Mona Bidier

Juckende erythematöse Papeln und bräunliche Maculae an Rumpf und Beinen

Zur Diagnosesicherung erfolgten zwei Probebiopsien (Abbildung 2 ). Histologisch zeigen sich in der ersten Biopsie (Abbildung 2 a) fokal basale Epithelproliferate, intraepidermale zystische Strukturen sowie eine diskrete suprabasale Akantholyse. Das Stratum corneum weist eine kompakte Orthohyperkeratose auf und es fi ndet sich ein kräftiges unterliegendes lymphohistiozytäres Infi ltrat. In der zweiten Biopsie (Abbildung 2 b) fi ndet sich deutlich weniger entzündliches Begleitinfi ltrat, jedoch ebenfalls „füßchenförmige“

Viral reactivation imitates relapse of pemphigus vulgaris in an immunosuppressed patient

A 52-year-old woman was admitted to our hospital with fl accid blisters and multiple erosions on the skin as well as the genital and oral mucosa. Histopathology showed suprabasal epidermal acantholysis along with cleft and blister formation. Direct immunofl uorescence testing was positive, with intercellular IgG deposits in the epidermis; enzyme-linked immunosorbent assay (ELISA) revealed autoantibodies to desmoglein 1 and 3 (138 U/mL and 143 U/mL, respectively). Based on these fi ndings, the patient was diagnosed with pemphigus vulgaris (PV). Initially, she was treated with prednisolone 120 mg/day (2 mg/kg body weight [BW]). However, due to an insuffi cient response and continued development of new lesions, the corticosteroid dose had to be increased to 200 mg/day; in addition, she was started on mycophenolate mofetil (MMF) 3 g/day. After two weeks of high dose corticosteroid therapy, the lesions began to heal, and no new blisters occurred. Subsequently, the prednisolone dose was slowly tapered, and the patient was released from the hospital – in stable clinical condition – on prednisolone 80 mg/day and MMF 3 g/day. Three weeks later, she presented to our emergency department with suspected relapse. Clinical examination showed necrotic plaques and vesicles, especially on the trunk but also on the extremities, as well as extensive erosions in the genital und perianal region (Figure 1 a). Histopathology of another biopsy revealed suprabasal cleft and blister formation. The blister lumen contained acantholytic cells and multinucleated giant cells; the adjacent epithelium showed necrotic keratinocytes (Figure 2 ). Polymerase chain reaction (PCR) from swabs taken from multiple lesions, as well as PCR from the biopsy, was highly positive for HSV1/2, VZV, and CMV (viral load 20.5 × 10 3 ; 1.7 × 10 6 ; 2.8 × 10 9 ; 7 × 10 3 copies/mL, respectively). The CMV pp65 antigen blood test was positive; CMV IgG and IgM were both positive. The patient underwent a complete diagnostic workup to rule out involvement of other organs. While there was no evidence of ocular or gastrointestinal involvement, a chest CT did show signs of atypical pneumonia, which prompted a bronchoalveolar lavage to rule out fungal or bacterial infection. The prednisolone dose was reduced to 20 mg/day, and the patient started on foscarnet (60 mg/kg

Virusreaktivierung täuscht Rezidiv des Pemphigus vulgaris bei einer immunsupprimierten Patientin vor

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