ARTICLE
Auteur(s) :, Teruki
Dainichi1,*, Hiromichi Takeshita1, Yoichi
Moroi1, Kazunori Urabe1, Mariko
Yoshida2, Yoshiko Hisamatsu2, Ayako
Komai2, Hong Duan1, Tetsuya Koga1,
Takashi Hashimoto2, Masutaka Furue1
1Department of Dermatology, Graduate School of
Medical Sciences, Kyushu University, Fukuoka, JapanFax:(+81)
92-642-5600.
2Department of Dermatology, Kurume University School of
Medicine, Fukuoka, Japan
accepté le 9 Août 2003
Cicatricial pemphigoid (CP) is an autoimmune bullous disease
involving the skin and mucosae, especially the conjunctivae and
oral cavity. This disease is provoked by autoantibodies to basement
membrane zone (BMZ) antigens, which participate in forming the
dermoepidermal junction [1, 2]. The majority of the patients have
autoantibodies recognizing the 180 KDa bullous pemphigoid antigen
(BP180) [1, 3-7]. Anti-laminin 5 (epiligrin) CP is relatively
rare.Laminin 5 is a member of the laminin family of glycoproteins,
of which at least seven distinct isoforms have been described [8].
Laminin 5 distributes in lamina lucida as anchoring filaments. The
precise mode of integration of laminin 5 is unclear but it is
probably mediated by covalent binding to α6β4 integrin in
hemidesmosome and type VII collagen in lamina densa. Laminin 5 is a
trimer consisting of three subunits, α3, β3 and γ2 chain. The α3
and γ2 chains undergo complex postsynthetic processing, leading to
a reduction in their molecular weights.Reportedly, almost all
autoantibodies from patients with anti-laminin 5 CP recognize α3
and/or β3 subunit of laminin 5 [9-15]. We report herein a case of
anti-laminin 5 CP with autoantibodies recognizing the γ2 subunit
that was successfully treated using salazosulfapyridine,
cyclophosphamide and plasmapheresis.
Methods
Histological and immunofluorescence studies
Perilesional skin was studied by direct immunofluorescence for
deposits of IgG, IgA, IgM, and C3. Circulating autoantibodies to
BMZ antigens were detected by indirect immunofluorescence for
deposits of IgG, IgA, IgM, and C3 using 1M sodium chloride (NaCl)
split skin. For preparation of the split skin, normal skin was cut
into small fragments and incubated for 72 hours in 1M NaCl
containing 50 μM phenylmethylsulphonyl fluoride and 0.1M
ethylenediaminetetraacetic acid (EDTA) at 4 ˚C. The epidermis
was then peeled from the dermis [16].
Immunoblotting
Immunoblot analysis using epidermal and dermal extracts prepared
from EDTA-treated normal human skin was performed as described
previously [7, 10, 17-20]. The sera from patients with several
bullous diseases were used as indicators for specific antibodies
against molecules composed to BMZ antigens. Bullous pemphigoid (BP)
sera reacted with both BP230 and BP180. Pemphigus vulgaris (PV)
sera reacted with 130KD-desmoglein (Dsg)-3 and occasionally with
160KD-Dsg-1. Pemphigus foliaceus (PF) sera reacted with
160KD-Dsg-1. Paraneoplastic pemphigus (PNP) sera reacted with
210KD-envoplakin and 190KD-periplakin. Epidermolysis bullosa
acquisita (EBA) sera reacted with the 290KD-EBA antigen (type VII
collagen). Immunoblotting with bacterial fusion protein containing
the NC16a domain, the most immunogenic region of the BP180, was
performed as described previously [7]. A specific immunoblotting
was performed using purified laminin 5 isolated from the
extracellular matrix of cultured human keratinocytes [21].
Results
Case report
A 50-year-old woman, who had been suffering from rheumatoid
arthritis for 5 years and was well controlled at the time by 5 mg
of prednisolone every 2 days, presented with pruritic blisters on
her back and lower legs. Several weeks later, she noted a discharge
from her eyes, gingival pain and nasal hemorrhage. Next she
developed a stomatitis and sore throat, accompanied by pruritic
blistering, crusts and erosions on the abdomen, buttocks and
thighs. She visited and was admitted to our hospital 2 months after
the beginning of her complaint. A physical examination revealed
tense bullae and erosions ranging from a few mm to a few cm in
diameter on the abdomen, lower back, spina iliaca anterior
superior, labium majus pudendi, and extremities ( (figure 1 )A and B).
Conjunctivae were bilaterally inflamed with fibrous adhesion (
(figure 1 )C).
There were some erosions on the oral cavity, gingiva, tongue and
laryngopharynx ( (figure
1 )D), but not in the genital mucosa. No rheumatic
deformity or stiffness of joints was observed.
Laboratory studies
Laboratory examination of blood chemistry showed elevation of
amylase (422 U/mL) which was primarily of the salivary type.
Antinuclear antigen was positive and showed homogenous, nuclear and
cytoplasmic pattern. Rheumatoid factor was elevated (122 IU/mL) and
rheumatoid arthritis hemagglutination was positive (640×). Results
of radiographic examinations showed the patient had no visible
malignant tumors.
Skin biopsy specimens revealed subepidermal bullae with a mild
to moderate chronic inflammatory infiltrate at the perivascular
area in the dermis ( (figure 2 )A). Direct
immunofluorescence demonstrated linear deposition of IgG, but not
of IgA, IgM or C3, along the basement membrane. Indirect
immunofluorescence with patient sera demonstrated linear deposition
of IgG (40×) along the dermal side of 1M NaCl split skin ( (figure 2 )B). In
patient sera, autoantibodies against BP230/BP180, 130KD-Dsg3,
160KD-Dsg1, 210KD-envoplakin, 190KD-periplakin or 290KD-EBA-antigen
(collagen type VII) could not be detected on immunoblot analysis
using epidermal or dermal extracts (data not shown). Anti-BP180
autoantibodies were undetectable on immunoblot analysis using
recombinant protein of BP180 NC16a (not shown). However, on
immunoblotting using purified laminin 5 as an antigen source,
patient sera strongly reacted with the γ2 subunit but not with the
α3 or β3 subunits ( (figure 3) ).
Diagnosis
From the above results, we diagnosed this case as anti-laminin 5
(epiligrin) CP.
Oral treatment with prednisolone 30 mg daily was started.
Daily 200 mg of minocycline hydrochloride, 1 500 mg of nicotinamide
and 150 mg of cyclosporin A was also administered. 250 mg of
methylprednisolone was intravenously administered for 3 days
followed by oral administration of betamethasone in doses of 5 mg
daily in place of prednisolone. However, the mucosal lesions and
parts of the skin lesions remained unresponsive despite these
treatments and the patient’s visual acuity was gradually impaired.
From day 49, in response to the treatment with salazosulfapyridine
in doses of 2 g daily, there was a striking clinical improvement
although ocular lesions were not improved, but the treatment was
discontinued because of its adverse effects, causing the patient to
develop agranulocytosis. From day 109, plasmapheresis was carried
out weekly for 3 weeks, followed by administration of 50 mg
cyclophosphamide daily. In response to these treatments,
progression of the ocular lesions was controlled and her visual
acuity was recovered. In indirect immunofluorescence studies,
anti-laminin 5 autoantibodies became undetectable in sera from the
patient after the disease was controlled. She was discharged on day
140 of her admission. Betamethasone was gradually reduced to a
maintenance dose of 1 mg daily and cyclophosphamide was
discontinued a few months after her discharge. She has had no
recurrence for a year.
Discussion
A majority of patients with CP show blisters or erosions on the
ocular or oral mucosae in the absence of the skin eruption. The
major autoantigen in CP is the hemidesmosome-associated protein
BP180 [1, 3-7]. IgG or both IgG and IgA classes of autoantibodies
are detected in the patients who have anti-BP180 CP. About 10% of
patients with CP have autoantibodies of IgG class against laminin 5
[1, 5]. Although the clinical features of anti-BP180 CP are
relatively mild and sometimes restricted to mucosal lesions without
skin lesions, many cases of anti-laminin 5 CP show more intense
illness with severe ocular and laryngopharyngeal lesions and skin
lesions. Previous cases of anti-laminin 5 CP with antibody against
the γ2 subunit showed extensive laryngeal and ocular involvement
accompanied by bullae formation on the skin of the trunk and of
extremities from the onset of disease [13, 21, 22]. Anti-laminin 5
CP with antibody against the γ2 subunit is thought to be clinically
indistinguishable from anti-laminin 5 CP with antibody against the
α3 and/or β3 subunits. In the present case, although anti-laminin
γ2 antibodies were strongly detected, neither anti-laminin 5 α3 nor
β3 antibodies were detected. These results were independently
confirmed in the laboratory of Professor Kim B. Yancey, Department
of Dermatology, Medical College of Wisconsin, by immunoblot
analysis using extracts from cultured keratinocytes. The existence
of anti-laminin 5 autoantibodies in this case was also confirmed by
immunoprecipitation techniques in his laboratory. These results
suggest that autoantibody against the laminin 5 γ2 subunit per se
can induce blistering of both mucosa and skin, and that the γ2
subunit of laminin 5 may play an important role in dermoepidermal
and dermomucosal junctions, although its autoantibody-eliciting
epitope remains unknown.
In our case, mucosal lesions persisted after autoantibodies
against the laminin 5 γ2 subunit became undetectable. Treatment
with cyclophosphamide, an immunosuppressive agent for T
lymphocytes, was of value in improving mucosal lesions. These
findings suggest the possibility that undetectable levels of
autoantibodies against BMZ antigens can contribute to progression
of the disease. It is also conceivable that at least the
progression of mucosal lesions depends on not only autoantibodies
against BMZ antigen, but also on T lymphocyte-mediated autoimmunity
in the disease. Direct immunofluorescence studies of the skin from
the patient have not been performed since the disease has been
controlled.
There are some reports of CP in patients with rheumatoid
arthritis treated with D-penicillamine [23]. Our patient had
suffered from rheumatoid arthritis for 5 years before the onset of
CP. However, she had never been treated with D-penicillamine. The
severity of the rheumatoid arthritis did not change, nor was it
ameliorated by the systemic steroids and other intensive treatment.
The patient showed dryness of the eyes and thirst accompanied by
decreased lacrimation and elevation of the salivary-type amylase in
the serum. Although these findings could not eliminate the
possibility that the patient also suffered from Sjögren’s syndrome
with exacerbation of CP, the diagnostic criteria of Sjögren’s
syndrome were not present. The decrease of lacrimation and
elevation of amylase were controlled with remission of the CP.
The treatment of CP is difficult, especially in progressive
cases with ocular and laryngopharyngeal lesions. The treatment
depends on the stage of the disease [1]. In mild cases, the use of
minocycline or tetracycline combined with nicotinamide is
effective. In moderate cases, systemic steroids are mostly used.
Potent topical steroids and systemic steroids are helpful for the
skin, but often less helpful for mucosal disease, which may
continue despite steroids. Dapsone or sulphapyridine may be of
value in controlling oral and cutaneous blistering and ocular
disease [24-26]. In some severe cases, steroid pulse therapy or
plasmapheresis may be effective [15]. Cyclophosphamide is helpful
in severe ocular disease [25-32]. In the present case, systemic
steroid treatment was effective against skin lesions to some
extent, but laryngopharyngeal and ocular lesions persisted.
Combined use of minocycline and nicotinamide, or cyclosporin had no
effect in the present case. Although sulphapyridine had a marked
effect, especially against the laryngopharyngeal complaint and
prolonged skin lesions, this drug had to be discontinued due to its
adverse effect of agranulocytosis. Dapsone, which is also a
sulfonamide, was not used after the onset of adverse effects.
Cyclophosphamide also had definite effects, especially in the
ocular lesions, in the present case.
Although cyclosporin A blocks the generation of interleukin-2 by
T-lymphocytes, cyclophosphamide inhibits T-lymphocyte
proliferation, and especially, B-lymphocyte proliferation.
Azathioprine is an inhibitor of purine metabolism so as to block
cell division and is used as an immunosuppressive drug in
transplantation and occasionally in controlling severe CP [32].
However, it is sometimes substituted with other drugs like
cyclophosphamide or mycophenolate mofetil because of its side
effects on hematopoiesis. There are recent reports that
mycophenolate mofetil, an immunosuppressive drug that also
selectively inhibits T- and B-lymphocyte proliferation and was
originally used to treat acute graft rejections in kidney
transplant recipients, is effective in ocular CP [33]. This drug
may be a promising treatment in severe cases.
Acknowledgements
We thank Professor Kim B Yancey, Department of Dermatology, Medical
College of Wisconsin, for confirming our results by
immunoprecipitation and immunoblot analysis using extracts from
cultured keratinocytes in his laboratory. We thank Dr. Junko Wakiya
and Dr Masahiro Yamamoto, Department of Ophthalmology, Graduate
School of Medical Sciences, Kyushu University, for ophthalmologic
attendance of the patient.
References
1 Hashimoto T. Skin diseases related to abnormality in
desmosomes and hemidesmosomes – editorial review. J Dermatol Sci
1999; 20: 81-4.
2 Bernard P, Prost C, Lecerf V, Intrator L,
Combemale P, Bedane C, et al. Studies of cicatricial
pemphigoid autoantibodies using direct immunoelectron microscopy
and immunoblot analysis. J Invest Dermatol 1990; 94: 630-5.
3 Bernard P, Prost C, Durepaire N,
Basset-Seguin N, Didierjean L, Saurat JH. The major
cicatricial pemphigoid antigen is a 180-kD protein that shows
immunologic cross-reactivities with the bullous pemphigoid antigen.
J Invest Dermatol 1992; 99: 174-9.
4 Stanley JR, Hawley-Nelson P, Yuspa SH,
Shevach EM, Katz SI. Characterization of bullous
pemphigoid antigen: a unique basement membrane protein of
stratified squamous epithelia. Cell 1981; 24: 897-903.
5 Murakami H, Nishioka S, Setterfield J,
Bhogal BS, Black MM, Zillikens D, et al.
Analysis of antigens targeted by circulating IgG and IgA
autoantibodies in 50 patients with cicatricial pemphigoid. J
Dermatol Sci 1998; 17: 39-44.
6 Egan CA, Hanif N, Taylor TB, Meyer LJ,
Petersen MJ, Zone JJ. Characterization of the antibody
response in oesophageal cicatricial pemphigoid. Br J Dermatol 1999;
140: 859-64.
7 Matsumura K, Amagai M, Nishikawa T,
Hashimoto T. The majority of bullous pemphigoid and herpes
gestationis serum samples react with the NC16a domain of the
180-kDa bullous pemphigoid antigen. Arch Dermatol Res 1996; 288:
507-9.
8 Burgeson RE, Chiquet M, Deutzmann R,
Ekblom P, Engel J, Kleinman H, et al. A new
nomenclature for the laminins. Matrix Biol 1994; 14: 209-11.
9 Domloge-Hultsch N, Anhalt GJ, Gammon WR,
Lazarova Z, Briggaman R, Welch M, et al.
Antiepiligrin cicatricial pemphigoid. A subepithelial bullous
disorder. Arch Dermatol 1994; 130: 1521-9.
10 Kirtschig G, Marinkovich MP, Burgeson RE,
Yancey KB. Anti-basement membrane autoantibodies in patients
with anti-epiligrin cicatricial pemphigoid bind the alpha subunit
of laminin 5. J Invest Dermatol 1995; 105: 543-8.
11 Hashimoto T, Murakami H, Senboshi Y,
Kanzaki H, Arata J, Yancey KB, et al.
Antiepiligrin cicatricial pemphigoid: the first case report from
Japan. J Am Acad Dermatol 1996; 34: 940-2.
12 Allbritton JI, Nousari HC, Anhalt GJ.
Anti-epiligrin (laminin 5) cicatricial pemphigoid. Br J Dermatol
1997; 137: 992-6.
13 Lazarova Z, Hsu R, Yee C, Yancey KB.
Antiepiligrin cicatricial pemphigoid represents an autoimmune
response to subunits present in laminin 5 (α3β3γ2). Br J Dermatol
1998; 139: 791-7.
14 Leverkus M, Schmidt E, Lazarova Z,
Brocker EB, Yancey KB, Zillikens D. Antiepiligrin
cicatricial pemphigoid: an underdiagnosed entity within the
spectrum of scarring autoimmune subepidermal bullous diseases? Arch
Dermatol 1999; 135: 1091-8.
15 Hashimoto Y, Suga Y, Yoshiike T,
Hashimoto T, Takamori K. A case of antiepiligrin
cicatricial pemphigoid successfully treated by plasmapheresis.
Dermatology 2000; 201: 58-60.
16 Ghohestani RF, Nicolas JF, Rousselle P,
Claudy AL. Diagnostic value of indirect immunofluorescence on
sodium chloride-split skin in differential diagnosis of
subepidermal autoimmune bullous dermatoses. Arch Dermatol 1997;
133: 1102-7.
17 Sugi T, Hashimoto T, Hibi T, Nishikawa T.
Production of human monoclonal anti-basement membrane zone (BMZ)
antibodies from a patient with bullous pemphigoid (BP) by
Epstein-Barr virus transformation. Analyses of the heterogeneity of
anti-BMZ antibodies in BP sera using them. J Clin Invest 1989; 84:
1050-5.
18 Hashimoto T, Ogawa MM, Konohana A,
Nishikawa T. Detection of pemphigus vulgaris and pemphigus
foliaceus antigens by immunoblot analysis using different antigen
sources. J Invest Dermatol 1990; 94: 327-31.
19 Amagai M, Nishikawa T, Nousari HC,
Anhalt GJ, Hashimoto T. Antibodies against desmoglein 3
(pemphigus vulgaris antigen) are present in sera from patients with
paraneoplastic pemphigus and cause acantholysis in vivo in neonatal
mice. J Clin Invest 1998; 102: 775-82.
20 Ishiko A, Hashimoto T, Shimizu H,
Nishikawa T. Epidermolysis bullosa acquisita: report of a case
with comparison of immunogold electron microscopy using pre- and
postembedding labelling. Br J Dermatol 1996; 134: 147-51.
21 Hisamatsu Y, Nishiyama T, Amano S,
Matsui C, Ghohestani R, Hashimoto T. Usefulness of
immunoblotting using purified laminin 5 in the diagnosis of
anti-lamanin 5 cicatricial pemphigoid. J Dermatol Sci 2003; 33:
113-9.
22 Nousari HC, Rencic A, Hsu R, Yancey KB,
Anhalt GJ. Anti-epiligrin cicatricial pemphigoid with
antibodies against the gamma2 subunit of laminin 5. Arch Dermatol
1999; 135: 173-6.
23 Peyri J, Servitje O, Ribera M, Henkes J,
Ferrandiz C. Cicatricial pemphigoid in a patient with
rheumatoid arthritis treated with D-penicillamine. J Am Acad
Dermatol 1986; 14: 681.
24 Zhu YI, Stiller MJ. Dapsone and sulfones in
dermatology: overview and update. J Am Acad Dermatol 2001; 45:
420-34.
25 Elder MJ, Leonard J, Dart JK. Sulphapyridine -
a new agent for the treatment of ocular cicatricial pemphigoid. Br
J Ophthalmol 1996; 80: 549-52.
26 Doan S, Lerouic JF, Robin H, Prost C,
Savoldelli M, Hoang-Xuan T. Treatment of ocular
cicatricial pemphigoid with sulfasalazine. Ophthalmology 2001; 108:
1565-8.
27 Foster CS, Wilson LA, Ekins MB.
Immunosuppressive therapy for progressive ocular cicatricial
pemphigoid. Ophthalmology 1982; 89: 340-53.
28 Werth VP. Pulse intravenous cyclophosphamide for
treatment of autoimmune blistering disease. Is there an advantage
over oral routes? Arch Dermatol 1997; 133: 229-30.
29 Bohn J, Jonsson S, Holst R. Successful
treatment of recalcitrant cicatricial pemphigoid with a combination
of plasma exchange and cyclophosphamide. Br J Dermatol 1999; 141:
536-40.
30 Fleischli ME, Valek RH, Pandya AG. Pulse
intravenous cyclophosphamide therapy in pemphigus. Arch Dermatol
1999; 135: 57-61.
31 Musette P, Pascal F, Hoang-Xuan T,
Heller M, Lok C, Deboise A, et al. Treatment of
cicatricial pemphigoid with pulse intravenous cyclophosphamide.
Arch Dermatol 2001; 137: 101-2.
32 Miserocchi E, Baltatzis S, Roque MR,
Ahmed AR, Foster CS. The effect of treatment and its
related side effects in patients with severe ocular cicatricial
pemphigoid. Ophthalmology 2002; 109: 111-8.
33 Megahed M, Schmiedeberg S, Becker J,
Ruzicka T. Treatment of cicatricial pemphigoid with
mycophenolate mofetil as a steroid-sparing agent. J Am Acad
Dermatol 2001; 45: 256-9.
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