Precision in treatment evaluation: importance of minimal clinically important differences (MCIDs) of outcome measures for autoimmune blistering diseases.

Autoimmune blistering diseases (AIBDs) comprise a group of rare conditions marked by autoantibodies that specifically target intercellular adhesion molecules. Despite the progress made in comprehending the disease and the increasing number of treatment options available, there is still no definitive cure for AIBDs such as pemphigus, and it continues to have a devastating impact on those affected. The challenges in achieving new approved therapies for AIBDs are complex and multifaceted. One significant obstacle was the prior lack of validated and standardized outcome measures, which are crucial for ensuring precise comparisons between new and traditional therapies. This gap in knowledge has prompted the development of minimal clinically important differences (MCIDs), which enable efficient and reliable comparison of therapeutic outcomes between trials. MCID is defined as the minimum difference in an outcome measure that indicates a clinically significant improvement/deterioration in disease severity. Additionally, MCIDs provide a patient-centered approach to evaluating treatment efficacy, by considering whether patients experience a subjective improvement in their symptoms. Therefore, this literature review will examine the derivation and significance of MCIDs for various scoring systems in AIBDs.

Considerations for the use of immunosuppression for the management of pemphigus during the COVID-19 pandemic with a focus on rituximab: Case reports from a single center experience in Australia.

Pemphigus is a rare group of autoimmune mucocutaneous blistering conditions for which the mainstay of treatment is immunosuppression. This is usually achieved with high dose corticosteroids as well as steroid sparing agents. Rituximab is now recommended as a first line treatment for moderate to severe pemphigus vulgaris, the commonest form of pemphigus, alongside corticosteroids. During the early stages of the COVID-19 pandemic the use of rituximab was reduced in our department due to its long term irreversible B-cell suppression. During the COVID-19 pandemic careful pharmacological selection was undertaken for our pemphigus patients to balance the risks of immunosuppression. To demonstrate this, we report three pemphigus patients who required treatment for COVID-19 and assessment throughout the pandemic. To date there has been limited published data regarding the clinical outcomes of pemphigus patients who have developed COVID-19 infections following rituximab infusions, especially in those patients who have received COVID-19 vaccinations. Following careful personalized consideration, all three pemphigus patients presented received rituximab infusions since the start of the COVID-19 pandemic. These patients had also received COVID-19 vaccinations prior to becoming infected with COVID-19. Each patient had a mild COVID-19 infection after receiving rituximab. We advocate for all pemphigus patients to have a full course of COVID-19 vaccinations. Antibody response to COVID-19 vaccinations should ideally be confirmed by measuring pemphigus patient's SARS-CoV-2 antibodies prior to receiving rituximab.

Erethism Mercurialis and Reactions to Elemental Mercury.

Mercury is an underrecognized cause of heavy metal poisoning. Typically, mercury exposure occurs though consumption of methylmercury in seafood or acute inhalation of elemental mercury vapors, with other routes of exposure being uncommon. We describe a case of mercury toxicity resulting from intentional injection of liquid mercury into the right antecubital fossa in a suicide attempt. Mercury poisoning may present with characteristic neuropsychologic signs and symptoms. Increasing anxiety, depression, tremors, irritability, and difficulty concentrating coupled with blood mercury levels higher than 100 µg/L and urine mercury levels of 477 µg/g led to the diagnosis of erethism mercurialis, a constellation of neuropsychologic signs and symptoms including restlessness, irritability, insomnia, emotional lability, difficulty concentrating, and impaired memory. Skin reactions associated with contact to elemental mercury are rare. However, this case presented with a mercury granuloma. Hives and dermatitis have been observed following accidental contact with inorganic mercury compounds.