T and B cells target identical regions of the non-collagenous domain 1 of type VII collagen in epidermolysis bullosa acquisita.

Epidermolysis bullosa acquisita (EBA) is a severe immunobullous disease and is caused by IgG against type VII collagen (Col VII) of anchoring fibrils. In this study, utilizing ELISA and immunoblot, 13/15 EBA sera but 0/20 bullous pemphigoid sera and 0/30 healthy control sera showed IgG reactivity with distinct recombinant subregions of the non-collagenous domain 1 (NC1) of Col VII. In two EBA patients, IgG titers against Col VII-NC1 were grossly correlated to clinical disease activity. Moreover, Col VII-reactive T cells were identified in a representative EBA patient which recognized identical subdomains of Col VII-NC1. These findings strongly suggest that (1) the Col VII-NC1 ELISA is a powerful tool for making the diagnosis of EBA, (2) Col VII-specific IgG grossly relates to disease activity and (3) IgG reactivity is associated with T cell recognition of identical subdomains of Col VII-NC1.

Autoantibody detection using indirect immunofluorescence on HEp-2 cells.

The detection of autoantibodies is an important element in the diagnosis and monitoring of disease progression in patients with autoimmune diseases. In laboratory diagnostic tests for connective tissue and autoimmune liver diseases, indirect immunofluorescence on HEp-2 cells plays a central role in a multistage diagnostic process. Despite the high quality of diagnostics, findings at different laboratories can differ considerably due to a lack of standardization, as well as subjective factors. The present paper formulates recommendations for the standardized processing and interpretation of the HEp-2 cell test for the detection of non-organ-specific (especially antinuclear) antibodies. It provides requirements regarding the diagnostic tests used, instructions for laboratory procedure and evaluation, and recommendations for interpretation. For an optimal laboratory diagnostic process, it is useful to have an informative, tentative clinical diagnosis and an experienced laboratory diagnostician. In addition, the following key elements are recommended: initial screening using indirect immunofluorescence on carefully chosen HEp-2 cells beginning with a serum dilution of 1:80 and evaluation under a microscope with powerful illumination; results from a titer of 1:160 upwards being considered positive; internal laboratory quality control; and standardized interpretation. The aim is to improve diagnostic tests and care of patients with autoimmune diseases as a central concern of the European Autoimmunity Standardization Initiative (EASI).

Use of high-dose immunoglobulins in dermatology.

The treatment of severe autoimmune skin diseases and of toxic epidermal necrolysis (ICD: L51.2) with high-dose intravenous immunoglobulins (IVIg) is an established therapeutic procedure in dermatology. As IVIg are usually only administered in rare autoimmune diseases or in particularly severe disease courses, use of immunoglobulins in dermatology is commonly not based on experience from controlled and randomized studies typically demanded by evidence-based medicine. In face of the rarity of indications for IVIg it is improbable that such studies will be performed in the foreseeable future. Further, as the high costs of IVIg treatment limits its use as first-line therapy, no clear guidelines exist yet on IVIg use in skin diseases. The present recommendation is based on a consensus of the Working Group on European Guidelines of the EDF (European Dermatology Forum) and the EADV (European Association of Dermato-Venereology) and should provide aid in decision making for the use of IVIg in treating dermatologic diseases

PR3-ANCA-positive necrotizing multi-organ vasculitis following cocaine abuse.

A 22-year-old man with a history of cocaine abuse from 2003 to 2005 developed recurrent bleeding of the nasal septum and a progressive cough and dyspnoea. He was admitted to the intensive care unit because of fulminant pneumonia, impaired renal function and progressive general deterioration. While hospitalized, he developed cutaneous vasculitis, thrombosis of the right subclavian and right jugular veins, testicular pain and, eventually, expanding red papules and plaques on the limbs. The symptoms were a diagnostic challenge, until skin biopsy showed immunoglobulin deposits in small vessels and kidney biopsy focal and segmental pauci-immune, crescentic glomerulonephritis. This led, together with anti-neutrophil cytoplasmic antibodies (cANCA and PR3-ANCA), to the diagnosis of Wegener granulomatosis. The number of affected organ systems in our patient exceeds that commonly found in the literature. Several clinical observations of cocaine abuse followed by Wegener granulomatosis suggest an active induction of a PR3-ANCA-positive vasculitis by cocaine.

Treatment of pemphigus vulgaris with protein A immunoadsorption: case report of long-term history showing favorable outcome.

A pemphigus vulgaris (PV) patient with a 14-year history of severe and painful blistering of skin and mucous membranes as well as side effects from corticosteroids and concomitant immunosuppressive drug treatment was managed successfully by protein A immunoadsorption (IA). After 19 sessions of protein A IA, the patient showed remission of PV and healing of mucocutaneous lesions and the skin. The level of the pathogenic autoantibodies to the adhesion proteins desmoglein 1 (Dsg-1) and desmoglein 3 (Dsg-3) measured by ELISA and immunofluorescence microscopy revealed a significant removal of autoantibodies after each IA therapy. There was a weak rebound of anti-Dsg-1 and anti-Dsg-3 antibodies between IA sessions but an overall decrease over the period of IA therapy. This case demonstrates the effective use of protein A IA as an adjuvant and corticosteroid-sparing therapy in severe pemphigus refractory to standard immunosuppressive therapy and underscores the need for careful monitoring of autoantibodies.

[Significant decrease in quality of life in patients with pemphigus vulgaris. Results from the German Bullous Skin Disease (BSD) Study Group]. / Deutliche Einschrankung der Lebensqualitat bei Patienten mit Pemphigus vulgaris: Ergebnisse der deutschen Bullous Skin Disease (BSD)-Studiengruppe.

BACKGROUND: Pemphigus vulgaris is a potentially life-threatening autoimmune disorder of the skin and mucous membranes characterized by antibodies against epidermal adhesion molecules. Clinically characteristic are painful chronic blisters or erosions of mucous membranes and skin. There are no published studies on the impact o this disease on quality of life. PATIENTS AND METHODS: This registration was performed within the scope of the German BSD (Bullous Skin Disease) study group, from November 1997 until January 2002. A total of 36 patients with the first diagnosis of pemphigus vulgaris were registered at the university hospitals of Dresden, Erlangen, Kiel, Mannheim, München and Würzburg. Thirty of the 36 (83 %) patients participated in the quality of life questionnaire utilizing the German version of 'Dermatology Life Quality Index' (DLQI) provided by A. Y. Finlay. The DLQI varies from 0 to 30 with an increased DLQI score indicating a decrease in quality of quality. RESULTS: The overall DLQI total score of 10 +/- 6.7 in the investigated pemphigus patients was significantly increased in comparison to other skin diseases. CONCLUSIONS: These results suggest that the DLQI can be a very useful additional outcome criteria for clinical studies with pemphigus vulgaris and in the treatment of these patients.

Immunoblotting and enzyme-linked immunosorbent assay for the diagnosis of pemphigoid gestationis.

OBJECTIVES: To investigate the sensitivity of immunoblotting and enzyme-linked immunosorbent assay (ELISA) to detect autoantibodies to bullous pemphigoid antigen 180 in patients with pemphigoid gestationis and to correlate autoantibody serum levels with disease activity. METHODS: In serum samples obtained from 44 pregnant patients before initiation of therapy and from the same number of healthy blood donors, the autoantibody reactivity was assayed by immunofluorescence microscopy on human skin sections as well as Western blot analysis and 2 different ELISAs by using recombinant forms of the immunodominant domain of BP180. In addition, ELISA reactivity with this autoantigen was assayed in 6 patients during the course of the disease, and its correlation with the clinical disease activity was estimated by applying the Spearman rank correlation test. RESULTS: By indirect immunofluorescence microscopy, complement-fixing autoantibodies to the dermal-epidermal junction were found in 93% of patients' sera. By immunoblotting and ELISA, autoantibodies to bullous pemphigoid antigen 180 were detected in 93% and 86.3% of pemphigoid gestationis patients, respectively, but in none of the healthy controls. Serum levels of autoantibodies as detected by ELISA paralleled the patients' disease activity. CONCLUSIONS: Our study shows that immunoblotting and ELISA are sensitive tools for the detection of autoantibodies to bullous pemphigoid antigen 180 in patients with pemphigoid gestationis. In addition, the ELISA is useful to monitor autoantibody serum levels. LEVEL OF EVIDENCE: II-2

A novel point mutation in the hormone binding domain of the androgen receptor associated with partial and minimal androgen insensitivity syndrome.

Mutations in the coding sequence of the androgen receptor (AR) gene result in a wide range of androgen insensitivity syndromes (AIS). We report an extended family in which at least five male individuals in different generations suffer from partial AIS. The index patient presented at birth with ambiguous genitalia; the karyotype was 46,XY and subsequent sex assignment male. Elevated stimulated testosterone (T) and normal baseline gonadotropins were found. Family history revealed four additional adult males affected with various abnormalities of their external genitalia. Molecular analysis of the coding sequence of the AR gene revealed in all a novel point mutation in exon 6, changing threonine to isoleucine at codon position 800 in the hormone-binding domain. We conclude that phenotypic variations in mild AR defects are striking and can remain undetected even until late in life.

[The use of high dose intravenous immunoglobulins in dermatology]. / Einsatz hochdosierter intravenöser Immunglobuline in der Dermatologie.

High dose intravenous immunoglobulins (IVIG) are important agents in the treatment of numerous diseases in rheumatology and dermatology. Because the diseases treated with IVIG are rare, their use is mostly not based on controlled randomized trials. Since the high costs of therapy often prohibit the use of IVIG as first line therapy and as there are no guidelines on the use of IVIG in dermatologic diseases, a consensus conference was held in Wiesbaden, Germany, to address these issues. This manuscript documents the expert consensus on the use of IVIG in dermatology and reflects current clinical practice. It should be a guideline for the practitioner for the use of IVIG in dermatologic diseases.

Clinical relevance of the TNF-alpha promoter/enhancer polymorphism in patients with aplastic anemia.

Immune-mediated inhibition of hematopoiesis has been suspected as a major cause of the suppressed growth of progenitor cells in aplastic anemia (AA). Overproduction of TNF-alpha by bone marrow and peripheral blood-derived cells was shown to be of pathogenetic importance. Genetic factors have been suggested by higher specific histocompatibility antigen frequencies among AA patients as a group and among those unresponsive to immunosuppressive therapy with cyclosporine. In the present work we expand on the evidence for the contribution of the TNF system to therapeutic responses in patients with AA. The response to immunosuppressive therapy at 3 months was found to be significantly more frequent among carriers of the TNF2 (TNF -308 A) gene (TNF2 homozygotes and heterozygotes of the TNF-alpha promoter/enhancer polymorphism) than among those patients not carrying the TNF2 gene. The allelic distribution of the LT-alpha (TNF-beta) NcoI and IL-1 receptor antagonist variable number tandem repeat (VNTR) polymorphisms did not differ among the subgroups of patients. The association of the TNF-alpha genotype with a response to immunosuppressive therapy points to an immunogenetic association that may contribute to the pathogenesis and therapeutic response of aplastic anemia.

Risk factors for lethal outcome in patients with bullous pemphigoid: low serum albumin level, high dosage of glucocorticosteroids, and old age.

BACKGROUND: Although bullous pemphigoid (BP) is the most frequent autoimmune bullous disease and is associated with a considerable case-fatality rate, little is known about factors that influence its prognosis. OBJECTIVE: To identify prognostic factors for lethal outcome in the first year after the initial hospitalization in patients with BP. DESIGN: A multicenter retrospective cohort study. SETTING: Seven dermatologic university hospitals in Germany. PARTICIPANTS: A total of 369 patients diagnosed as having BP between January 1, 1987, and December 31, 1997. STATISTICS: Univariate (Kaplan-Meier) and multivariate (Cox regression) analysis. RESULTS: Of the 369 patients with BP, 209 (57%) died, 106 (29%) within the first year after hospitalization. Fifty-four percent were women. The mean +/- SD age at entry was 77.3 +/- 11.1 years. The patients with BP were followed up to 10.5 years, with a median time of 1.8 years to death or interview (25th and 75th quartiles, 0.5 and 4.0 years). The major risk factors for lethal outcome in the first year after hospitalization were an increased age, with a multivariate risk estimate of 3.2 (95% confidence interval [CI], 1.9-5.2) for age greater than 80.4 years (median); a daily glucocorticosteroid dosage of more than 37 mg (75th quartile) at discharge, with a multivariate risk estimate of 2.5 (95% CI, 1.5-4.3); serum albumin levels of 3.6 g/dL or less (25th quartile), with a multivariate risk estimate of 2.6 (95% CI, 1.5-4.4); and an erythrocyte sedimentation rate greater than 30 mm/h (75th quartile), with a multivariate risk estimate of 1.7 (95% CI, 1.1-2.8). CONCLUSIONS: There is a considerable case-fatality rate in patients with BP. Older patients who require a higher dosage of oral glucocorticosteroids at hospital discharge and who have low serum albumin levels are at greater risk of death within the first year after hospitalization. These prognostic factors should be considered in the care of patients with BP as well as in the design of future clinical trials.