Pemphigus-like antibodies in a patient with cicatricial ...

Pemphigus-like antibodies in a patient with cicatricial pemphigoid

M a r y a n n Fitzmaurice, Ph.D. Rafae l Valenzuela , M.D.

Department of Immunopathology

J a m e s S. Taylor , M . D .

Department of Dermatology

Laurence K. Groves, M.D.

Department of Thoracic and Cardiovascular Surgery

Sharad D. Deodhar , M.D. , Ph.D.

Department of Immunopathology

Immunofluoroscent testing has become a valua-ble ad junc t to histopathologic studies in the diag-nosis of the bullous dermatoses.1"3 In pemphigus, the acantholyt ic intraepithelial bul lae in the strat-ifield squamous epithelia of the skin and mucous membranes associated with deposits of anti-inter-cellular substances (ICS) antibodies are detectable by direct immunofluorescence (DIF).4 In pemphi-goid, including the bullous and cicatricial forms (benign mucous m e m b r a n e pemphigoid) , nonacan-tholytic subepithelial bul lae in the stratified squa-mous epithelia of the skin and mucous membranes associated with deposits of an t ibasement mem-brane (BM) antibodies are detectable by DIF.

Circula t ing ant i - ICS antibodies in the serum of pemphigus pat ients can be detected by indirect immunofluorescence (IIF).4 Like pemphigus , bul-lous pemphigoid is also characterized by circulating an t i -BM antibodies detectable in the serum by IIF. However , circulat ing an t i -BM antibodies are seen much less f requent ly in cicatricial pemphigoid . 5

T r u e pemphigus ant i - ICS and t rue pemphigoid an t i -BM antibodies are believed to be disease-spe-cific. However, there have been increasing reports of pemphigus-like ant i - ICS ant ibodies in pat ients with other clinical conditions, including severe ther-mal burns,6"9 abnormal ly high isohemagglutinin

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138 Cleveland Clinic Quarter ly Vol. 49, No. 3

titers,10"12 and certain bullous drug eruptions.13-18 Pemphigus-like anti-ICS antibodies have been detected in pa-tients with bullous dermatoses other than pemphigus1 9 - 2 1 including three pa-tients with cicatricial pemphigoid.

In this report, we present a patient with the clinical history and physical findings of cicatricial pemphigoid with a pemphigus-like anti-ICS antibody in the serum detected by IIF.

Case report

A 78-year-old white man was referred to the Department of Thoracic and Cardiovas-cular Surgery at The Cleveland Clinic Foun-dation in September 1978 with a 10-year history of progressive dysphagia. At that time the dysphagia was total, resulting in frequent episodes of nocturnal aspiration, and requiring gastrostomy feeding over the last two years. Physical examination re-vealed ulcerations of the buccal mucosa and severe distortion of the oral pharynx that interfered with speech. There was no clinical history or physical findings of skin involve-ment.

A normal barium swallow was impossible, and injection of barium through the gastros-

tomy tube allowed only some back filling of the distal esophagus. Esophagoscopy re-vealed severe distortion of the lower pharynx well above the level of the larynx that pre-vented passage of the esophagoscope but not a small bougie into the esophagus. Esopha-gogastroduodenoscopy revealed an inflam-matory fibrous stricture that prevented ret-rograde passage of the esophagogastroduo-denoscope into the esophagus above the level of T7 or T8.

The patient had been blind in the left eye for the past 15 years and there was marked ptosis of the left eyelid. Ophthalmologic ex-amination revealed end-stage ocular pem-phigoid in the left eye with symblepharon, shortening of the fornices, fixation of the eyelid, and parchment membrane destruc-tion of the cornea (Fig. /).

The Department of Dermatology was then consulted and histopathologic studies were done. A biopsy specimen of buccal mucosa submitted at that time for routine hematoxylin-eosin staining as paraffin sec-tions was devoid of stratified squamous epi-thelium and showed only angioplasia and chronic inflammation in the remaining sub-mucosal connective tissue when examined by light microscopy. A diagnosis of cicatri-cial pemphigoid was made on the basis of the history and classical physical findings.

»

1 Fig. 1. Cica t r ic ia l pemph igo id changes in the left



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The patient showed no significant pro-gression of his disease over the next two years and was reexamined by his family physician in November 1980. At that time biopsy spec-imens of both normal buccal mucosa and normal skin of the arm were obtained for further DIF studies.

Methods

Skin and buccal mucosa specimens for DIF studies were obtained by punch biopsy, transported in Michel's me-dium, quick-frozen in liquid nitrogen, and stored at —70 C until cut into 4fi frozen sections with a Lipshaw cryostat. Direct immunofluorescence was per-formed on the frozen sections by stan-dard techniques23 with use of fluorescein isothiocyanate (FITC) conjugates of monovalent rabbit antisera to h u m a n IgG (Behring Diagnostics) (F /P = 2.5), IgM (Behring Diagnostics) (F /P = 2.5), IgA (Behring Diagnostics) (F /P = 2.5), C3 (Behring Diagnostics) (F /P = 2.5), and fibrinogen (Behring Diagnostics) ( F / P = 2.5).

Sera for IIF studies were obtained by aspiration from whole peripheral blood that was collected by antecubital fossa venipuncture, allowed to clot at room temperature, and then centrifuged at 1500 rpm for 15 minutes at room tem-perature. T h e sera were then stored at 4 C until tested. African green monkey esophagus (Pelfreez Biologicals), h u m a n esophagus, and h u m a n skin were used as tissue substrates. H u m a n skin speci-mens were obtained at hair t ransplant surgeries, and h u m a n esophagus speci-mens at autopsy. All three tissues were quick-frozen in liquid nitrogen and stored at — 70 C until cut into 4fi frozen sections with a Lipshaw cryostat. Indi-rect immunofluorescence was performed on the frozen sections by s tandard tech-niques23 with use of F I T C conjugates of a goat antiserum to human total gamma

Pemphigus-like antibodies 139

globulin (Kallestaad) (F /P = 2.7-3.7) as well as the monovalent antisera de-scribed above. Sera diluted at 1:20 were absorbed with an equal volume of packed pooled type A or type B red blood cells from normal donors for one hour each at 37 C, room temperature, and 4 C and then retested by IIF. Both pemphigus vulgaris patient sera with true pemphigus antibodies and anti-A and anti-B blood group substance typ-ing sera (American Hospital Supply) were used as controls for the absorption studies.

Results

A biopsy specimen of buccal mucosa obtained at the time of initial diagnosis was devoid of stratified squamous epi-thelium and was negative for deposition of IgG, IgM, IgA, C3, and fibrinogen in the remaining submucosal connective tissue. A second biopsy specimen of nor-mal buccal mucosa obtained at the time of réévaluation was intact, and was neg-ative for deposition of IgG, IgM, IgA, C3, and fibrinogen. A normal skin bi-opsy specimen from the arm obtained at the time of réévaluation was also negative for deposition of IgG, IgM, IgA, C3, and fibrinogen in both the dermis and epidermis.

Sera taken both at the time of initial diagnosis and at réévaluation contained anti-ICS antibodies at a titer of 1:80 when studied by IIF with African green monkey esophagus as the tissue sub-strate (Fig. 2). These antibodies bound largely to the lower layers of the mucosal epithelium, exclusive of the basal cell layer. Anti-ICS antibodies present in the initial serum specimen bound to African green monkey esophagus but not to hu-man esophagus or skin substrates when screened for tissue specificity. Anti-ICS antibodies present in the second serum specimen bound to both African green



140 Cleveland Clinic Quarter ly Vol. 49, No. 3

monkey and human esophagus but not to h u m a n skin substrates. Anti-ICS anti-bodies present in both serum specimens did not bind to the patient 's own skin or buccal mucosa when these tissues were used as substrates.

T h e anti-ICS antibodies present in both serum specimens were found to be of the IgG class when screened by IIF with FITC conjugates of the monova-lent antisera on the African green mon-key esophagus tissue substrate. Neither the patient 's anti-ICS antibodies nor anti-ICS antibodies in the sera of the patients with pemphigus vulgaris were removed by absorption with either type

A or B h u m a n red blood cells, as were anti-A and anti-B antibodies in the com-mercial typing sera used as controls.

Discussion

T h e clinical history and physical find-ings of oral ulceration, severe esophageal stricture requiring gastrostomy feeding, and cicatricial ocular involvement re-sulting in blindness are strongly sup-portive of the diagnosis of cicatricial pemphigoid in this patient. Unfortu-nately. as may be characteristic in this disorder, the diagnosis could not be con-firmed histopathologically or by DIF. In fact, vesicles or bullae are rarely present

Fig. 2. Indirect immunof luo rescen t s t a in ing for IgG (arrow) in the in terce l lu lar s u b s t a n c e of Afr ican green monkey esophagus tissue subs t ra t e (X 250).



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in cicatricial pemphigoid. T h e initial biopsy specimen of buccal mucosa was completely devoid of stratified squa-mous epithelium including the basal cell layer, which may have resulted from a subepithelial bullous disorder or artifi-cial removal in processing. There were no significant histopathologic or DIF findings in the remaining submucosal connective tissue. Hence, neither the presence of subepithelial bullae nor B M zone ant ibody deposits characteristic of cicatricial pemphigoid could be docu-mented in this patient. In addition, IIF revealed the presence of circulating anti-ICS rather than B M antibodies as might be expected in cicatricial pemphigoid. A conjunctival biopsy specimen for DIF, which might have shown immunoglob-ulin deposition in cicatricial pemphi-goid, was not obtained in this patient.

It is possible, but not likely, that the correct diagnosis of this case is pemphi-gus vulgaris with esophageal and ocular involvement. Although pemphigus vul-garis usually does present in the buccal mucosa, it almost always progresses to the skin.4 In addition, esophageal24 and ocular25 involvement are both rare in true pemphigus. In comparison, cicatri-cial pemphigoid is frequently restricted to the buccal or esophageal mucosa.5 In fact, the combination of esophageal and ocular involvement is virtually pathog-nomonic of cicatricial pemphigoid. Nei-ther the acantholysis nor the intraepi-thelial bullae characteristic of pemphi-gus could be documented histopatho-logically in this patient. T h e diffuse dep-osition of IgG or C3 in the ICS, which is characteristic of pemphigus vulgaris, was not detected in the biopsy speci-mens.

Pemphigus-like anti-ICS antibodies have been detected in 2 patients by Roenigk and Deodhar,1 9 in 2 patients with cicatricial pemphigoid by Cram et


al,20 and in one patient with bullous pemphigoid by Heine et al. 1 In these patients, the diagnoses were confirmed histopathologically and by DIF. T h e pemphigus-like anti-ICS antibodies in Heine's patient with bullous pemphi-goid, like those in our patient, were of the IgG class and were not removed by absorption with ABO blood group sub-stances. It is interesting tha t the pem-phigus-like anti-ICS antibodies in our pat ient bound to mucosal but not to skin substrates in the IIF assay. Wha t relation this has to the fact that bullae were seen in the mucosa bu t not in the skin is still unknown

Pemphigus-like anti-ICS antibodies have also been reported in association with severe thermal burns,6"9 abnor-mally high isohemagglutinin titers,10-12

and adverse reactions to certain drugs including penicillin,1 penicillamine,14"1

and azathioprine.1 8 These antibodies are frequently transient, of either the IgG or IgM class, and, in the case of the isohem-agglutinins, are removed by absorption with the appropriate A B O blood group substances.

Pemphigus-like anti-ICS antibodies have been distinguished in general from true pemphigus antibodies by their ap-parent inability to bind in vivo.26 This was demonstrated in our patient not only by our inability to detect anti-ICS antibodies prebound to the patient 's own tissues by DIF, but also by our ability to detect ant i-ICS ant ibody binding to the patient 's own tissues when they were used as substrates for IIF.

T h e presence of pemphigus-like anti-bodies can be explained as a predictable immunologic response to epithelial an-tigens released dur ing tissue injury in patients with severe thermal burns or adverse drug reactions. T h e pemphigus-like binding pat tern of serum isohem-



142 Cleveland Clinic Quarterly Vol. 49, No. 3

agglutinins is also not unexpected, as the blood group substances are depos-ited in the ICS of the stratified squa-mous epithelia used as tissue substrates for IIF.27

T h e production of these antibodies in bullous dermatoses other than pemphi-gus is difficult to explain, and we may have to modify our interpretation of immunofluorescent results in these con-ditions.

Acknowledgments

The authors gratefully acknowledge the cooperation of Ernest H. Winterhoff, M.D. in obtaining the biopsy specimens for this study, and the technical assistance of Marcia Yeip, MT(ASCP)I, Sharon Slaughter, MT(ASCP)I, Kathleen Pristas, MT(ASCP), and Laura Lunt, MT(ASCP)I.

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skin an t ibod ies in sera of p e m p h i g u s vulgaris pa t i en t s by indirect immunof luo re scen t s ta in-ing. Proc Soc E x p Biol M e d 1964; 117: 5 0 5 -510.

2. B e u t n e r E H , Lever W F , Wi tebsky E, J o r d o n R , Cer tock B. A u t o a n t i b o d i e s in p e m p h i g u s vulgaris. J A M A 1965; 192: 682-688 .

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14. Hewi t t J , Benvenis te M , Lessana-Leibowi tch M . P e m p h i g u s i nduced by D-pen ic i l l amine (letter). Br M e d J 1975; 3: 371.

15. M a r s d e n R A , D a w b e r R P R , Mi l l a rd P R , M o w a t AG. H e r p e t i f o r m p e m p h i g u s i nduced by penic i l lamine . B r J D e r m a t o l 1977; 97: 451-452 .

16. Kr is tensen J K , W a d s k o v S. Penici l lamine- in-d u c e d p e m p h i g u s foliaceous. Ac ta D e r m a t o -venereol 1977; 57: 69 -71 .

17. S p a r r o w G P . Pen ic i l l amine p e m p h i g u s a n d t h e n e p h r o t i c s y n d r o m e occurr ing s imul ta -neously. Br J D e r m a t o l 1978;98: 103-105.

18. Barker D J , Cot ter i l l J A . A z a p r o p a z o n e in-d u c e d bul lous d r u g e rup t ions . Ac ta D e r m a -tovenereol 1977; 57: 461-462.

19. R o e n i g k H H J r , D e o d h a r S. P e m p h i g u s t rea t -m e n t w i th aza th iopr ine . Arch D e r m a t o l 1973; 107: 353-357 .

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21. H e i n e K G , K u m a r A, J o r d o n R E . P e m p h i -gus-like an t ibodies in bul lous pemph igo id . Arch D e r m a t o l 1977; 113: 1693-1695.

22. Miche l B, Mi lne r Y, Dav id K . Preservat ion of t issue-fixed i m m u n o g l o b u l i n s in skin biop-sies of pa t i en t s w i th lupus e ry thema tosus a n d bu l lous diseases; p re l imina ry repor t . J Invest D e r m a t o l 1973; 59: 449-452 .



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23. Beu tne r E H , Chorzelski T P , J o r d o n R E . Ap-pendix I V . M e t h o d s of immunof luo re scen t s ta in ing for p e m p h i g u s a n d bul lous p e m p h i -goid an t ibodies . [In] Beu tne r E H . Autosensi-t izat ion in P e m p h i g u s a n d Pemph igo id . Spr ingf ie ld ; T h o m a s , 1970; 160-272.

24. R a q u e C J , Stein K M , Sami t z M H . P e m p h i -gus vulgar is involv ing the esophagus . Arch D e r m a t o l 1970; 102: 371-373.

25. Bean SF, H o l u b a r K, Gillett RB . P e m p h i g u s involving the eyes. Arch D e r m a t o l 1975; 111:


1484-1486. 26. Chorzelski T P , Beu tne r E H , J a b l o n s k a S. T h e

role a n d n a t u r e of autoimmunity in p e m p h i -gus. [In] Beu tne r E H , Chorzelski T P , Bean SF, eds. I m m u n o p a t h o l o g y of the Skin . New York: J o h n Wiley & Sons, 2nd ed, 1979: 206-207.

27. S z u l m a n AE. T h e histological d i s t r ibu t ion of b lood g roup subs tances A a n d B in man . J E x p M e d 1960; 111: 785-799.



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