Letters to Editor

Konishi et al[8] have demonstrated induction of bullous Bullous systemic by Western Blot analysis of circulating antibodies against BP 180 and BP 230 antigen which erythematosus: Response to lead them to propose that some of the occurring dapsone in two patients in bullous are true bullous pemphigoid. Sir, Bornhovd et al[9] postulated persistence of parasites as Bullous systemic lupus erythematosus (SLE) is a cause of Th cells activation with increased IL and 2 5 transient autoimmune bullous disease that occurs in secretion of proteolytic enzymes near BMZ established cases of SLE. Some authors use this term (basement membrane zone) producing bullae for all subepidermal autoimmune bullous conditions formation. The exact mechanism for bullae formation in SLE, whereas others use it for conditions where is not known and further studies need to be done to dermal antigens are involved.[1] explain the pathogenesis of bullous scabies. In a patient with itchy, vesiculobullous lesions, burrows should be Histopathologically, this condition is characterized by looked for, as they are seen in majority of cases of subepidermal bullae with neutrophilic microabscesses, bullous scabies. nuclear dust and fibrin at the tips of dermal papillae. Direct reveals a linear deposition D. K. Jena, M. L. Dash, R. Chhetia of IgG, IgA, IgM and C3 in the basement membrane Departments of Skin and VD, S.C.B. Medical College and Hospital, Cuttack. zone. The target antigen is believed to be type VII in the . We came across two cases of Address for correspondence: Dr. DK Jena, Professor and HOD, bullous SLE at our institute. Department of Skin and VD, S.C.B. Medical College and Hospital, Cuttack. E-mail: [email protected] An 18-year-old female presented with arthritis of both REFERENCES knee and ankle joints since the last 1 month, fever since 15 days, oral ulcerations since 10 days, and lacrimation 1. Stone SP. Scabies and Pediculosis in Fitzpatrick’s and irritation of the left eye since 4 days. After 3 days in General Medicine. Edited by Irwin M. of hospitalization, she developed asymptomatic th International Ed, 6 Ed, Freedberg: McGraw Hill Publishing; erythematous, non-itchy, maculopapular over the 2003, p. 2283-9. 2. Sciammarella J. Scabies. E-Medicine: Article by 2002, July 8, 4/ abdomen, which remained confined to the trunk. On th 16/2004. the 7 day of hospitalization, she developed vesicles 3. Shahab RK, Loo DS. Bullous scabies. J Am Acad Dermatol on the left retroauricular area, left upper eyelid, right 2003;49:346-50. axillary area, chest and abdomen. These vesicles 4. Bhawan J, Milstone E, Malhotra R, Rosenfeld T, Appel M. gradually increased in size and number. Scabies presenting as Bullous Pemphigoid like eruption. J Am Acad Dermatol 1991;24:179-81. 5. Veraldi S, Scarabelli G, Zerboni R, Pelosi A, Gianotti R. Bullous On examination, she had pallor, bilateral cervical scabies. Acta Derm Venereol 1996;76:167-8. lymphadenopathy, multiple tense over 6. Herman PS. Scabies and bullae. JAMA 1975;231:1134. apparently normal skin, oral erosions over the hard 7. Brenner S, Wolf R, Lindau M. Scab1id; an unusual id reaction to scabies. Int J Dermatol 1993;32:128-9. palate, and redness of the left eye. Nikolsky’s sign was 8. Konishi N, Suzuki K, Tokura Y, Hashimoto T, Takigawa M. negative. Bullous eruption associated with scabies; evidence for scabetic induction of true bullous pemphigoid. Acta Derm Venereol The second patient was a 20-year-old female who 2000;80:281-3. 9. Bornhovd E, Partscht K, Flaig MJ, Messer G [Bullous scabies presented with arthritis of both ankle and wrist joints and scabies triggered bullous pemphigoid] Hautarzt with low grade fever, swollen feet and face and bullous 2001;52:56-61 (Abstract) lesions over the face and neck. She was a known case of nephrotic syndrome since the last 1 year and gave a

Indian J Dermatol Venereol Leprol January-February 2005 Vol 71 Issue 1 54 Letters to Editor history suggestive of photosensitivity. Examination Table 1: Summary of investigations revealed pallor, edema, and tense bullae over normal Investigations Patient No. 1 Patient No. 2 appearing skin of the face (Figure 1) and lateral aspect Hb% 6 g% 7.8 g% of the neck. Nikolsky’s sign was negative and there were Total leukocyte count 4.9x103/mm3 8.6x103/mm3 ESR 90 mm/1st hr 76 mm/1st hr no oral lesions. Platelet count 1.6 lakhs/mm3 1.2 lakhs/mm3 Blood urea 45 mg% 34 mg% Serum creatinine 1.4 mg% 1.2 mg% Both the patients were subjected to hematological and Anti-nuclear antibody 4.01 OD Ratio 3.40 OD Ratio biochemical investigations and histopathological study Anti-dsDNA 79.71 IU/L 23.00 IU/L Urine (Table 1). Direct immunofluorescence could not be done 24 hour protein 1600 mg% 1300 mg% because this facility was not available. Albumin +++ +++ RBCs 30-40/hpf 30-40/hpf Histopathology Subepidermal bullae Subepidermal bullae On the basis of the above findings, a diagnosis of with neutrophilic with neutrophilic microabscesss microabscess bullous SLE was made. Both the patients were treated X-ray chest Cardiomegaly Normal with dapsone 100 mg orally once daily. The maculopapular rash disappeared within 3 days of glomerulonephritis may be associated. The target institution of therapy in the first patient, and the bullae antigen is type VII collagen, but at times other antigens started regressing by the 7th day. Ultimately, the lesions may be involved.[3,4] healed with residual . However, in the second patient, the bullous lesions did not respond Clinically similar, and bullous till the 15th day and regressed very slowly thereafter, pemphigoid can be differentiated by direct showing complete resolution with hyperpigmentation immunofluorescence. Bullous lesions in SLE due to by the 45th day. photosensitivity, acute lupus or drugs can be differentiated by both histopathology and Bullous systemic lupus erythematosus is a rare immunopathology. acquisita condition, with an incidence of 0.2 per million. It (EBA) is histopathologically and immunopathologically predominantly affects young adult females.[2] Tense identical since both diseases are mediated by circulating bullae appear predominantly over the face, neck and antibodies against type VII collagen. However, a upper trunk. Oral ulcerations, photosensitivity and dramatic therapeutic response to dapsone in bullous SLE differentiates it from EBA.[5]

Both of our patients were young adult females having lesions predominantly in the head and neck region which is consistent with the reports of other authors.[1,2,6] Both had renal abnormalities and both of them responded to dapsone.

C. S. Sirka, T. Padhi, P. Mohanty, D. K. Patel*, P. R. Parida*, C. R. Kar** Departments of Skin and VD, *Medicine and **Nephrology, VSS Medical College, Burla, Orissa, India.

Address for correspondence: Dr. C. S. Sirka, Department of Skin and VD, V.S.S. Medical College, Burla, Sambalpur, Orissa - 768017, India. E-mail: [email protected]

REFERENCES

1. Gammon WR, Briggaman RA. Bullous SL. A phenotypically Figure 1: Bullae and over eyelid and nose distinctive but immunologically heterogenous bullous

55 Indian J Dermatol Venereol Leprol January-February 2005 Vol 71 Issue 1 Letters to Editor

disorder. J Invest Dermatol 1993;100:28s-34s. 4. Yell JA, Wojnarowska F, Allen J, Burge SM. Bullous systemic 2. Bernard P, Vaillant L, Labeille B, Bedane C, Arbeille B, Denoeux lupus erythematosus- a variable disease. Lupus 1993;2: JP, et al. Incidence and distribution of subepidermal 383-5 autoimmune bullous skin diseases in three French regions. 5. Odom RB, James WD, Berger TG, editors. Andrew’s Diseases Arch Dermatol 1995;131:48-52. of the Skin. Philadelphia: WB Saunders; 2000. 3. Hall RP, Lawley TJ, Smith HR, Katz SI. Bullous eruptions of 6. Yell JA, Allen J, Wojnarowska F, Kirtschig G, Burge SM. Bullous systemic lupus erythematosus. Dramatic response to dapsone. systemic lupus erythematosus: Revised criteria for diagnosis. Ann Intern Med 1982;97:165-70. Br J Dermatol 1995;132:921-8.

Announcement Contact and Occupational Dermatoses Forum of India (CODFI) Fellowships

Contact and Occupational Dermatoses Forum of India is offering two fellowships in “ and Patch Testing” in the year 2005. The applicant must be a qualified dermatologist (Degree or Diploma in Dermatology and Venereology). Preference would be given to candidates below 40 years and working as faculty or senior resident in a teaching institution. The fellowship comprises an award of Rs. 5000/- only and selected candidates need to make their own arrangement for travel and stay. The candidates can train for 4 weeks at any of three centers listed below:

Dr. V. K. Sharma, Professor and Head, Department of Dermatology and Venereology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029. Email: [email protected]

Prof. C. R. Srinivas, Department of Skin and STD, PSG Hospitals, P.O. Box 1674, Coimbatore - 641 004.

Prof. A. K. Bajaj, Bajaj Skin Clinic, 3/6 Panna Lal Road, Allahabad.

The application along with biodata (2 copies) and copy of M.D. Dermatology certificate should be submitted to Prof. V.K. Sharma, Head, Department of Dermatology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi. Candidates are required to submit a 200-word write-up justifying award of fellowship. Last date of receipt of application is 31.03.05. Successful candidates would be informed by email.

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