Case for diagnosis. Radiotherapy-induced pemphigus vegetans | Anais Brasileiros de Dermatologia (Portuguese)

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Radiotherapy-induced pemphigus vegetans" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "376" "paginaFinal" => "378" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Hiram Larangeira de Almeida Jr, Antônia Larangeira de Almeida, Pedro Henrique Evangelista Martinez, Ana Letícia Boff" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Hiram Larangeira de" "apellidos" => "Almeida Jr" "email" => array:1 [ 0 => "hiramalmeidajr@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Antônia Larangeira de" "apellidos" => "Almeida" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Pedro Henrique Evangelista" "apellidos" => "Martinez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "Ana Letícia" "apellidos" => "Boff" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Pós-Graduação em Saúde e Comportamento, Universidade Católica de Pelotas, Departamento de Dermatologia, Universidade Federal de Pelotas, Pelotas, RS, Brazil" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Liga de Dermatologia, Universidade Federal de Pelotas, Pelotas, RS, Brazil" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Laboratório Dermapat and Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, RS, Brazil" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 611 "Ancho" => 905 "Tamanyo" => 70089 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Initial clinical aspect with perianal and intergluteal erosion with circinate pustular edges and some isolated pustules." ] ] ] "textoCompleto" => "Case reportA 73-year-old male patient developed a vegetating lesion in the anal canal nine months ago; the histopathology showed a non-keratinizing poorly differentiated squamous cell carcinoma. He was treated with two cycles of 5-fluorouracil and cisplatin and concomitant radiotherapy (6 MeV linear photon accelerator, total dose of 54 Gy), with complete remission. The control colonoscopy and endoscopy after six months of treatment were normal. Forty-five days before coming to the clinic again, he had a painful perianal and intergluteal erosion with circinate pustular borders and some isolated pustules, with surrounding erythema (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). He was hospitalized and received systemic antibiotics (ceftriaxone and clindamycin) and famciclovir. A computed tomography on admission ruled out tumor recurrence, showing a normal anal canal. An incisional biopsy was performed, which showed pseudoepitheliomatous hyperplasia with microabscesses of inflammatory cells (neutrophils and eosinophils) (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). In some microscopic fields, clefts with isolated keratinocytes next to microabscesses were observed (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).<elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia>What is your diagnosis?<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">a)Ulcerated herpes simplex associated with immunosuppression</li><li class="elsevierStyleListItem" id="lsti0010">b)Ulcerated radiodermatitis</li><li class="elsevierStyleListItem" id="lsti0015">c)Pemphigus vegetans</li><li class="elsevierStyleListItem" id="lsti0020">d)Tinea associated with immunosuppression</li></ul>The histopathological findings were suggestive of pemphigus vegetans, which may present with acantholytic clefts associated with polymorphonuclear microabscesses,<a class="elsevierStyleCrossRef" href="#bib0005">1</a> unlike classic pemphigus vulgaris in which the cleavage is accompanied by little inflammation.There was no therapeutic response to systemic antibiotics and antivirals initiated before the results of the investigation, and there was significant regression with oral prednisone (40 mg) and topical betamethasone. After seven days, the pustular border disappeared, and there was total symptom regression, with the appearance of some hyperkeratotic and verrucous central areas (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>). Later, the result of indirect immunofluorescence was positive for IgG, with an intercellular pattern, 1:80 titer.<elsevierMultimedia ident="fig0020"></elsevierMultimedia>There are several reports of radiotherapy-induced pemphigus vulgaris, but not of the vegetans variant. Reported cases are restricted to the irradiated area,<a class="elsevierStyleCrossRefs" href="#bib0010">2,3</a> (similarly to the case described here) or generalized.<a class="elsevierStyleCrossRefs" href="#bib0020">4,5</a> There have also been reports of pemphigus foliaceus induction.<a class="elsevierStyleCrossRef" href="#bib0030">6</a>The mechanism of induction of autoimmune acantholytic diseases by radiotherapy must be complex. One possibility is the antigenic alteration by radiation;<a class="elsevierStyleCrossRef" href="#bib0005">1</a> another possibility would be the alteration of the immune response. Corroborating the hypothesis of antigenic alteration, there are reports of laboratory investigation with immunoblotting demonstrating antibodies against antigens other than desmogleins.<a class="elsevierStyleCrossRef" href="#bib0035">7</a>This case demonstrates the possibility that pemphigus vegetans lesions may occur locally on a previously irradiated area.Financial supportNone declared.Authors’ contributionsHiram Larangeira de Almeida Jr.: Approval of the final version of the manuscript; design and planning of the study; drafting and editing of the manuscript; collection, analysis, and interpretation of data; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases; critical review of the literature; critical review of the manuscript.Antônia Larangeira de Almeida: Approval of the final version of the manuscript; design and planning of the study; drafting and editing of the manuscript; collection, analysis, and interpretation of data; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases; critical review of the literature; critical review of the manuscript.Pedro Henrique Evangelista Martinez: Approval of the final version of the manuscript; design and planning of the study; drafting and editing of the manuscript; collection, analysis, and interpretation of data; intellectual participation in propaedeutic and/or therapeutic conduct of the studied cases; critical review of the literature; critical review of the manuscript.Ana Letícia Boff: Approval of the final version of the manuscript; design and planning of the study; drafting and editing of the manuscript; collection, analysis, and interpretation of data; critical review of the literature; critical review of the manuscript.Conflicts of interestNone declared." 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Estatísticas

What is your diagnosis?

Case for diagnosis. Radiotherapy-induced pemphigus vegetans

Hiram Larangeira de Almeida Jra,

Autor para correspondência

hiramalmeidajr@hotmail.com

Corresponding author.

, Antônia Larangeira de Almeidab, Pedro Henrique Evangelista Martinezb, Ana Letícia Boffc

a Pós-Graduação em Saúde e Comportamento, Universidade Católica de Pelotas, Departamento de Dermatologia, Universidade Federal de Pelotas, Pelotas, RS, Brazil

b Liga de Dermatologia, Universidade Federal de Pelotas, Pelotas, RS, Brazil

c Laboratório Dermapat and Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, RS, Brazil

Lido

4817

Vezes
que se leu este artigo

1946

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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Initial clinical aspect with perianal and intergluteal erosion with circinate pustular edges and some isolated pustules&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect1005">Case report</span><p id="par0005" class="elsevierStylePara elsevierViewall">A 73-year-old male patient developed a vegetating lesion in the anal canal nine months ago&#59; the histopathology showed a non-keratinizing poorly differentiated squamous cell carcinoma&#46; He was treated with two cycles of 5-fluorouracil and cisplatin and concomitant radiotherapy &#40;6&#8201;MeV linear photon accelerator&#44; total dose of 54&#8201;Gy&#41;&#44; with complete remission&#46; The control colonoscopy and endoscopy after six months of treatment were normal&#46; Forty-five days before coming to the clinic again&#44; he had a painful perianal and intergluteal erosion with circinate pustular borders and some isolated pustules&#44; with surrounding erythema &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; He was hospitalized and received systemic antibiotics &#40;ceftriaxone and clindamycin&#41; and famciclovir&#46; A computed tomography on admission ruled out tumor recurrence&#44; showing a normal anal canal&#46; An incisional biopsy was performed&#44; which showed pseudoepitheliomatous hyperplasia with microabscesses of inflammatory cells &#40;neutrophils and eosinophils&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; In some microscopic fields&#44; clefts with isolated keratinocytes next to microabscesses were observed &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">What is your diagnosis&#63;</span><p id="par0010" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">a&#41;</span><p id="par0015" class="elsevierStylePara elsevierViewall">Ulcerated herpes simplex associated with immunosuppression</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">b&#41;</span><p id="par0020" class="elsevierStylePara elsevierViewall">Ulcerated radiodermatitis</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">c&#41;</span><p id="par0025" class="elsevierStylePara elsevierViewall">Pemphigus vegetans</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">d&#41;</span><p id="par0030" class="elsevierStylePara elsevierViewall">Tinea associated with immunosuppression</p></li></ul></p><p id="par0035" class="elsevierStylePara elsevierViewall">The histopathological findings were suggestive of pemphigus vegetans&#44; which may present with acantholytic clefts associated with polymorphonuclear microabscesses&#44;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> unlike classic pemphigus vulgaris in which the cleavage is accompanied by little inflammation&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">There was no therapeutic response to systemic antibiotics and antivirals initiated before the results of the investigation&#44; and there was significant regression with oral prednisone &#40;40&#8201;mg&#41; and topical betamethasone&#46; After seven days&#44; the pustular border disappeared&#44; and there was total symptom regression&#44; with the appearance of some hyperkeratotic and verrucous central areas &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; Later&#44; the result of indirect immunofluorescence was positive for IgG&#44; with an intercellular pattern&#44; 1&#58;80 titer&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">There are several reports of radiotherapy-induced pemphigus vulgaris&#44; but not of the vegetans variant&#46; Reported cases are restricted to the irradiated area&#44;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a> &#40;similarly to the case described here&#41; or generalized&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a> There have also been reports of pemphigus foliaceus induction&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The mechanism of induction of autoimmune acantholytic diseases by radiotherapy must be complex&#46; One possibility is the antigenic alteration by radiation&#59;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> another possibility would be the alteration of the immune response&#46; Corroborating the hypothesis of antigenic alteration&#44; there are reports of laboratory investigation with immunoblotting demonstrating antibodies against antigens other than desmogleins&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">This case demonstrates the possibility that pemphigus vegetans lesions may occur locally on a previously irradiated area&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect1015">Financial support</span><p id="par0060" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Authors&#8217; contributions</span><p id="par0065" class="elsevierStylePara elsevierViewall">Hiram Larangeira de Almeida Jr&#46;&#58; Approval of the final version of the manuscript&#59; design and planning of the study&#59; drafting and editing of the manuscript&#59; collection&#44; analysis&#44; and interpretation of data&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#59; critical review of the literature&#59; critical review of the manuscript&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Ant&#244;nia Larangeira de Almeida&#58; Approval of the final version of the manuscript&#59; design and planning of the study&#59; drafting and editing of the manuscript&#59; collection&#44; analysis&#44; and interpretation of data&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#59; critical review of the literature&#59; critical review of the manuscript&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Pedro Henrique Evangelista Martinez&#58; Approval of the final version of the manuscript&#59; design and planning of the study&#59; drafting and editing of the manuscript&#59; collection&#44; analysis&#44; and interpretation of data&#59; intellectual participation in propaedeutic and&#47;or therapeutic conduct of the studied cases&#59; critical review of the literature&#59; critical review of the manuscript&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Ana Let&#237;cia Boff&#58; Approval of the final version of the manuscript&#59; design and planning of the study&#59; drafting and editing of the manuscript&#59; collection&#44; analysis&#44; and interpretation of data&#59; critical review of the literature&#59; critical review of the manuscript&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conflicts of interest</span><p id="par0085" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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Informação do artigo

ISSN: 03650596
Idioma original: Inglês

DOI:10.1016/j.abd.2021.09.005

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2022 Outubro	82	50	132
2022 Setembro	64	67	131
2022 Agosto	42	48	90
2022 Julho	55	58	113
2022 Junho	89	72	161
2022 Maio	105	97	202
2022 Abril	43	52	95
2022 Mar�o	29	44	73

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