Case and Research Letters
Mucous membrane pemphigoid: When the mouth can give a clue to the diagnosis of an esophageal stenosis of unknown origin
Penfigoide de mucosas: cuando la mucosa oral puede ser la clave para el diagnóstico de una estenosis esofágica de origen desconocido
O. Corral-Magaña
, D. Morgado-Carrasco, X. Fustà-Novell, P. Iranzo
Corresponding author
Servicio de Dermatología, Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, Spain
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Corral-Magaña, D. Morgado-Carrasco, X. Fustà-Novell, P. Iranzo" "autores" => array:4 [ 0 => array:4 [ "nombre" => "O." "apellidos" => "Corral-Magaña" "email" => array:1 [ 0 => "ocorral@cst.cat" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "D." "apellidos" => "Morgado-Carrasco" ] 2 => array:2 [ "nombre" => "X." "apellidos" => "Fustà-Novell" ] 3 => array:2 [ "nombre" => "P." "apellidos" => "Iranzo" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Dermatología, Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Penfigoide de mucosas: cuando la mucosa oral puede ser la clave para el diagnóstico de una estenosis esofágica de origen desconocido" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2057 "Ancho" => 2334 "Tamanyo" => 840752 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Clinical images. Erosions in hard palate (a) and erosive gingivitis (b) without lichenoid striae. Genital mucous erosions (c) with effacement of <span class="elsevierStyleItalic">labia minora</span> and synechiae.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Mucous membrane pemphigoid (MMP) is an uncommon heterogeneous group of autoimmune subepidermal blistering disorders which predominantly involves mucosal membranes. Diagnosis and treatment are challenging and delay may cause severe scarring and complications such as esophageal and urethral stenosis, conjunctival synechia and blindness.</p><p id="par0010" class="elsevierStylePara elsevierViewall">An 88-year-old woman with a 9-year history of dysphagia secondary to an indeterminate esophageal stenosis, requiring several endoscopic dilatations (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), was referred to our clinic for evaluation of oral erosions. Examination revealed erosive gingivitis, and extensive oral and genital erosions (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Biopsies of vulvar lesions were non-specific and direct immunofluorescence (IFD) of non-affected genital and labial mucosa were negative. Indirect immunofluorescence on salt-split skin (IIF) revealed IgG antibodies binding to the epidermal side of the blister. IIF showed IgG deposition at the basement membrane. ELISA tests were negative for anti Dg1, Dg3 and BP180 antibodies. Immunoblotting of non-affected epidermal extracts was negative for IgG: BP230, BP180, 210<span class="elsevierStyleHsp" style=""></span>kDa envoplakin, 190<span class="elsevierStyleHsp" style=""></span>kDa periplakin, Dg1 and Dg3. Immunoblotting of recombinant protein of C-terminal domain of BP180 (BP180ct) detected IgG reactivity of patient serum. A diagnosis of MMP was established and treatment with prednisone (30<span class="elsevierStyleHsp" style=""></span>mg/day) in a tapering regimen, dapsone 50<span class="elsevierStyleHsp" style=""></span>mg/day and tacrolimus in a 2<span class="elsevierStyleHsp" style=""></span>mg/liter mouth rinse formulation was initiated. Dysphagia, oral and genital erosions remitted, but the patient has developed a scarring fibrosis of the vulva with fusion of labia and urethral meatus.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Erosive esophagitis (EE) is a common finding in esophagogastroduodenoscopy (EGD) of patients with gastroesophageal reflux disease (GERD), drug-induced mucosal damage, infections, malignancies and autoimmune disorders.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Among autoimmune disorders, a possible underdiagnosed pathology is MMP. The frequency of esophageal involvement in MMP is between 2% and 30%, and this may be an underestimation as EGD is only performed on symptomatic patients.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In patients with MMP and esophageal lesions, a mean of another 3 mucosal areas are involved, and the oral cavity is affected in 86 % of the cases.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Dysphagia can signal esophageal involvement, although clinically it can be difficult to distinguish it from odynophagia. For all the above-mentioned reasons, performing an EGD on every newly diagnosed patient with MMP has been suggested.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,4</span></a> Although, EGD is not free of complications and not always available, we agreed with other authors<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2–4</span></a> that it should be especially indicated in symptomatic patients or patients with involvement of several mucous membranes.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The mouth is the beginning and the most accessible portion of the digestive tract, and as EGD is performed with a transnasal videogastroscope in these patients, oral exploration may be omitted. In any patient with esophageal erosions, scarring or stenosis, the oral cavity must be clinically explored. The presence of gingivitis or erosions makes examining the anogenital area, nose, throat, eyes and skin necessary in order to rule out MMP, and to evaluate the severity of the disease.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Diagnosis and treatment of MMP can be challenging. In our patient, IIF revealed an epidermal side positivity, which is compatible with bullous pemphigoid, lichen planus pemphigoides and MMP. This finding excludes the diagnosis of acquired bullous epidermolysis, P200 pemphigoid and MMP anti-laminin 332.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Finally, immunoblotting was positive for BP180ct, a very specific finding of MMP.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> On the basis of clinical, pathological and molecular features, a diagnosis of MMP was made.</p><p id="par0035" class="elsevierStylePara elsevierViewall">First-line therapies for MMP include systemic corticosteroids, usually in combination with other immunosuppressive treatments.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Dapsone or methotrexate can be considered in mild-to-moderate stages.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> In more severe cases, particularly in ocular involvement, cyclophosphamide has been used in monthly intravenous low-dose pulsed 500<span class="elsevierStyleHsp" style=""></span>mg with good outcomes and with better tolerance than continuous regimen.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Off-label use of anti-TNF and especially, anti-CD20 with or without intravenous immunoglobulins, have also been described in recalcitrant cases with satisfactory results, but frequent relapses.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In conclusion, multidisciplinary management is indispensable to achieve a rapid diagnosis and a better assessment of the disease extension and severity, identifying early involvement of high-risk areas such as the larynx, eye and esophagus, which require more aggressive therapies.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Corral-Magaña O, Morgado-Carrasco D, Fustà-Novell X, Iranzo P. Penfigoide de mucosas: cuando la mucosa oral puede ser la clave para el diagnóstico de una estenosis esofágica de origen desconocido. Actas Dermosifiliogr. 2020. https://doi.org/10.1016/j.ad.2019.04.011</p>" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1281 "Ancho" => 1708 "Tamanyo" => 168209 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Esophagogastroduodenoscopy. Friable esophageal mucosa with erosions and strictures.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2057 "Ancho" => 2334 "Tamanyo" => 840752 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Clinical images. Erosions in hard palate (a) and erosive gingivitis (b) without lichenoid striae. Genital mucous erosions (c) with effacement of <span class="elsevierStyleItalic">labia minora</span> and synechiae.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Gastroesophageal Reflux Disease" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "R. Kellerman" 1 => "T. 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Elder" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1001/archderm.138.3.370" "Revista" => array:7 [ "tituloSerie" => "Arch Dermatol" "fecha" => "2002" "volumen" => "138" "paginaInicial" => "370" "paginaFinal" => "373" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11902988" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S221326001630087X" "estado" => "S300" "issn" => "22132600" ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack497197" "titulo" => "Acknowledgement" "texto" => "<p id="par0045" class="elsevierStylePara elsevierViewall">We are very grateful to Dr. JM Mascaró Jr. from Hospital Clínic (Barcelona), Dr. N. Ishii from Kurume University School of Medicine (Fukoka) and Dr. T. Hashimoto from University Graduate School of Medicine (Osaka) for their help with this case.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/15782190/0000011100000009/v1_202012010756/S1578219020302699/v1_202012010756/en/main.assets" "Apartado" => array:4 [ "identificador" => "6157" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Case and Research Letters" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/15782190/0000011100000009/v1_202012010756/S1578219020302699/v1_202012010756/en/main.pdf?idApp=UINPBA000044&text.app=https://actasdermo.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219020302699?idApp=UINPBA000044" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 3 | 3 | 6 |
| 2024 October | 82 | 52 | 134 |
| 2024 September | 63 | 23 | 86 |
| 2024 August | 102 | 66 | 168 |
| 2024 July | 85 | 38 | 123 |
| 2024 June | 100 | 26 | 126 |
| 2024 May | 103 | 36 | 139 |
| 2024 April | 85 | 27 | 112 |
| 2024 March | 77 | 36 | 113 |
| 2024 February | 73 | 23 | 96 |
| 2024 January | 76 | 30 | 106 |
| 2023 December | 93 | 45 | 138 |
| 2023 November | 88 | 46 | 134 |
| 2023 October | 83 | 22 | 105 |
| 2023 September | 69 | 29 | 98 |
| 2023 August | 53 | 11 | 64 |
| 2023 July | 101 | 30 | 131 |
| 2023 June | 66 | 34 | 100 |
| 2023 May | 93 | 21 | 114 |
| 2023 April | 72 | 21 | 93 |
| 2023 March | 115 | 42 | 157 |
| 2023 February | 118 | 38 | 156 |
| 2023 January | 88 | 52 | 140 |
| 2022 December | 64 | 45 | 109 |
| 2022 November | 34 | 29 | 63 |
| 2022 October | 27 | 16 | 43 |
| 2022 September | 33 | 35 | 68 |
| 2022 August | 28 | 51 | 79 |
| 2022 July | 28 | 57 | 85 |
| 2022 June | 32 | 28 | 60 |
| 2022 May | 85 | 43 | 128 |
| 2022 April | 106 | 47 | 153 |
| 2022 March | 99 | 78 | 177 |
| 2022 February | 96 | 39 | 135 |
| 2022 January | 95 | 87 | 182 |
| 2021 December | 71 | 65 | 136 |
| 2021 November | 84 | 77 | 161 |
| 2021 October | 87 | 83 | 170 |
| 2021 September | 83 | 66 | 149 |
| 2021 August | 68 | 56 | 124 |
| 2021 July | 69 | 56 | 125 |
| 2021 June | 60 | 59 | 119 |
| 2021 May | 69 | 70 | 139 |
| 2021 April | 202 | 126 | 328 |
| 2021 March | 114 | 61 | 175 |
| 2021 February | 54 | 61 | 115 |
| 2021 January | 74 | 46 | 120 |
| 2020 December | 66 | 59 | 125 |
| 2020 November | 29 | 22 | 51 |
| 2020 October | 21 | 16 | 37 |
| 2020 September | 14 | 10 | 24 |
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