A case of bleeding duodenal ulcer with pemphigus vulgaris during steroid therapy

Abstract

We report a rare case of bleeding duodenal ulceration in the different form of pemphigus vulgaris (PV). A 52-year-old female was diagnosed with acute pharyngitis and administered methylprednisolone. After several days, melena and many blisters were noted on her body. Endoscopy revealed blood oozing from the second part of a duodeneal ulcer around the major duodenal papilla. After initial endoscopic hemostasis, we observed a large regional, shallow duodenal ulcer. The blisters were suspected to represent the Nikolsky's sign. The histological findings of her skin were characterized by suprabasal acantholysis and mixed inflammatory cell infiltrates, including scattered eosinophils. There were no other significant findings on skin biopsy or by direct immunofluorescence. Enzyme-linked immunosorbent assay showed an elevated titer of anti-desmoglein 3 autoantibodies in her serum, and the patient was finally diagnosed with mucosal-dominant PV. Although we performed multiple biopsies from the esophagus, stomach and duodenum, the samples did not contain significant findings to enable us to distinguish from pemphigus vulgaris. Corticosteroids remain an essential component of PV treatment. When clinicians encounter PV development during steroid therapy, upper gastrointestinal complications should be considered and diagnostic endoscopy conducted.

Thromboembolism and bleeding in patients with autoimmune blistering disease

“…Although we have in the past treated VTE primarily with heparin sodium and warfarin potassium, we can now use the novel oral anticoagulants, which may reduce bleeding risk 5 . There are several previous reports of bleeding occurring in patients with BP or PV 6,7 . Attention should be paid to acquired haemophilia A in patients with BP, 7,8 although none of our patients were diagnosed with this.…”

“…5 There are several previous reports of bleeding occurring in patients with BP or PV. 6,7 Attention should be paid to acquired haemophilia A in patients with BP, 7,8 although none of our patients were diagnosed with this. The association between neurological disorders and BP has also been shown recently; patients with BP have an increased risk of stroke, dementia, Parkinson disease and epilepsy/ seizures.…”

Eosinophils in patients with pemphigus vulgaris

“…При аутоиммунной пузырчатке инфильтрат в дерме, наряду с плазмоцитами и лимфоцитами, содержит эозинофилы, однако в содержимом внутриэпидермальных пузырей, возникших вследствие акантолиза, эозинофилы в типичных случаях отсутствуют [11,12]. Появление эозинофилов в содержимом субэпидермальных пузырей, периферической крови считается характерным признаком герпетиформного дерматита Дюринга.…”