Silke C. Hofmann

Recommendations for the use of rituximab (anti-CD20 antibody) in the treatment of autoimmune bullous skin diseases.

Autoimmune bullous skin disorders are induced by autoantibodies against distinct adhesion complexes of the epidermal and dermal‐epidermal junction. Since most of these disorders are characterized by a severe, potentially lethal course,they require long‐term immunosuppressive treatment to reduce the de novo synthesis of pathogenic autoantibodies by B lymphocytes. Rituximab, a chimeric monoclonal antibody against CD20 on B lymphocytes, has shown promise in several case reports or cohort studies in the treatment of paraneo‐plastic pemphigus,refractory cases of pemphigus vulgaris and foliaceus and in other autoimmune bullous disorders.Treatment with rituximab leads to depletion of pathogenic B‐cells which may last up to 12 months resulting in a reduction of plasma cells secreting pathogenic autoantibodies.Rituximab is usually administered in an adjuvant setting at a dose of 375 mg/m2 i.v.in weekly intervals for four consecutive weeks in addition to the standard immunosuppressive treatment.The present consensus statement of German‐speaking derma‐tologists,rheumatologists and oncologists summarizes and evaluates the current evidence for the use and mode of application of rituximab in autoimmune bullous skin disorders.

Multicenter prospective study of the humoral autoimmune response in bullous pemphigoid

Bullous pemphigoid (BP) is an autoimmune bullous disease, associated with autoantibodies directed against the hemidesmosomal components BP180 and BP230. In this study for the first time different laboratories have analyzed the autoantibody profile in the same group of 49 prospectively recruited BP patients. The results show that: 1) disease severity and activity correlated with levels of IgG against the BP180-NC16A domain, but also against a COOH-terminal epitope of BP180, 2) distinct epitopes of the BP180 ectodomain other than BP180-NC16A were recognized by 96% of the BP sera; and 3) the combined use of BP180 and BP230 ELISA led to the detection of IgG autoantibodies in all the BP sera. These results demonstrate the usefulness of the combined ELISAs based on various BP180 and BP230 fragments in establishing the diagnosis of BP and support the concept that BP180 is the major autoantigen of BP.

Demonstration of Epitope-Spreading Phenomena in Bullous Pemphigoid: Results of a Prospective Multicenter Study

Bullous pemphigoid (BP), the most common autoimmune subepidermal bullous disease, is associated with an autoantibody response to BP180 and BP230, two components of junctional adhesion complexes in human skin promoting dermo-epidermal cohesion. Retrospective analyses demonstrated that these autoantigens harbor several epitopes targeted by autoaggressive B and T cells. The aim of this prospective multicenter study was to assess the evolution of IgG autoantibodies in 35 BP patients over a 12-month observation period. Epitope-spreading (ES) events were detected in 17 of 35 BP patients (49%). They preferentially occurred in an early stage of the disease and were significantly related to disease severity at diagnosis. Moreover, in three patients, spreading of IgG reactivity to intracellular epitopes of BP180 and BP230 was preceded by recognition of the BP180 ectodomain. Finally, IgG reactivity with extracellular epitopes of BP180 and intracellular epitopes of BP230 correlated with the severity of BP in disease course. These findings support the idea that IgG recognition of the BP180 ectodomain is an early and crucial event in BP disease, followed by variable intra- and intermolecular ES events, which likely shape the individual course of BP.

Recommendations for the use of immunoapheresis in the treatment of autoimmune bullous diseases

Despite the use of high‐dose systemic corticosteroids in combination with other immunosuppressants, in some patients with autoimmune bullous diseases only insufficient improvement is achieved. In these cases and in acute severe disease, adjuvant immunoapheresis has been increasingly used. A consensus meeting was held in mid‐2005 in Hamburg, aiming at developing guidelines for the use of immunoapheresis in the treatment of autoimmune bullous diseases.This paper summarizes the experts‘ recommendations.

Plasmin Plays a Role in the In Vitro Generation of the Linear IgA Dermatosis Antigen LADB97

Collagen XVII (BP180) and its shed ectodomain represent major autoantigens in dermatoses of the pemphigoid group. The 120 kDa ectodomain is constitutively shed from the cell surface by disintegrin-metalloproteinases (ADAMs). Part of it is further processed to a 97 kDa fragment (LABD97), an autoantigen in linear IgA dermatosis (LAD), but the responsible proteinases remain elusive. In this study, we identified the 120 and the 97 kDa ectodomain in blister fluids of bullous pemphigoid patients using new mAbs. As blister fluids contain significant plasmin-like serine protease activity, HaCaT keratinocytes or purified 120 kDa ectodomain were incubated with several human serine proteases. In vitro, only plasmin generated a stable 97 kDa fragment that was also targeted by LAD sera. Characterization of the plasmin-derived 97 kDa fragment with domain-specific collagen XVII antibodies, heparin binding and N-glycosylation studies indicates that the N-terminus is located approximately at AA 515 and the C-terminus N-terminally from AA 1,421. Interestingly, plasmin-derived LABD97 was also generated in the presence of ADAM inhibitors and remained stable over more than 12 hours incubation at 37 degrees C, indicating that this disease relevant collagen XVII fragment can also arise in an ADAM-independent manner through direct action by plasmin.

Distribution of collagen XVII in the human brain

We have recently discovered collagen XVII to be present in neurons of the human central nervous system. Collagen XVII has previously been primarily studied in the field of dermatopathology since it is abundantly expressed in the skin, which, like the nervous system, is ectodermal in origin. A link between dermatopathological and neurological entities has been implied due to clinical case studies revealing an association between bullous pemphigoid and age-related neurodegenerative disorders. The objective of this study was to assess the distribution of collagen XVII in the human brain in relation to normal ageing. Post-mortem brain tissue was obtained from 11 neurologically unimpaired subjects who had died from cardiovascular causes at the age of 17 to 78 years. Collagen XVII expression in various neuroanatomical regions, representing essentially the entire human brain, was then assessed using immunohistochemistry. We found collagen XVII to be expressed widely in the brain and to be located primarily in the soma and proximal axons of neurons. In contrast, glial cells did not express collagen XVII. The expression varied strikingly between different neuroanatomical regions, being most notable in motor nuclei and Betz cells followed by pyramidal neurons. There was no correlation between collagen XVII expression and variables such as gender, age at death, post-mortem delay and fixation time whereas a mode of death leading to notable neuronal ischemia depleted the protein expression. Many neurodegenerative disorders display a specific pattern of neuroanatomical involvement, thus the regionally variable expression of collagen XVII offers new prospects for research.

Imatinib mesylate as a novel treatment option for hypereosinophilic syndrome: two case reports and a comprehensive review of the literature

Hypereosinophilic syndromes (HES) are a heterogenous group of rare disorders characterized by sustained and otherwise unexplained overproduction of eosinophils with organ involvement and consecutive dysfunction. Recent reports document the efficacy of imatinib mesylate in a large proportion of HES patients (65%). Rearrangements involving the platelet-derived growth factor receptor genes (PDGFRA and PDGFRB), both tyrosine kinase receptors, have been demonstrated to be pathogenetically linked to the dysregulated clonal overproduction of eosinophils. This refined hypothesis has been confirmed by the discovery of the novel FIP1L1–PDGFRA fusion gene, which is a gain-of-function gene on chromosome 4q12. Its product is an imatinib-sensitive tyrosine kinase, which can be found in a subset of patients with HES, particularly in those responding to treatment with imatinib mesylate. Here, we sum up recent knowledge of clinical features, pathophysiology and novel treatment aspects of HES by performing a comprehensive search of the available literature and report on 94 patients. We particularly address the issue of organ involvement and specific characteristics of the variable clinical pictures. In addition, two cases will be presented, which illustrate typical clinical scenarios and treatment outcome.

Ectodomain Shedding Generates Neoepitopes on Collagen XVII, the Major Autoantigen for Bullous Pemphigoid

As a type II transmembrane protein in basal keratinocytes, collagen XVII provides stable adhesion between epidermis and dermis in the skin. Its ectodomain can be shed from the cell surface, and autoantibodies in certain blistering diseases preferentially recognize the shed form. Major epitopes of collagen XVII are clustered within the juxtamembranous noncollagenous 16th A domain, and ectodomain shedding occurs within this region, suggesting that cleavage generates neoepitopes. However, the candidate cleavage sites have been controversial, and the mechanism of neoepitope generation is unclear. In this study, we investigated cleavage sites in the noncollagenous 16th A domain to understand the generation of neoepitopes and their pathological role. Polyclonal Abs recognizing the stretch Leu524-Gly532 preferentially reacted with the shed ectodomain, but not with the full-length form, indicating that a neoepitope was localized at this site. The neoepitope-specific Ab fixed complement and induced granulocyte-dependent dermal-epidermal separation in cryosections of normal human skin. The physiological cleavage sites were identified using mass spectrometry. N termini were found at Asp514, Leu524, Glu525, and Gly526, among which Asp514 and Glu525 were blocked by acetylation and pyroglutaminate. In silico prediction of B cell epitopes indicated that the antigenicity of the Leu524-Gly532 region increased substantially after shedding, regardless of the cleavage sites. Correspondingly, neoepitopes were found in the skin and blister fluids of patients with bullous pemphigoid, and bullous pemphigoid sera reacted with the peptide Leu524-Gly532. Taken together, these data demonstrate that physiological shedding of collagen XVII generates neoepitopes, which may serve as a target of blister-inducing autoantibodies.

S2k guidelines for the treatment of pemphigus vulgaris/foliaceus and bullous pemphigoid.

(1) Department of Dermatology and Allergology, Philipps-Universität Marburg, Germany (2) Department of Dermatology, University Hospital Erlangen, Erlangen, Germany (3) Helios Hospital Wuppertal, Department of Dermatology, Allergology and Dermatosurgery, Wuppertal, Germany (4) Department of Dermatology and Venereology, University of Cologne (5) Department of Dermatology, Medical Center, University of Freiburg, Germany (6) Dermatologist in Private Practice, Fulda, Germany (7) Department of Dermatology and Allergology, University Hospital Ulm, Germany (8) Pediatric Immunology and Rheumatology, University Hospital and Outpatient Clinic for Pediatrics, Leipzig, Germany (9) Department of Dermatology, Allergology, and Venereology, Campus Luebeck, University Hospital Schleswig-Holstein (UKSH), Luebeck, Germany (10) Department of Dermatology, Venereology, and Allergology, University Hospital Wuerzburg, Wuerzburg, Germany (11) Division of Evidence-based Medicine (dEBM), Department of Dermatology, Charité University Hospital Berlin, Germany (12) Shire Deutschland GmbH, Berlin, Germany (13) Department of Dermatology and Venereology, University Hospital Munich (LMU), Munich, Germany (14) Allergy Center, Department of Dermatology, Charité University Hospital Berlin, Germany

Dynamic Interactions of Epidermal Collagen XVII with the Extracellular Matrix Laminin 332 as a Major Binding Partner

Transmembrane collagen XVII, a major component of the hemidesmosomes, is crucial for stable adhesion of the epidermis and dermis in the skin, and its dysfunction results in blistering diseases. The ectodomain of collagen XVII (Ecto-ColXVII) is constitutively shed from the cell surface, but its binding partner(s) in the extracellular matrix (ECM) and the physiologic roles of the ligand interactions remain elusive. Herein, we used a new cleavage site-specific antibody to address the dynamics of collagen XVII shedding and the interactions of Ecto-ColXVII with the ECM. Ecto-ColXVII was present in the migration tracks of primary human keratinocytes and co-localized with laminin 332. The presence of this laminin, but also of collagen IV and Matrigel, in the ECM enhanced shedding and incorporation of Ecto-ColXVII into the matrix. Laminin 332 is a major, but not exclusive, interaction partner in vivo because Ecto-ColXVII deposited in the ECM of laminin 332-deficient keratinocytes was drastically reduced, but Ecto-ColXVII was present in laminin 332-negative human skin. Expression of collagen XVII deletion mutants in HEK 293 cells identified the C-terminal ectodomain stretch Ser(978)-Pro(1497) as necessary for ECM binding. Taken together, migrating keratinocytes shed the Ecto-ColXVII, and this dynamically binds via its C-terminal domain to distinct partners in the ECM.