Pemphigus/pemphigoid (NAVDF Tham + Olivry acantholytic 2009 review, Tham Deep Pemphigus review 2020, Tizard Autoimmune) Flashcards
What layer of epidermis does pemphigus foliaceus affect
Stratum spinosum + Stratum granulosum
What layer of epidermis does pemphigus vulgaris affect
Stratum basale
Major autoantigen for canine PF
DSC-1
Major autoantigen in PF in humans
DSG-1
Major autoantigen of PF in cats
Unknown.
Anti-keratinocyte IgG in 23/30 cats in 1 study
What is the etiology of PF usually?
*Spontaneous
Possibly UV triggered
Other triggers:
*Drug/insecticide
What drugs can cause PF in dogs?
*TMS
*Topical ketoconazole
*Insecticide (Promeris, Certifect (Amitraz/ metaflumizone), Vectra 3D. Nexgard!)
*Oxacillin, ampicillin, cephalexin
No drug challenged performed, so cannot CONFIRM it was drug
What drugs can cause PF in cats?
*Cimetidine
*Doxycycline
*Econazole/Neomycin/Triamcinolone/Amoxicillin
*Itraconazole/lime sulfur
What is ENDEMIC pemphigus foliaceus?
*Fogo salvagem (Brazil)
*Sand fly salivary antigen LJM11
Also: young, poor women in S Tunisia. High temp, UV radiation, contact with ruminants, infections, genetic susceptibility
IgE to insect, then transforms to TgG4 against Dsg1 on keratinocytes
Pathomechanism of endemic PF
*Body makes IgG4 (instead of nonpathogenic IgG1) against sandfly salivary antigen
*IgG4 binds to EC1 and EC2 of DSG1
*DSG1 then cannot function for cell adhesion –> acantholysis
Sandfly salivary antigen that can trigger PF
LJM11
Canine PF clinical distribution types
*Facial dominant
*Generalized
*Footpad exclusive
*Trunk-dominant
Is the ability to detect anti-DSC1 IgG lower in trunk-dominant or facial PF? (Bizikova 2022)
Trunk dominant has lower anti-DSC IgG (58%) compared to facial dominant PF (100%)
T or F: Absence of anti-DSC IgG can be used to rule out PF
FALSE.
Many dogs with trunk-dominant PF do not have detectable anti-DSC IgG, even though their major autoantigen is still DSC-1
How can you differentiate between trunk-dominant PF, pustular dermatophytosis, and pyoderma?
*Dermatophytosis: centrifugal expansion of lesions
*Pyoderma: footpads shouldn’t be affected
What are the clinical distribution types of feline PF?
*Claw fold exclusive (11%)
*Periareolar region (10%)
In addition to facial regions
Treatment canine PF
*Oral glucocorticoids to induce remission
*Consider PULSE GCs
+/- steroid-sparing agents
*Azathioprine
*Cyclosporine
*Mycophenolate
*Apoquel
+/- adjunct immunomodulatory drugs
*Doxy/niacinamide (only 1/8 dogs benefit)
*Polysulfated glucosaminoglycans (usually arthritis tx; can act as steroid sparing agent! Mechanism: inhibition of proteases in complement cascade?? Reduces inflammatory cell migration??)
IF REFRACTORY:
*IVIG (efficacy may reduce over time)
IN THE FUTURE:
*Bruton’s tyrosine kinase inhibitor (BTKi)
Benefits of pulse GC therapy for canine PF
*Higher proportion of dogs achieve CR in 3 months
*Average dose of GC is lower overall
*Minimal AEs compared to conventional dosing
Feline PF treatments
*Oral glucocorticoids
*Pulse therapy not helpful in cats
*Apoquel (1 mg/kg BID tapered to 0.5mg/kg BID)
+/-
*Cyclosporine
*Chlorambucil
Pemphigus vulgaris major autoantigen in humans
Mucosal form: DSG-3 only
Mucocutaneous form: DSG-3 + DSG-1
Pemphigus vulgaris major autoantigen in dogs
DSG-3
Pemphigus vulgaris major autoantigen in cats
Unknown
Which layer of haired skin/foot pad as the most DSG3
Stratum basale
Which layer of haired skin/foot pad has the most DSC1
Stratum granulosum, Stratum spinosum
What layer of buccal mucosa has highest amount of DSG 3?
Stratum basale
How does autoantigen IgG lead to blisters in AISBDs?
Fab region binds to autoantigen, which induces C1q component of complement system –> Complement-dependent cytotoxicity –> Blisters
T or F: acantholysis requires interaction between IgG and complement system
FALSE.
PF/PV only need Fab region of IgG to induce acantholysis. Do NOT need Fc region/complement interactions
Mechanisms of acantholysis (3)
1) Steric hinderance
2) Desmoglein internalization and depletion
3) Signaling pathway interfering with cell adhesion
Mechanism of steric hinderance –> acantholysis
Binding of auto-Ab prevents bonding of desmoglein on same cell AND desmosomes between 2 cells
Mechanism of desmoglein depletion –> acantholysis
Binding of auto-Ab inhibits desmosome assembly
Also affects CLUSTERING of desmoglein, so it can’t function appropriately
When desmoglein is clustered (and nonfunctional), the desmosome is endocytosed and recycled –> depletion
Mechanism of signal transduction –> acantholysis
Auto-Ab affects the signal transduction pathway is affected. Leading to steric hinderance and desmoglein depletion
*Overexpression of c-myc in PV dogs interferes with signaling cascade needed for DSG-3 expression
Function of c-myc
Proto-oncogene
*Induces proliferation, transformation, and apoptosis
*Over expressed in canine PV
Clinical lesions of canine PV
*Erosions/ulcerations
*Mucous membranes +/- MC junctions involved
*Nail exclusive form (n=2), w/ onychomadesis
*Footpad only form (n=1)
Histopath of PV
Suprabasilar cleft w/tombstone appearance of basal keratinocytes
Treatment for canine PV
BEST FOR CR: GC + aza
*Apoquel 0.5mg/kg BID, CR in 6w
*GC, AZA, CsA, heparin, doxycycline
Diseases of pemphigoid complex
*MMP
*EBA
*BP
Most common AISBD in dogs
MMP > EBA > BP
Autoantigen for EBA
Type VII collagen (NC1 domain)
Lamina densa, anchoring fibrils
Autoantigen for BP
*BP180 (Collagen 17)
>
*BP230 (BPAG1e)
Autoantigen for MMP in dogs
*BP180 (Collagen 17, NC16A domain)
*BP230 (BPAG1e)
*Laminin 332
Pathogenesis of blister formation in AISBD
*Activation of complement system
Binding of autoantibodies –> antigen-antibody complex formation –> activation of complement pathway
3 Pathways for Complement Activation
1) Classical pathway (initiated by antigen-antibody complexes)
2) Lectin pathway (binding to mannose residues on cell or pathogen surfaces)
3) Alternative pathway (activated by spontaneous hydrolysis of C3 or via classical/lectin pathways)
Mechanism of classical complement pathway
*C1q binds to Ab-Ag complex
*Complement cascade activated
*Results in anaphylatoxins (C3a, C5a), opsonization (C3b), and MAC formation (C5b)
Which type of complement cascade activation occurs in AISBDs?
Classical complement pathway (via C3a, C5a)
What factors are released by inflammatory cells that lead to blister formation in AISBDs?
*Neutrophil elastase
*MMP-9
*ROS
Clinical features of AISBDs
*Vesicles/bullae
*Ulcerations
*Crust
*Depigmentation/scarring if chronic
Histopath for AISBDs
*Subepidermal cleft on histopath
*intact vesicles, ulcers
Which AISBD is mucosal/MC dominant with minimal skin lesions
MMP