P‐50 Clinical,histological and immunological characteristics of Neumann‐type pemphigus vegetans in a dog

Pemphigus vegetans is a very rare cutaneous autoimmune blistering acantholytic disease of humans that combines features of both pemphigus foliaceus and mucosal lesions of pemphigus vulgaris. We report here the clinical, histopathological and immunological findings in a dog whose lesions resembled those of pemphigus vegetans of humans. A 4‐year old, greater Swiss mountain dog was presented with verrucous papules and crusts on the axillae and inguinal region. Within 3 months, lesions progressed to involve the thorax and ear pinnae, and then became generalized. Ulcers were observed in the oral cavity, anus and prepuce. Microscopic examination of mucosal and cutaneous biopsy specimens revealed a mixed pattern of deep intraepidermal neutrophilic and eosinophilic pustules with isolated and clustered acantholytic keratinocytes, along with suprabasal epidermal clefts leaving rounded basal keratinocytes at the bottom of the vesicles. These dual changes were also observed within the hair follicle epithelium. Dermal inflammation was mixed and perivascular. Direct immunofluorescence revealed IgG deposited around epidermal keratinocytes. Indirect immunofluorescence performed on normal canine gingival substrate uncovered antikeratinocyte IgG autoantibodies with a serum titre of 1:2500. Immunoblotting confirmed that circulating IgG autoantibodies recognized the extracellular segment of canine desmoglein‐1 and human desmoglein‐3. Treatment with azathioprine and oral glucocorticoids resulted in long‐lasting complete remission. In this dog, clinical signs, microscopic skin lesions and immunological findings were deemed analogous to those of human Neumann‐type pemphigus vegetans. Funding: Self‐funded.     

Canine hyperplastic intraepidermal pustular and suprabasal acantholytic dermatosis with features of human pemphigus vegetans

Pemphigus vegetans is a rare autoimmune blistering acantholytic dermatosis of humans that combines unusually hyperplastic and verrucous pustular skin lesions and mucosal erosions. We report herein the clinical, histopathologic, and immunologic findings in a dog whose lesions resembled, but were not identical to, those of human pemphigus vegetans. A 4-year-old male Greater Swiss Mountain Dog presented with multifocal cutaneous verrucous and crusted papules and pustules, as well as skin and mucosal erosions and ulcers. Microscopic lesions consisted of exophytic papillated epidermal hyperplasia, superficial and deep intraepidermal acantholytic neutrophilic and eosinophilic pustules, and suprabasal epidermal clefts leaving rounded basal keratinocytes at the bottom of the vesicles. Direct and indirect immunofluorescence revealed antikeratinocyte IgG autoantibodies. Immunoprecipitation immunoblotting and immunoabsorption experiments with recombinant canine desmogleins confirmed that autoantibodies recognized desmoglein-1. In this dog, clinical and histopathologic features resembled those of human pemphigus vegetans, while circulating autoantibodies against canine desmoglein-1 were solely identified. This antigen target is different from that of the human disease in which antidesmoglein-3 autoantibodies are detected most commonly.     

Paraneoplastic pemphigus in a dog with splenic sarcoma

Paraneoplastic pemphigus (PNP) is an autoimmune blistering skin disease of humans that consists of characteristic skin lesions associated with concurrent neoplasia. In this study we provide histologic and serologic evidence to support a diagnosis of PNP in a dog with splenic sarcoma. Skin lesions consisted of widespread erosions involving haired skin, mucocutaneous junctions, and oral mucosa. Microscopic examination of skin and mucosae revealed lesions consistent with both pemphigus vulgaris and erythema multiforme. Immunoprecipitation confirmed that circulating IgG autoantibodies from this patient recognized five distinct antigens, presumed to represent epidermal plakins. Clinical, histopathologic, and immunologic findings in this patient were similar to those observed in human patients with PNP. The splenic neoplasia in this dog was diagnosed as a phenotypically variable spindle cell sarcoma. To date, only one other dog has been reported with PNP. This is the second reported case of canine PNP and the first patient in whom skin lesions were identified in association with splenic neoplasia.     

Investigations on the nature and pathogenicity of circulating antikeratinocyte antibodies in dogs with pemphigus foliaceus

In humans with pemphigus foliaceus (PF), pathogenic autoantibodies are principally of IgG4 subclass and they cause superficial vesiculation when injected into neonatal mice. The objectives of this study were to determine the isotypes of circulating antikeratinocyte antibodies in dogs with PF, to assess whether serum antikeratinocyte antibody titres decreased during successful treatment, and to study whether such antibodies were pathogenic in passive transfers. Using indirect immunofluorescence with neonatal mouse skin substrates, circulating antikeratinocyte IgG antibodies were detected in 36 of 44 dogs with PF (82%). Serum autoantibodies belonged predominantly to IgG4 (three of 44; 80%) and IgG1 (30 of 44; 68%) subclasses. Antikeratinocyte IgG antibodies were detected in 16 of 20 normal dogs (80%), and these antibodies were IgG1 (16 of 20, 80%) but rarely IgG4 (two of 20; 10%) isotypes. In four dogs, IgG4 antikeratinocyte antibody titres decreased concomitantly to lesions nearing or reaching complete remission. In contrast, IgG or IgG1 titres remained stable or increased when lesions abated. Antikeratinocyte antibodies targeted mainly intercellular autoantigen(s) in the stratum granulosum, while in fewer dogs, such antibodies bound to cytoplasmic basal antigen(s). Intradermal injections of PF or pemphigus vulgaris (PV) IgG into neonatal mice caused subgranular or suprabasal acantholytic vesiculation without granulocyte infiltration, respectively. Similar transfers of normal dog IgG did not cause vesiculation. These observations suggest that antikeratinocyte IgG4 antibodies could be relevant to disease pathogenesis. Importantly, canine PF or PV IgG appear to be pathogenic when transferred passively into mice, causing vesiculation at epidermal levels similar to those of the natural disease.     

Equine bullous pemphigoid IgG autoantibodies target linear epitopes in the NC16A ectodomain of collagen XVII (BP180, BPAG2)

Bullous pemphigoid (BP) is an autoimmune subepithelial blistering dermatosis of humans, dogs, cats and pigs. It is characterized by skin-fixed and circulating IgG autoantibodies that target one or both BP antigens. An immunological homologue of BP in humans was diagnosed in two horses with cutaneous and mucosal ulcerations as well as microscopic subepithelial vesiculation. Immunological investigations revealed similar findings for both the horses. Direct immunofluorescence demonstrated the presence of IgG deposited linearly at the dermoepidermal junction in mucosal and skin biopsy specimens. Indirect immunofluorescence testing confirmed the existence of circulating basement membrane-specific IgG autoantibodies. Using intact and salt-split epithelial substrates, serum IgG were shown to target antigens situated not only at the basal, but also at the lateral and apical aspects of stratum basale keratinocytes. Immunoblotting and ELISA corroborated that the IgG from affected horses, but not those from normal controls, exhibited high immunoreactivity against the NC16A extracellular domain of type XVII collagen (BPAG2, BP180). Equine BP could be proposed, therefore, as another spontaneous model of this most common basement membrane autoimmune dermatosis of humans.     

Anti-plakin and desmoglein autoantibodies in a dog with pemphigus vulgaris

Paraneoplastic pemphigus was suspected in a 14-year-old Labrador retriever because of mucocutaneous erosions, microscopic suprabasal acantholysis, and keratinocyte apoptosis. In this patient, circulating IgG autoantibodies recognized plakin (envoplakin, periplakin) and desmoglein (desmoglein-1 and -3) antigens. Necropsy, however, failed to confirm the concurrent existence of hematopoietic or solid neoplasia. The diagnosis of pemphigus vulgaris therefore was proposed. This study illustrates that such a combination of clinicopathologic lesions and plakin/desmoglein-specific autoantibodies is not restricted to canine paraneoplastic pemphigus but can also be detected in another form of suprabasal pemphigus.     

Metaflumizone-amitraz (Promeris)-associated pustular acantholytic dermatitis in 22 dogs: evidence suggests contact drug-triggered pemphigus foliaceus

Promeris Duo (PD) is a novel topical flea and tick preventative for dogs, which is also licensed for treatment of canine demodicosis. In this article, we present 22 dogs that all developed pemphigus foliaceus (PF)-like cutaneous drug reactions at the site of PD application. In eight dogs, the lesions were restricted to the application site (localized group). Signs of systemic illness were reported in three dogs, and four required immunosuppressive treatment. Direct immunofluorescence for IgG was positive in four dogs, although circulating antikeratinocyte IgG could not be detected in any tested sera. Complete remission was achieved in all dogs, with one patient still remaining on treatment. Fourteen dogs developed skin lesions at the application site as well as other noncontiguous areas (distant group). Systemic signs were reported in 11 dogs, and immunosuppression was required in 10 cases. Direct and indirect immunofluorescence tests were positive for antikeratinocyte autoantibodies in 10 of 13 and six of 10 patients with distant disease, respectively. Complete remission was achieved in 10 of 13 dogs with distant disease; one-third are still on treatment. Histological changes were similar to canine PF. Desmosomal architectural changes, assessed by desmoglein-1 immunostaining, were also similar to those of dogs with spontaneous autoimmune PF. Apoptosis did not appear to contribute to lesion formation, in either autoimmune or PD-associated PF. In conclusion, PD has the potential of triggering a variant of PF that resembles spontaneously occurring autoimmune PF at clinical, morphological, immunological and treatment outcome levels.     

Neutrophils contact to plasma membrane of keratinocytes including desmosomal structures in canine pemphigus foliaceus

Pemphigus foliaceus (PF) is an autoimmune blistering skin disease that affects certain mammals including dogs. In canine PF, neutrophils are infiltrated intensely into pustular lesions including acantholytic cells, although neutrophilic infiltration is not characterized in human PF. The roles of the neutrophils in the cutaneous lesions of canine PF have not yet been understood. The purpose of this study was to characterize the ultrastructural features underlying the acantholysis with pustule formation in canine PF. Four dogs diagnosed as PF on the basis of clinical signs, histopathological findings, and direct and indirect immunofluorescence examinations were performed. Electron microscopy revealed that the acantholytic cells were adjacent to multiple neutrophils in the pustules. At the contact points between neutrophils and acantholytic keratinocytes, half-desmosomes of acantholytic keratinocytes with intact attachment plaques were observed within invaginations of neutrophils. Furthermore, on the surface of acantholytic cells in the pustules, neutrophil granules seemed to be secreted to the surface of acantholytic cells and to degenerate the half-desmosome structures. Neutrophils were also observed within the epidermis adjacent to the pustule. At the intercellular gap between two dissociated keratinocytes, neutrophils inserted its pseudopodia into the gap between the two half-desmosomes of keratinocytes. These findings taken together suggested that, at least in the areas where we analyzed ultrastructurally, neutrophils contact desmosomal structures and seem to play some parts in separation of keratinocytes and degeneration of split-desmosomes in pustules of dogs with PF.     

IgG autoantibodies directed against desmoglein 3 cause dissociation of keratinocytes in canine pemphigus vulgaris and paraneoplastic pemphigus

Pemphigus is a group of autoimmune blistering diseases of the skin and mucous membranes. In human patients with pemphigus vulgaris (PV) and paraneoplastic pemphigus (PNP), IgG autoantibodies against desmoglein (Dsg) 3 and Dsg1 play pathogenic roles in blister formation. In contrast, the target for IgG autoantibodies that induce keratinocyte dissociation has not been elucidated in canine pemphigus. The aim of the present study was to determine whether anti-Dsg IgG autoantibodies are present and disrupt the cell-cell adhesion of keratinocytes in canine PV and PNP. The extracellular domains of canine Dsg3 were recognized by IgG in 3/5 (60%) canine PV sera tested. IgG against the extracellular domains of canine Dsg1 was detected exclusively in two dogs that had PV with the mucocutaneous phenotype. In addition, anti-Dsg3 IgG was identified in canine PNP serum. Furthermore, incubation of normal human keratinocytes (NHK) with mucocutaneous canine PV serum and canine PNP serum resulted in dissociation of the NHK sheets, whereas the removal of anti-Dsg3 IgG from these canine sera blocked this dissociation. The present study indicates for the first time that circulating anti-Dsg3 IgG antibodies capable of dissociating keratinocytes are present in dogs with PV and PNP.     

Paraneoplastic pemphigus in a dog

This report presents a case of paraneoplastic pemphigus in a 7-year-old female Bouvier. The dog initially showed extensive oral ulcerations that exacerbated upon treatment with trimethoprim-sulfadiazine. Subsequently, the dog developed vesiculobullous and ulcerative lesions on the ear margins, the nose, periocular, and at the nail beds. Due to complete therapy resistance and a deteriorating general condition, the dog was euthanized. During post-mortem examination a thymic lymphoma was found. While an early biopsy of the oral cavity revealed features of erythema multiforme, skin lesions at necropsy were typical of pemphigus vulgaris. Indirect immunofluorescence of patient serum revealed an antikeratinocyte membrane pattern typical for pemphigus. The serum was also positive on bovine bladder epithelium. In a Western blot, autoantibodies to a 210 and a 190 kDa protein were detected.     

Comparative analysis of canine dermatophytosis and superficial pemphigus for the prevalence of dermatophytes and acantholytic keratinocytes: a histopathological and clinical retrospective study

Acantholytic dermatophytosis is a rarely reported condition of dogs that clinically and histopathologically mimics superficial pemphigus (erythematosus, foliaceus). Histologically, periodic acid-Schiff (PAS) and Grocott's methenamine-silver (GMS) are often necessary to show the fungus. A retrospective histopathological study was conducted on 190 canine skin biopsy specimens: 95 each with the diagnosis of canine dermatophytosis or of superficial pemphigus. All specimens were stained with haematoxylin and eosin, PAS, and GMS. Dermatophytes were not seen in any superficial pemphigus cases. Acantholytic keratinocytes were noted in 14% of the dermatophytosis cases, none of which had clinical signs consistent with superficial pemphigus. Among cases with acantholytic keratinocytes, superficial pemphigus had significantly more acantholytic cells than dermatophytosis (P = 0.02). When comparing face and nonface cases, there was no difference in prevalence of acantholytic keratinocytes in dermatophytosis or number of acantholytic keratinocytes in superficial pemphigus. All dermatophyte cases were both GMS and PAS positive with neither stain being visually superior. No dermatophyte cases where acantholytic keratinocytes were noted had a history, clinical signs and histopathological features compatible with acantholytic dermatophytosis.     

Laminin-5 is targeted by autoantibodies in feline mucous membrane (cicatricial) pemphigoid

In human and canine patients with mucous membrane (cicatricial) pemphigoid (MMP), circulating autoantibodies have been shown to target multiple epidermal basement membrane antigenic epitopes. These autoantigens include collagen XVII in humans and dogs, as well as laminin-5, laminin-6 or integrin alpha-6/beta-4 in human beings. The purpose of this study was to determine if autoantibodies targeted laminin-5 in a cat exhibiting clinical and microscopic lesions resembling those of MMP in humans. In this patient, an indirect immunofluorescence (IF) assay revealed circulating IgG and IgA autoantibodies that bound to the basement membrane zone on the dermal side of salt-split gingiva (titer 1:1000 for IgG and 1:50 for IgA). Immunoblotting, performed with affinity-purified human laminin-5, demonstrated that the autoantibodies bound the alpha-3 chain of this heterotrimer. These observations identify laminin-5 as one of the antigens recognized by circulating autoantibodies in this feline homologue of MMP in humans and dogs.     

Altered immunohistochemical staining for desmoglein in skin biopsies in canine pemphigus foliaceus.

In this study, 50 cases of canine pemphigus foliaceus and 49 cases of canine superficial pyoderma were examined by immunohistochemical staining for patterns of desmoglein expression. In 31/50 (62%) of pemphigus foliaceus cases, there was an altered staining pattern for desmoglein consisting of distinct clumped deposits at the periphery of keratinocytes and/or dark cytoplasmic staining of acantholytic cells (consistent with internalization of desmoglein). In contrast, desmoglein staining in biopsies from cases of superficial pyoderma was diffusely pale without evidence for clumping or distinct internalization. This study demonstrates that epidermal desmoglein expression is altered in some cases of pemphigus foliaceus in dogs and suggests that immunohistochemical staining for this protein may be useful in diagnosis.     

Immunomapping of desmosomal and nondesmosomal adhesion molecules in healthy canine footpad,haired skin and buccal mucosal epithelia: comparison with canine pemphigus foliaceus serum immunoglobulin G staining patterns

Pemphigus foliaceus (PF) is the most common canine autoimmune skin disease. In contrast to human PF (hPF), desmoglein‐1 is a minor autoantigen in the canine disease. The major autoantigen(s) of canine PF (cPF) remain(s) unknown, which limits the ability to perform mechanistic studies of lesion formation and the development of novel diagnostic and therapeutic strategies for this disease. The immunofluorescence patterns of selected desmosomal (desmoglein‐1, desmoglein‐3, desmocollin‐1, desmocollin‐3, desmoplakin‐1/2, plakoglobin and plakophilin‐1) and nondesmosomal adhesion proteins (E‐cadherin, claudin‐1, zona occludens‐1 and occludin) in healthy canine footpad, haired skin and buccal mucosal epithelia were determined using hPF and pemphigus vulgaris sera and specific antibodies. The immunostaining patterns were then compared with that of indirect immunofluorescence staining with 66 cPF sera. Most cPF sera (58 of 66; 88%) exhibited positive staining along keratinocyte margins in the stratum spinosum and stratum granulosum of canine footpad. One serum contained autoantibodies binding solely to stratum granulosum keratinocytes. Concurrent intercellular fluorescence in the stratum basale was limited to seven of 66 cPF sera (11%). Only 12 of 66 cPF sera (18%) also exhibited positive IF staining of the buccal mucosa. This study confirms the immunological heterogeneity of cPF immunoglobulin G autoantibodies. Moreover, the major indirect immunofluorescence staining pattern and the inability of most cPF sera to label the buccal mucosa closely matched that of desmocollin‐1. These observations warrant further investigation of desmocollin‐1 as a potential major cPF autoantigen.     

Desmoglein-1 is a minor autoantigen in dogs with pemphigus foliaceus

The majority of human patients with pemphigus foliaceus (PF) have circulating IgG autoantibodies that target conformational epitopes on the desmosomal cadherin desmoglein-1 (dsg1). Limited studies using immunoblot techniques suggested that the principal autoantigen in dogs with PF might also be dsg1. It was the objective of this study to test this hypothesis. A comprehensive survey of canine PF sera was conducted using a novel screening strategy that detects conformational epitopes. This method consists of the ectopic expression of canine dsg1 at the surface of human 293T epithelial kidney cells and their live screening, i.e. prior to fixation. Out of seven control human PF sera that bound to canine epidermis, three (57%) contained IgG autoantibodies that recognized ectopically expressed canine dsg1 with a membrane and punctate pattern. Out of 83 canine PF sera only five (6%) contained IgG that recognized canine dsg1. Consistent with findings for human PF sera obtained in this study, autoantibody binding was conformation- and glycosylation-dependent as demonstrated by calcium chelation with EDTA and tunicamycin or wheat germ agglutinin treatment, respectively. In conclusion, these studies establish canine dsg1 as a minor autoantigen for canine PF. Antigenic epitopes appear to be conformation- and glycosylation-dependent.     

Pathogenesis of pemphigus vulgaris in dog and man - a review

Pemphigus vulgaris is a vesiculobullous disorder that predominantly involves the oral mucous membrane of the canine and human patients. The oral lesions are usually painful erosions and ulcers. This predilection for mucous membrane may reflect the smaller number of desmosomes in the oral epithelium as compared with the epidermis. The discovery of autoantibodies against the intercellular substance of stratified epithelium in patients with pemphigus vulgaris suggests that this disease represents an autoimmune disease. The exact role of these autoantibodies in the pathogenesis of pemphigus vulgaris is not clearly understood. The diagnosis is usually based on the presence of the characteristic flaccid bullae and erosions. Biopsy specimen taken from the edge of a fresh blister and adjacent epithelial layers is suitable for routine microscopic examination and direct immunofluorescence study. Combination of corticosteroids and immunosuppresive agents are used for treatment of this disease.     

Parvovirus infection of keratinocytes as a cause of canine erythema multiforme

Erythema multiforme major was diagnosed in a dog with necrotizing parvoviral enteritis. Skin lesions consisted of ulceration of the footpads, pressure points, mouth, and vaginal mucosa; vesicles in the oral cavity; and erythematous patches on the abdomen and perivulvar skin. Microscopic examination of mucosal and haired skin specimens revealed lymphocyte-associated keratinocyte apoptosis at various levels of the epidermis. Basophilic cytoplasmic inclusions were seen in basal and suprabasal keratinocytes. Immunohistochemical staining, performed with canine parvovirus-2-specific monoclonal antibodies, confirmed the parvovirus nature of the inclusions in the nucleus and cytoplasm of oral and skin epithelial cells. This is the first case of canine erythema multiforme reported to be caused by a viral infection of keratinocytes. This case study indicates that the search for epitheliotropic viruses should be attempted in cases of erythema multiforme in which a drug cause cannot be identified.     

A canine pemphigus foliaceus case showing parallel relationship of disease activity and titer of serum anti-keratinocyte cell surface antibodies

A seven-year-old, spayed female mongrel dog was diagnosed as pemphigus foliaceus (PF) by clinical, histopathological and immunopathological observations. Serum antibodies against the cell surface of keratinocytes in the dog were detected by indirect immunofluorescence (IIF) using cryosectioned bovine esophagus as well as living cultured-canine keratinocytes as the substrates. When we compared the titers of IIF on bovine esophagus with its disease activity, the IIF titers reflected the disease activity throughout the time course. Our findings will suggest that sequential titration of serum antibodies by IIF will be useful for monitoring the serological disease activity in canine PF.     

A review of autoimmune skin diseases in domestic animals: I - superficial pemphigus

In humans, the pemphigus denomination encompasses a group of autoimmune blistering skin diseases with intraepidermal separation resulting from cell-cell detachment by acantholysis. Entities are classified based on the level of blistering in the epidermis, and both superficial (pemphigus foliaceus, IgA pemphigus) and deep (pemphigus vulgaris, pemphigus vegetans and paraneoplastic pemphigus) variants are recognized. In domestic animals, subsets of pemphigus have been recognized since the mid-1970s, and the disease classification resembles that used for human patients. This article reviews up-to-date knowledge on the epidemiology, clinical signs, histopathology, immunopathology and treatment outcome of superficial pemphigus in domestic animals. Detailed information on canine, feline, equine and caprine pemphigus foliaceus, canine and feline pemphigus erythematosus and canine panepidermal pustular pemphigus is provided.     

Diagnosing new autoimmune blistering skin diseases of dogs and cats

Autoimmune blistering skin diseases have been recognized for decades in humans and dogs. In the dog, most of these diseases unfortunately were grouped under the generic denomination of bullous pemphigoid without any confirmation that the autoantibodies targeted bullous pemphigoid antigens. In recent years, advanced diagnostic methods have permitted the recognition of new autoimmune blistering skin diseases in humans and companion-animal species. At this time, the diagnosis of these entities is made by combining clinical signs and results of histopathology. Immunologic methods serve to establish the presence of skin-fixed and circulating autoantibodies that target various epidermal or basement membrane antigens. In this article, salient features of the most common canine and feline subepidermal blistering dermatoses (mucous membrane pemphigold, bullous pemphigold, epidermolysis bullosa acquisita) and new variants of cutaneous lupus (type I bullous systemic lupus erythematosus and vesicular cutaneous lupus erythematosus) are presented.