life.science.discovery. life.science.discovery. ™ Autoimmune Blistering Disease - Diagnostic Methodology for Pemphigus and Pemphigoid - Pemphigus BP EBA Epidermal side Epidermal side Dermal side Dermal side Epidermal cell-cell junction BP230 BP230 Anti-BP230 BP180 BP180 Dsg3 Anti-BP180 Anchoring fibril Anchoring fibril Dsg1 Blister Blister Anti-type VII collagen NC16a Complement www.mblintl.com Structure of the epidermis CONTENTS The epidermis generally consists of four layers: basal Normal skin Epidermal cell-cell junction layer (stratum basale), spinous layer (stratum spinosum), Structure of the epidermis 3 Desmocollin granular layer (stratum granulosum), and cornified layer Classification of autoimmune blistering diseases 3 Dsg3: desmoglein 3 (stratum corneum). Keratinocytes are the major component Epidermal cells of the epidermis. These cells progressively differentiate Pemphigus 4 from basal cells to the finally differentiated, cornified Desmosome Dsg1: desmoglein 1 Clinical characterization 4 layer, the outermost layer of the epidermis. Several Epidermal cells types of intercellular junctions in the epidermis, such as Cornified layer Pemphigus (PV/PF) and anti-desmoglein 1 & 3 IgG autoantibodies 5 Plakoglobin desmosomes and tight junctions, are involved in protection Desmoplakin Granular layer against mechanical stress, physical stimulation or infectious Plakophilin Pemphigoid 6 agents. Desmosomes are composed of transmembrane Epidermis Clinical characterization 6 proteins [e.g., desmoglein (Dsg) 1, Dsg3, and desmocollin] Dermal-epidermal junction BP230 and intracellular proteins ( , desmoplakin). Desmogleins Plectin BOX Salt-split skin immunofluorescence 7 e.g. Spinous layer and desmocollins, which are the cadherin family proteins, BP180 Basal cells Bullous pemphigoid (BP) and anti-BP180 and anti-BP230 IgG autoantibodies 8 Integrin α6β4 maintain epidermal cohesion in a Ca2+-dependent manner. Hemi-desmosome Epidermolysis bullosa acquisita (EBA) and anti-type VII collagen IgG autoantibodies 8 Basal layer Basal layer, the deepest layer of the epidermis, rests Lamina lucida Basement membrane zone Basement membrane zone Sites of the skin blister formation in BP and EBA 8 upon the basement membrane zone (BMZ) of dermal- Lamina densa epidermal junction (DEJ). Keratinocytes in basal layers Dermis Anchoring fibril (Type VII collagen) have hemidesmosome, a structure comparable to a half Dermis TOPICS Desmoglein 1 is a target in bullous infectious diseases 9 Laminin 332 of desmosome, being involved in adhesion in DEJ. Two Dermis collagen hemidesmosomal components, BP180 [BPAG2 (bullous pemphigoid antigen 2), or type XVII collagen] and Classification of autoimmune blistering diseases ELISA kits for the diagnosis of autoimmune blistering diseases 10 integrin α6β4 are transmembrane proteins which link to Pemphigus BMZ. BP230 (BPAG1) and plectin (HD-1) are cytoplasmic group Pemphigus foliaceus, PF 11 proteins involved in the organization of the cytoskeleton. Differential diagnoses of autoimmune blistering diseases with ELISA Pemphigus vulgaris, PV BMZ is divided into the lamina densa and the lamina lucida. Mucosal dominant type Pemphigus erythematosus (PF localized type) Screening of autoimmune blistering diseases 11 The major component of the lamina densa is type IV Mucocutaneous type Differential diagnosis of pemphigus 11 collagen. The lamina lucida contains heparan sulfate Pemphigus vegetans (PV subtype) Brazilian pemphigus (PF endemic type) Differential diagnosis of BP 12 proteoglycan, fibronectin and Laminin 332 (laminin 5). Laminin 332 serves as a major anchoring protein between Others Differential diagnosis of epidermolysis bullosa acquisita (EBA) 12 the lamina lucida and the lamina densa and connects Herpetiform pemphigus BP180 and integrin α6β4 in the lamina lucida with type VII Paraneoplastic pemphigus, PNP Drug-induced pemphigus Monitoring disease activities by ELISA 13 collagen. Type VII collagen secures the lamina densa to the Neonatal pemphigus dermis through association with dermis collagens. Monitoring disease activity in mucocutaneous PV with IgA pemphigus (Intraepidermal neutrophilic IgA dermatosis) MESACUP Desmoglein ELISA kits 13 Blistering disease is the general term for several diseases with blisters and erosion on the skin and mucous membrane Monitoring disease activity in BP with MESACUP BP180 TEST 13 Pemphigoid caused by congenital or acquired interruptions of group Monitoring disease activity in EBA with MESACUP Anti-Type VII collagen TEST 13 epidermal or epidermal-dermal cohesions. 1-3) This brochure summarizes the clinical manifestations, the Bullous pemphigoid, BP Epidermolysis bullosa acquisita, EBA Herpes gestationis, HG (BP subtype) Acknowledgements / References 14 mechanism of the blister formation, and the serological diagnosis on various autoimmune blistering diseases. Mucous membrane pemphigoid, MMP Dermatitis herpetiformis [Dühring] Linear IgA bullous dermatosis, LAD Anti-p200 pemphigoid (Anti-laminin γ1 pemphigoid) Autoimmune Blistering Diseases - Diagnostic Methodology for Pemphigus and Pemphigoid - 3 Paraneoplastic pemphigus (PNP) Figure 2 PNP is an autoimmune mucocutaneous disease associated Skin lesion Histopathology Pemphigus with underlying malignancy, particularly lymphoproliferative neoplasms. Painful erosions and ulcerations occur in the oral mucous membrane. In addition, many patients with PNP have ocular mucosal lesions and pseudomembranous conjunctivitis, resulting in ankyloblepharon in severe Pemphigus is a group of autoimmune blistering diseases of the skin and mucous membranes which are characterized cases. 6) histologically by intraepidermal blisters due to acantholysis (i.e., disruption of the intercellular connections between keratinocytes of the epidermis) and immunopathologically by in vivo bound and circulating immunoglobulin G (IgG) antibodies directed against the cell surface of keratinocytes. Most common ages of disease onset is about 40 to 60 Acantholytic blisters in the epidermis are formed years. Nikolsky’s sign ( ., blistering induced by lateral pressure to the normal-appearing skin) is also a characteristic Other types of pemphigus in the superficial epidermis. Overview i.e Direct immunofluorescence staining of feature of pemphigus. The target antigens in pemphigus are Dsg1 and 3, 4, 5) members of the cadherin super family. Pemphigus Herpetiform pemphigus is characterized clinically by the skin taken from a patient with PF can be classified into pemphigus vulgaris (PV), pemphigus foliaceus (PF), paraneoplastic pemphigus (PNP), and others. erythematous urticarial plaques and vesicles that present The blisters in PV and PF occur in the deeper region of the epidermis (just above the basal layer) and the upper layer, in a herpetiform arrangement, histologically eosinophilic respectively. spongiosis with minimal or no acantholysis, and serologically IgG autoantibodies against cell surfaces of keratinocytes. Drug-induced pemphigus is induced by drugs such as Figure 1 Clinical characterization D-penicillamine or captopril. Neonatal pemphigus is a Oral lesion Histopathology disease that rarely occurs in infants born to mothers with Pemphigus vulgaris (PV) PV. IgA pemphigus is characterized by tissue-bound and IgG deposits on the cell surface of the epidermis, PV is the most common of pemphigus diseases. The circulating IgA autoantibodies that target the desmosomal and stronger staining in the upper layers of the majority of patients have painful mucous membrane proteins or unidentified cell surface antigens in the epidermis. epidermis than the lower layers. erosions, especially in the oral cavity (Figure 1). While mucous membranes are mainly affected in mucosal Figure 3 dominant PV (MDPV), in mucocutaneous PV (MCPV), Pemphigus (PV/PF) and anti-desmoglein 1 & 3 blisters and erosions are not only present on the mucosal IgG autoantibodies area but also on the skin, predominantly the regions Dsg1 Dsg3 Anti-Dsg1 Anti-Dsg3 Acantholytic blisters in the epidermis are formed prone to pressure and friction, such as scalp, axilla, just above the basal layer. Dsg1 and Dsg3, the pemphigus target antigens, have Pemphigus vulgaris（ PV, Mucosal dominant type) groin, upper part of back, and buttock. Pemphigus different intraepidermal expression patterns in the skin Skin lesions Skin lesion: None or only localized Mucosal lesion: Suprabasal epithelia vegetans, a rare form of PV, is characterized by vegetating and mucous membranes (Figure 3). In the skin, Dsg1 is Dsg1 Dsg1 granulomatous lesions. distributed throughout the epidermis, but more strongly in the superficial layers, whereas Dsg3 is expressed in the lower part of the epidermis (basal or parabasal Dsg3 Dsg3 Pemphigus foliaceus (PF) layers). In the mucous membranes, on the other hand, Dsg3 function suppressed Dsg3 function suppressed PF is characterized by scaly crusted erosions. These Dsg1 and Dsg3 are expressed throughout the mucous lesions are scattered in seborrheic regions such as the membrane, but the expression level of Dsg1 is much Pemphigus vulgaris (PV, Mucocutaneous type) scalp, face, and upper trunk, while the mucous membranes lower than that of Dsg3. The clinical features of pemphigus Skin lesion: Suprabasal epidermis Mucosal lesion: Suprabasal epithelia are never affected (Figure 2). Symptoms of patients with can be explained by “desmoglein compensation theory”, Dsg1 Dsg1 PF are generally not as serious compared to those of PV. i.e., these antigens can compensate their adhesive Direct immunofluorescence staining of