Pemphigus Vulgaris After COVID-19: a Case of Induced Autoimmunity

Abstract

Bullae autoimmune diseases can be induced by environmental factors in a genetically susceptible individual, and viruses may be important triggers for this process. Coronavirus disease 2019 (COVID-19) is a multisystemic disease known for developing many types of skin lesions. However, little is known about post-COVID-19 manifestations. A previous healthy male patient, 43 years old, with resistant mediastinal Hodgkin's lymphoma stage II diagnosed in 2019, without treatment at the moment, developed monomorphic flaccid bullae on the trunk 40 days after testing positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Although he had risk factors for IgA and paraneoplastic pemphigus, there were no elements for these diseases. The investigation confirmed a pemphigus vulgaris (PV). PV had a good response to treatment with prednisolone 1 mg/kg per day, and methotrexate 15 mg subcutaneously was added per week. The patient was discharged with oral methotrexate and prednisolone at the same dose. Prednisolone was decreased by 20 mg per day during the follow-up. Viruses such as herpesvirus, cytomegalovirus, and varicela zoster can act as triggers for PV. This process is not immediate after the infection because it depends on the change in antibodies initially produced against the virus that start to identify antigens present in the skin's anchoring structures. SARS-CoV-2 can induce autoimmunity, as seen in Guillán-Barré syndrome and in Kawasaki disease. It is a highly immunogenic virus that is the perfect agent for triggering PV. This case can be considered a cutaneous autoimmune post-COVID-19 manifestation.

Oral Manifestations of COVID-19 in Hospitalized Patients: A Systematic Review

“…A total of 35 articles were judged as low risk [ 21 , 26 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 ], 12 as a moderate risk [ 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 ], and 12 as high risk [ 79 , 80 , 81 , 82 , 83 , 84 , 85 , 86 ,…”

“…Ulcerative and erosive lesions were frequently present in COVID-19 patients, both before and during hospital admission. In particular, 14 studies reported that lesions appeared during hospitalization [ 21 , 34 , 36 , 37 , 42 , 45 , 47 , 48 , 52 , 57 , 64 , 69 , 70 , 82 ], while 6 articles referred to lesions that emerged before hospitalization [ 36 , 37 , 38 , 41 , 61 , 70 ]. The sample consisted of 111 males (age: 56.7 ± 15.3) and 90 females (age: 53.2 ± 22.4).…”

“…The ulcers emerged after a latency time of 4 to 7 days after the onset of COVID-19 symptoms, and most of them were diagnosed upon hospital admission. Only in one case did small oral ulcers appear 40 days after a COVID-19 positive test [ 42 ]. Some patients displayed painful herpetic and hemorrhagic ulcers with irregular margins, which were variable in size and number.…”

Diagnosis and Treatment Challenges of an Atypical Case of Pemphigus vulgaris During the COVID-19 Pandemic

“…Bystander activation involves the possibility when there is no antigenic similarity, but cytolysis causes an increased amount of antigens that exceeds the capacity of phagocytosis, autoantigen exposure, and generation of autoreactive cells. After either of these two processes, epitope spreading is the amplification of the immune response that leads to the targeting of autoantigens different from the first targeted antigen, and the development of autoantibodies [ 15 ].…”

Case Report: Infantile Bullous Pemphigoid: Triggering by COVID-19 Is Speculative

“…Autoimmune diseases concomitant with coronaviruses have been suggested to be associated with cross-reactivity of antibodies or activated lymphocytes with different antigens which own the same or similar epitopes ( 16 ). Two cases of pemphigus vulgaris following SARS-CoV-2 infection, as well as BP in an elderly female and a middle-aged female with COVID-19 were reported ( 17 – 20 ).…”