgA pemphigus; the main difference was the prevailing association with IgG antibodies to Dsg1. The presence of IgA anti-Dsg1 antibodies was confirmed by IgA enzyme-linked immunosorbent assay and IgG anti-Dsc3 antibodies were detected by a novel enzyme-linked immunosorbent assay with the use of baculovirus expressing recombinant Dscs for IgG and IgA. The reactivity of IgG antibodies with Dsc3 was confirmed by COS-7 cell cDNA transfection method using cDNA of human Dsc1 to Dsc3. We discuss the differentiation of pemphigus herpetiformis, associated with both IgG and IgA antibodies, from IgA pemphigus, particularly in regard to the autoimmune reaction with Dsgs and Dscs. (J Am Acad Dermatol 2003;48:117-22.)
P
emphigus herpetiformis (PH) is considered a variant of pemphigus displaying clinical features similar to dermatitis herpetiformis and a diverse histopathologic pattern with intraepidermal and subcorneal microabscesses, eosinophilic spongiosis, or superficial bullae with usually scant acantholytic cells.1,2 The clinical picture is variable, often with coalescent annular or gyrate vesiculopustular lesions. The diagnosis is based on detection of IgG antikeratinocyte cell surface antibodies, both bound in vivo and in circulation. The target antigen for PH antibodies is most often desmoglein 1 (Dsg1),3 and the clinical and immunologic findings are closer to pemphigus foliaceus (PF). In some cases the autoantibodies are directed to multiple epidermal antigens4 or to Dsg3, the pemphigus vulgaris (PV) antigen.5 However, the study of a large series of patients with PH showed that the main target autoantigen is Dsg1, and that Dsg3 is detected in fewer cases.3 From the Department of Dermatology, Warsaw School of Medicine, Warsawa; Kurume University School of Medicine, Fukuokab; and Keio University School of Medicine, Tokyo.c Funding sources: None. Conflict of interest: None identified. Reprint requests: Stefania Jablonska, MD, Department of Dermatology, Warsaw School of Medicine, 02-008 Warsaw, Koszykowa 82a str, Poland. E-mail: [email protected]. Copyright © 2003 by the American Academy of Dermatology, Inc. 0190-9622/2003/$30.00 ⫹ 0 doi:10.1067/mjd.2003.23
Abbreviations used: Dsc3: Dsg1: ELISA: PF: PH: PV:
desmocollin 3 desmoglein 1 enzyme-linked immunosorbent assay pemphigus foliaceus pemphigus herpetiformis pemphigus vulgaris
Of special interest are PH cases with coexistent IgG and IgA antibodies and their relationship with a heterogeneous group of IgA pemphigus cases.6-10 Only some cases are positive for anti-Dsg1 IgA antibodies,9,10 and only a single case was found positive for anti-Dsg3 IgA antibodies.9 Similar cases have also been reported in children, recognized as a vesiculopustular dermatosis with pemphigus-like IgA deposits11 or with IgA antibodies not directed to Dsg.12 One such case has been described as IgA PH,13 and a case of PH with IgG antibodies was found to have predominant neutrophilic infiltrates.14 We describe a patient with PH associated with both IgG and IgA circulating and in vitro bound anti-cell surface antibodies. The important finding is the confirmation of the IgA anti-Dsg1 antibodies by a new IgA enzyme-linked immunosorbent assay (ELISA) technique10 and detection of IgG anti-desmocollin 3 (Dsc3) antibodies. 117
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Fig 1. Vesicular and pustular eruption on the thorax. Some larger pustular lesions are more erythematous and partly covered with crusts.
CASE REPORT In December 2000, a 42-year-old Polish man presented with a 4-month history of vesicular and pustular eruption, localized mainly on the thorax and gradually spreading to the neck, face, and scalp. The eruption consisted of irregularly disseminated small blisters, partly pustular, irregular erythematous plaques with desquamation and crusts, and in some places coalescent (Fig 1). Erosions, seborrheic crusts, and hyperpigmentations prevailed on the back. No oral mucosal lesions were present. After the histopathologic and immunopathologic studies confirmed the diagnosis of PH, treatment with antimalarial (Plaquenil) and nicotinamide was started; however, this therapy proved to be unsatisfactory, and prednisolone (40 mg/d) was introduced in April 2001. From May to June 2001, the patient developed sepsis with kidney complications, followed by thrombosis of the lower extremity and pulmonary embolism. The patient was treated with various antibiotics, antithrombotic compounds, intravenous IgG, and blood transfusions. During his severe ill-
J AM ACAD DERMATOL JANUARY 2003
ness, prednisolone (25-40 mg) was continued, but this did not prevent repeated relapses of cutaneous eruption. His general condition improved considerably in July 2001. His main complaint at this time, in addition to pruritic eruption, was arthralgia, which preceded the skin disease for 2 years. The cutaneous involvement was as mentioned previously: papular, pustular, and erythematous eruptions on the trunk and face, with erosions, crusts, and desquamation predominantly on the back and seborrheic crusts on the scalp. The lesions in some areas were arranged in annular pattern. Oral mucosa was not involved. The general condition of the patient was satisfactory. The results of laboratory tests were within normal limits except for increased levels of triglycerides 248 mg/dL (normal range, 45-150 mg/dL) and cholesterol 254 mg/dL (normal range, 120-200 mg/dL). The abnormal findings also included strongly positive lupus anticoagulant IgM 176.4 U/mL (positive ⬎26) and increased anticardiolipin antibody level 50.43 GPL U/mL (strongly positive ⬎50). Antinuclear antibodies were repeatedly negative. There were no laboratory findings or clinical manifestations characteristic of systemic lupus erythematosus: normal serum immunoglobulins and complement components, normal complete blood cell count, thrombocytes, urinalysis, and x-rays of joints and bones. Lupus band test in sun-exposed and nonexposed skin was negative. Capillaroscopic study did not disclose Raynaud’s loops, and the capillaries were thin, tortuous, and of spastic type. Histologic examination of the skin specimen revealed intraepidermal vesicles filled with neutrophils (Fig 2, A) and numerous eosinophils, and scant (single) acantholytic cells (Fig 2, B). Immunologic studies Direct immunofluorescence showed cell surface IgG and IgA deposits (Fig 3, A and B). Indirect immunofluorescence was negative for the first 2 months; after that, on the substrate of guinea pig esophagus, it showed IgG anti-cell surface antibodies at a titer of 640 (Fig 4, A) and IgA anti-cell surface antibodies at a titer of 160 (Fig 4, B). Indirect immunofluorescence of human skin sections showed IgG and IgA anti-cell surface antibodies at a titer of more than 160. Both the IgG and IgA antibodies reacted stronger in the upper epidermis, with a staining pattern compatible with the distribution of Dsg1. Repeated immunofluorescence studies showed some fluctuations of the antibody titers reflecting the disease activity. By immunoblotting of human epidermal extracts (Fig 5),15 IgG antibodies in the patient’s serum did not react with either the 130-kd Dsg3 or the 160-kd
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Fig 3. Direct immunofluorescence. A, IgG cell surface deposits throughout the whole epidermis. B, IgA intercellular deposits in the epidermis in the same location.
Fig 2. Histopathologic features. A, Intraepidermal bulla filled with neutrophils and numerous eosinophils. Single acantholytic cells are seen. B, Intraepidermal bulla filled with neutrophils and eosinophils, characteristic of eosinophilic spongiosis.
Dsg1. However, IgG antibodies showed a clear doublet of the 110- kd and 100- kd protein bands, which showed exactly the same migration as the “a” form and “b” form of Dsc shown by monoclonal antibody specific to Dsc1 to Dsc3 (Fig 5). No specific reactivity was shown by IgA antibodies. IgG ELISA using baculovirus-expressing human
Dsg1 and Dsg3,3 in which the cut-off value was index value 20, showed high titer anti-Dsg1 antibodies (index value 188.32), but negative anti-Dsg3 (index value 4.02). IgA ELISA,10 in which the cut off value was OD490 0.1, showed high titer anti-Dsg1 antibodies (OD490 2.571), but very weak or negative anti-Dsg3 antibodies (OD490 0.120). In addition, we performed a novel ELISA using baculovirus-expressing Dsc1 to Dsc3 recombinant proteins for both IgG and IgA (Nagata Y, manuscript in preparation). Preliminary data of the studies using the ELISA showed that classic types of pemphigus, such as PV and PF, do not have anti-Dsc antibodies, whereas autoantibodies to the Dsc1 to Dsc3 of both IgG and IgA classes were detected in some atypical pemphigus cases, particularly in cases showing anticell surface antibodies of both IgG and IgA classes. In this ELISA, we consider OD490 more than 0.2 as positive, OD490 0.1 to ⫺0.2 as the gray zone, and OD490 less than 0.1 negative. All of the 10 negative controls for these ELISAs showed OD490 less than 0.100. The ELISA for IgG antibodies showed a relatively high titer of anti-Dsc3 antibodies (OD490 0.246) and a weak reactivity with Dsc1 (OD490
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Fig 4. Indirect immunofluorescence on the substrate of guinea pig esophagus. A, Anti-IgG antibodies: staining stronger in the upper epidermis. Titer 640. B, Anti-IgA antibodies: staining stronger in the upper epidermis. Titer 160.
0.148). IgA ELISA showed no reactivity with any Dsc1 to Dsc3. We also performed COS-7 cell cDNA transfection method for both IgG and IgA antibodies using cDNAs of human Dsc1 to Dsc3 (see Hashimoto et al16 and Dmochowski et al17). In this assay, IgG antibodies reacted clearly with Dsc3 (Fig 6). Although this serum showed a considerable background reactivity as in the previous study,17 the characteristic spotted positive reactivity with Dsc3 was expressed on the cell surfaces of the COS-7 cells. No IgG reactivity with either Dsc1 or Dsc2 was seen. IgA antibodies of the patient serum did not react with any Dscs, although control subcorneal pustular dermatosis type IgA pemphigus sera clearly reacted with Dsc1. Course of the disease After treatment with Plaquenil and nicotinamide proved unsuccessful, administration of prednisolone (30-40 mg/d) was continued, with improvement. However, there were steady relapses of vesiculopustular eruptions that were not controlled by topical steroids. Because of a widespread relapse in early July 2001, we introduced sulfones (Disulone)
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Fig 5. Immunoblotting of normal human epidermal extracts. A control pemphigus vulgaris (PV) serum reacted with both the 160-kd Dsg1 and the 130-kd Dsg3 (lane 1, PV); a control paraneoplastic pemphigus sera reacted with both the 210-kd envoplakin and the 190-kd periplakin (lane 2, PNP); an anti-desmoplakin monoclonal antibody reacted with the 250-kd desmoplakin I and 210-kd desmoplakin II-5F (lane 3, DPL); and an anti-Dsc monoclonal antibody 52-3B reacted with the 110-kd “a” form and the 100-kd “b” form of Dscs, as well as weakly with Dsg1 and Dsg3 (lane 4, Dsc). The IgG antibodies of this patient’s serum reacted clearly with the doublet protein of Dscs (lane 5, Pt), whereas IgA antibodies did not show any positive reactivity.
100 mg per day, and this produced a dramatic improvement after 1 to 2 days and almost complete clearing after 5 days. The patient is presently under maintenance therapy, with no recurrences for some months. However, the disease is not fully controlled because the antibodies to keratinocyte cell surface are still present, and from time to time small blisters appear on the trunk.
DISCUSSION The reported case was clinically almost typical of PH but with some features compatible with intraepidermal neutrophilic dermatosis of IgA pemphigus type and/or PF. The histology was also characteristic of PH: intraepidermal vesicles filled with neutrophils and eosinophils, scant acantholysis, and eosinophilic spongiosis. Immunopathologic studies confirmed the diagnosis, revealing the presence of circulating and in vivo bound anti-cell surface antibodies. However,
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Fig 6. The results of cDNA transfection study for IgG antibodies. A, The IgG antibodies of the patient’s serum reacted with Dsc3 expressed on the cell surfaces of the COS-7 cells. B, Negative results on Dsc2- expressing cells
in addition to IgG anti-cell surface antibodies and IgG deposits, IgA anti-cell surface antibodies and IgA deposits characteristic of IgA pemphigus were also detected. IgA PF with a clinical presentation of PH also may display the histologic pattern of PH and presence of both IgA and IgG antibodies.18 Several cases with vesiculopustular eruption, neutrophilic abscesses, and anti-cell surface antibodies showed clinical and histologic similarity to PH.19,20 However, the main difference is the presence of IgG antibodies in PH, in contrast with the association of intraepidermal neutrophilic IgA dermatosis type IgA pemphigus with IgA antibodies or IgA deposits. In our case, both IgG and IgA anti-cell surface antibody titers were high. Specific IgG ELISA showed Dsg1 antibodies with a very high index of 188.32. In addition, IgA antibodies detected by a recently developed IgA ELISA10 were strongly positive for Dsg1, OD490 2.517 by a cutoff value of OD490 0.15. Thus, it has been confirmed that IgG and IgA antibodies are of PF type, as in the majority of PH cases.3 Antibodies to Dsg1 were also found in a case of PF with prominent neutrophilic pustules.21 Al-
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though differentiation between PH associated with IgG antibodies and the heterogeneous group of IgA pemphigus is based on immunopathology (IgG vs IgA antibodies), differentiation of PH from PF also associated with IgG antibodies may be difficult in very early stages and/or remission periods of PF when similarity to dermatitis herpetiformis may be even striking.1 It has been speculated that the phenotypic difference between PF and PH is due to other epitopes reacting with anti-Dsg antibodies, which in PH are unable to produce full acantholysis.3,21 Activation of complement system was regarded as an important factor for chemoattraction of neutrophils and induction of inflammation.3 In a proportion of our cases, complement (C3) was disclosed by direct immunofluorescence and/or indirect immunofluorescence.2 It is conceivable that complement activation is, in part, responsible for neutrophilic abscesses in PH, which in a majority of cases develop despite exclusive association with IgG antibodies.14 An important feature of our case is the presence (in addition to IgG antibodies) of IgA antibodies, which was confirmed by a novel IgA ELISA.10 A highly significant finding was the clear detection of IgG anti-Dsc3 antibodies, by Dsc ELISA and COS-7 cell cDNA transfection methods, and weak anti-Dsc1 IgG antibodies. Dsc1 is regarded as an autoantigen for the subcorneal pustular dermatosis IgA pemphigus type.16,22 The presence of IgA antiDsc antibodies have been indicated by immunoblotting of bovine desmosome.23 Although anti-Dsc antibodies were detected in various types of pemphigus, especially in Brazilian PF,17,23 and antibodies to Dsc in a case of PV were also reactive with Dsg3 and Dsg1,24 the presence of IgG antibodies to Dsc3 (and weak to Dsc1) associated with IgG and IgA anti-Dsg1 antibodies in our PH case seems to be especially significant. In an unusual case of atypical bullous dermatosis with pronounced acantholysis, pustule formation, and IgG and IgA keratinocyte cell surface deposits, the only detected antibodies were reactive with Dscs..25 Thus, Dscs are conceivably the target antigen for the heterogenous group of vesiculopustular dermatoses with cell surface IgA and IgG deposits. In the present PH case, the target for the autoimmune reaction with both IgG and IgA antibodies was Dsg1, and for IgG, Dsc3. This complex immunoreactivity may explain the presence of somewhat larger pustules in our patient and could also provide some explanation for the heterogeneity of PH and its possible relationship with IgA pemphigus.
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