Anti–Laminin-332 Mucous Membrane Pemphigoid Developing After a Diphtheria Tetanus Vaccination

Abstract

accine administration is an effective tool to prevent infectious diseases, but its powerful stimulus on the immune system has generated the fear of exacerbating preexisting autoimmune diseases or inducing autoimmune disorders in otherwise healthy individuals.1 Bullous pemphigoid (BP) is the most frequent autoimmune blistering skin disease. It affects predominantly elderly individuals but has also been reported in children. The etiologic characteristics of BP are unknown, but there have been 26 BP cases suspected of having been induced by vaccinations (Table). [2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21] In all of the postvaccination BP cases in which immunoblotting and/or enzyme-linked immunosorbent assay (ELISA) studies were performed, the target antigens were found to be BP180 and/or BP230. 3,8,12,16,17 We report a unique case of mucous membrane pemphigoid (MMP) that developed acutely in a 29-yearold man 2 days after he received a diphtheria tetanus (DT) vaccination. The results of laboratory studies were compatible with anti-laminin-332 MMP, which to our knowledge has not been previously described following vaccination. Report of a CaseAn otherwise healthy 29-year-old man was admitted to our department as a result of a sudden mucocutaneous eruption of blisters that occurred 2 days after receiving a DT vaccine for a traumatic skin cut. There were no available medical records of previous DT vaccinations, although the pediatric population in Israel is vaccinated regularly several times during childhood. The patient did not have a history of skin diseases or allergies to medications. The superficial cut was 1.5 cm long. It was treated with povidone-iodine solution and closed with adhesive surgical tape strips. There was no wound infection, and the patient did not receive any systemic antibiotics. On physical examination, there were tense blisters along with flaccid blisters and erosions on the face, inguinal area, and lower abdomen ( Figure 1). There were also widespread erosions on the oral mucosa (Figure 1). The Nikolsky sign was absent, and the rest of the physical examination had normal results. Histopathologic analysis of a skin blister revealed a subepidermal blister with complete epidermal-dermal separation and a sparse mononuclear cell infiltrate in the papillary dermis (Figure 2A and B). Immunohistochemical staining demonstrated type IV collagen on the dermal floor of the split ( Figure 2C). Direct immunofluorescence microscopy showed linear deposits of IgG and C3 along the basement membrane zone. An indirect immunofluorescence test on the patient's serum, which was performed on monkey esophagus, revealed linear deposits of IgG along the basement membrane zone with a titer of 1:160. Indirect immunofluorescence microscopy performed on 1M so-IMPORTANCE Bullous pemphigoid (BP) has been previously described to develop after vaccination in 26 patients. Immunoblotting or enzyme-linked immunosorbent assays (ELISAs), which were performed for 7 of these patients, have always shown circ...

Immune‐mediated adverse reactions to vaccines

“…41,42 EMM, unlike SJS/TEN, is recurrent in the absence of reexposure to the initial inciting event. 43 Other rare delayed cutaneous reactions potentially associated with vaccines have been reported (Table 2) and include acute generalized exanthematous pustulosis, 44,45 erythema nodosum, [46][47][48][49] granuloma annulare, 50 bullous pemphigoid, [51][52][53] Sweet's syndrome, [54][55][56][57][58][59] Gianotti-Crosti syndrome, 60 lichenoid eruptions, 46,50,61-66 cutaneous lupus, 46,67 lupus vulgaris [68][69][70] and serum sickness-like reactions. [71][72][73][74][75][76] Similar to vaccine associated EMM, the presence of an ongoing infection prior to both vaccination and the development of these cutaneous syndromes is frequently reported in these cases.…”

Case of pemphigoid with immunoglobulin G antibodies to BP180 C‐terminal domain and laminin‐γ1 (p200) developed after pneumococcal vaccination

“…However, cases following non-influenza vaccinations have been rarely reported (Table 1). [1][2][3][4][5][6] Some reports indicated that vaccination may trigger pemphigoid diseases. All patients developed skin lesions after the vaccination, while time of disease onset after vaccination was variable from 1 day to a few weeks.…”

Bullous Systemic Lupus Erythematosus and Cicatricial Pemphigoid

“…The etiopathogenesis is still unknown; however, it is thought that environmental factors combined with genetic susceptibility lead to CP. There have been some reported cases of CP triggered by human immunodeficiency virus, diphtheria vaccination, and some medications such as methyldopa, clonidine, and D-penicillamine [110,111]. In addition, other autoimmune diseases may occur more frequently in patients with CP [112].…”