Acta Allergologica, ig76, 31, 2^5-282
From the Sec?ao de Alergia e Imunopatologia, Departamento de Clinica Medica do Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paula, e Escola Paulista de Medicina, Sao Paulo, Brasil.
AUTOIMMUNITY IN PATIENTS WITH PEMPHIGUS FOLIACEUS By ERNESTO MENDES & RAIMUNDO MARTINS DE CASTRO
The chronic, nonhereditary buUous diseases are usually classified as: Pemphigus vulgaris. Pemphigus foliaceus, BuUous pemphigus, Dermatitis hepetiformis, benign chronic bullous dermatosis and Pemphigus erythematosus. Patients with Pemphigus foliaceus were found to have antibodies reacting specifically with antigens present only in the subcorneal intercellular substance of the epidermis (8), while patients with bullous pemphigoid have antibodies for the basement membrane zone, both suggesting an autoimmune mechanism (11). On the other hand, it is usual to find different autoantibodies in the so-called autoimmune diseases, and for this reason the present study was designed to investigate the presence of other autoantibodies in patients with Pemphigus foliaceus. MATERIAL
AND
METHODS
Sera from 28 patients with Pemphigus foliaceus were examined. The diagnosis of Pemphigus foliaceus was based on conventional clinical and histological criteria. The age of the patients ranged between 20 and 55 years. In order to demonstrate autoantibodies, the following techniques were used: i) antibody to smooth muscle, according to the technique described by Johnson et al. (18); 2) antimitochondrial antibodies, according to the technique of Doniach et al. (14) ; 3) antibody to parietal cells, according to Roitt & Doniach (23) ; 4) antinuclear antibodies, according to Roitt & Doniach (23) ; 5) antiglomerular components, according to Whittingham et al. (27); 6) thyreoglobuHn
276 antibody, using the hemagglutination technique, according to Boyden (7) ; 7) rheumatoid factor, using Hyland Lab. Latex Test; 8) anti-salivary ducts, according to Bertram & Halberg (5) and Feltkamp & van Rossum (16). The search for , antibodies against salivary ducts, thyreoglobulin and rheumatoid factor was made in only 10 patients.
RESULTS
The results are summarized in Table i. Antibodies to parietal cells were demonstrated In six patients (21.4 per ecnt), and In two of them antibodies against mitochondria were also found. Antibody against smooth muscle was found in one patient. The clinical reevaluation of the patients with antibodies to parietal cells, mitochondria and smooth muscle showed no other pathological reasons for these autoantibodies.
DISCUSSION
In the 28 sera studied, the high proportion of parietal cell antibody and the presence of mitochondrial antibody in two suggest autoimmune mechanisms in Pemphigus foliaceus. Indirect evidence of the autoimmune mechanisms of pemphigus derives from the coexistence of this disease with other autoimmune syndromes, such as Myasthenia gravis and thymona and Lupus erythematosus (10). The coexistence of pemphigus with discoid Lupus erythematosus has also been described and the condition is known as the Senear-Usher syndrome. The occurrence of nuclear antibodies and pemphigus antibodies has been noted in Pemphigus erythematosus and buUous pemphigoid (19). The coexistence of pemphigus with other autoimmune diseases points to the existence of immunological defects which may predispose to autoimmune responses. On the other hand, there are some observations which do not support this view; identical antibodies have been found in the serum of burn patients, suggesting that the pemphigus antibody may be secondary to some other primary event (13). Pemphigus-like antibodies have also been de-
277 TABLE I. Serum Antibodies in 28 Patients with Pemphigus foliaceus. No. serum I 2
3 4 5 6 7 8 9 IO II 12
13 14 15 i6 17 i8 19 2O 21 22
24 25 26 27 28
* N P M Ms
= = = —
Autoantibodies*
N
P
M
Ms
G
— — — — — — — — — — — — — — — — — — — — — —
— — — —
— — — — -1— — — — — —
— — — — — — — —
— — — — — — — — — — — — — — — — — — — — —
— — — — —
— — + — —
+ — — — — + — + — — — — — — — — +
antinuclear antiparietal cell antimitochondrial antimuscle
+ — — — — — — — — — — — — — —*
+ — — — — — — — — — — — —
I — — — —
S
T
L
—~
~~
" ~
•
—
—
"'"" "
—
G S T L
•
•
I I — — _ _
' • • • "
"
= = =: =
"
" '
antiglomerular components antisalivary ducts antithyreoglobulin latex test
278 scribed in cases of morbilliform eruption to penicillin, and in unclassified lesions which macroscopically seem to be of erythema multiform type (i, 15). For this reason, it is still not clear whether these antibodies are the cause of the disease or whether they arise as a result of the tissue damage. The direct role of pemphigus antibody in the pathogenesis of the disease is not conclusive (25). Transfusion of human pemphigus plasma into monkeys and rabbits failed to produce disease, in spite of a small local lesion and strong binding of antibody to the epidermal intercellular space (17). Both pemphigus and buUous pemphigoid antibodies appear to be directly associated with the evolution of these diseases. They arise during active phases of the disease and fall during remission. Rising titers usually precede the appearance of lesions. Nevertheless, in some active cases there may be no demonstrable circulating buUous pemphigoid antibodies, while sera of some reactive cases have high titers (24). Pemphigus foUaceus is frequent in some regions of Brazil {South America pemphigus) and epidermiological data strongly suggest an unknown infection origin (virus?) (9). In this case the Pemphigus foliaceus autoantibodies should be considered secondary to some other primary event; this is so far highly speculative. Our findings have some points in common with other investigations on buUous dermatosis, with special reference to Dermatitis herpetiformis. Dick et al. (12) found antibodies reacting with the basement membrane and reported the occurrence of thyroid and gastric parietal cell antibodies in patients with Dermatitis herpetiformis. Seah et al. (26) reported the occurrence of circulating anti-connective tissue antibodies in patients with Dermatitis herpetiformis, possibly directed against reticulum antigens and a variety of different autoantibodies, such as antinuclear antibodies, parietal cell antibodies, thyroid microsomal antibodies and mitochondrial antibodies, and did not find thyreoglobulin and smooth muscle antibodies. Mitochondrial antibody was found by Andersen & Hale (2) in two cases of pemphigus, one of which was Pemphi-
279 gus erythematosus. Two of our patients had antimitochondrial antibodies and parietal cell antibodies. According to the literature, parietal cell antibodies occur in up to 95 per cent of patients between 30-60 years with pernicious anemia, and in about 80 per cent of patients over 60. There is a 60 per cent incidence of parietal cell antibodies in females with gastritis and about 30 per cent in patients with autoimmune thyroid disease. Gastric parietal cell antibodies are found in varying percentages in normal subjects: 2 per cent under 20 years and 8 per cent under 60 years. Our findings of 21.4 per cent in patients with Pemphigus foUaceus, without other pathological reasons for their presence, were considered significant. High levels of IgE were found in the blister fluids as well as in the sera of buUous pemphigoid patients (4) and the serum IgE level was high (3). It seems that both IgE and IgG respond to the antigen of the basement membrane, and the immune complexes thus formed participate in the formation of the eosinophil chemotatic factor in the lesion, thus explaining the large amount of eosinophils present in the skin. The role of complement is being studied and its presence has been detected by direct immunofluorescence staining only in patients not undergoing steroid treatment. In treated patients complement was not demonstrable, even in the active stage of the disease (20). On the contrary, the studies of the complement system in buUous pemphigoid are suggestive of local activation and utilization of complement (21). Complement activation by an alternative pathway has been suggested. By analogy and based on the immune complex deposit theory in patients with Dermatitis herpetiformis (22), one could speculate that antibodies found in Pemphigus foliaceus could induce immune complexes which would be transported as soluble substances in the blood circulation. Since kidney function in Pemphigus foliaceus is generally not disturbed, the immune complexes should be less than 19S in size. Probably, for immunological and non immunological reasons, the immune complexes would be deposited at a specific point in the skin. Chemotatic factors could induce the migration of cells.
28O
mainly neutrophils and eosinophils, responsible in part for the elicitation of the lesions. SUMMARY
The presence of conventional autoantibodies in the sera from 28 patients with Pemphigus foliaceus {South American pemphigus) was investigated. Gastric parietal cell antibody was found in six patients (21.4 per cent); and in two of them mitochondrial antibody was also detected. Antibody to smooth muscle was found m one patient. Based on the above results, the role of autoimmunity in Pemphigus foliaceus was discussed. Nuclear and rheumatoid factors were not detected, and antibodies against glomerular components, salivary duct and thyreoglobulin were not found. ACKNOWLEDGEMENTS We are indebted to Dr. Clovis Jose Lage, Director of Pemphigus Hospital, for selecting the patients, to Dr. Jose Daniel Lopes for the immunofluorescent studies and discussions, and Lucia Musenek for technical aid. REFERENCES 1. Ablin, R. J. (1969) : Immunopathologic studies of experimental pemphiguslike auto-antibodies and bullous-like lesions. J. invest. Derm. 53, 463. 2. Anderson, P. & Hale, W. L. (1973) : Immunopathology of human antibodies on monkey esophagus. In Beutner, E. H. et al. (eds.) : Immunopathology of the skin, pp. 271-286. Dowden, Hutchinson & Ross, Inc., Pennsylvania. 3. Arbesman, C. E., Wypych, J. I., Reisman, R. E. & Beutner, E. H. (1974): IgE levels in sera of patients with pemphigus or bullous pemphigoid. Arch. Derm, no, 378. 4. Baba, T., Sonozaki, H., Seki, K., Uchiyama, M., Ikesawa, Y. & Torisu, M. (1976): An eosinophil chemotatic factor present in blister fluids of bullous pemphigoid patients. J. Immunol. 116, 112. 5. Bertram, U. & Halberg, P. (1964) : A specific antibody against epithelium of salivary ducts in sera from patients with Sjogren's syndrome. Acta allergol. ig, 458. 7. Boyden, S. V. (1951): The adsorption of protein on erythrocytes treated
28l tannic acid and subsequent hemagglutination by antiproteinsera. J. exp. Med. ^3, 107. 8. Bystrin, J. C , Abel, E. & De Feo, C. (1974): Pemphigus foliaceus—subcorneal intercellular antibodies of unique specificity. Arch. Derm, no, 857. 9. Castro, R. M. & Proenga, N. (1972): South American pemphigus foliaceus. The Glaxo Volume 36, 17. 10. Chorzelski, T. P., Jablonska, S. & Blaszczyk, M. (1968) : Immunopathologic investigation in the Senear-Usher syndrome. Coexistence of pemphigus with lupus erythematosus. Brit. J. Derm. 80, 211. 11. Chorzelski, T. P., Jablonska, S. & Beutner, E. H. (1973): Clinical significance of pemphigus antibodies. In Beutner, E. H., Chorzelski, T. P., Bean, S. F. & Jordon, R. E. (eds.) : Immunopathology of the skin-labeled antibody studies, pp. 25-43. Dowden, Hutchinson & Ross, Inc., Pennsylvania. 12. Dick, H. M., Fraser, N. G. & Murray, D. (1969): Immunofluorescent antibody studies in dermatitis herpetiformis. Brit. J. Derm. 81, 692. 13. Dobmeier, L. J., Sams, W. M., Jr. & Beutner, E. H. (1971) : Intercellular antibodies in a patient without clinical pemphigus. Ann. N.Y. Acad. Sci. 177. 218. 14. Doniach, D., Roitt, I. M., Walker, J. G. & Sherlock, S. (1966): Tissue antibodies in primary biliary cirrhosis, active chronic (lupoid) hepatitis, cryptogenic cirrhosis and other liver diseases and their clinical implications. Clin. exp. Immunol. / , 237. 15. Fellner, M. J. & Prutkin, L. (1970) : Morbilliform eruption caused by penicillin. J. invest. Derm. ss> 39o. 16. Feltkamp, T. E. & van Rossum, A. L. (1968) : Antibodies to salivary duct cells, and other autoantibodies in patients with Sjogren's syndrome and other idiopathic autoimmune diseases. Clin. exp. Immunol. 3, 1. 17. Holubar, J., Chorzelski, T. P., Gauto, M. & Beutner, E. H. (1973) : Studies in immunodermatology. III. Induction of intraepithelial lesions in monkeys by intramucosal injections of pemphigus antibodies. Int. Arch. Allergy 44, 631. 18. Johnson, G. D., Holborow, E. J. & Glynn, L. E. (1965) : Antibody to smooth muscle in patients with liver disease. Lancet ii: 878. 19. Jordon, R. E., Muller, S. A., Hale, W. L. & Beutner, E. H. (1969) : Bullous pemphigoid associated with systemic lupus erythematosus. Arch. Derm, pp, 1720. Jordon, R. E., Sams, W. M., Jr. & Beutner, E. H. (1969): Complement immunofluorescent staining in bullous pemphigoid. J. Lab. clin. Med. 74, 548. 21. Katz, S. J., Inderbitzin, T. M. & Halprin, K. M. (1970) : Serum complement (C3) levels in patients with autoimmune bullous skin diseases. Arch. Derm. 102, 368. 22. Meer, J. B. van der (1972): Dermatitis herpetiformis: a specific (immunopathological?) entity. Battelie and Terp., Publ., W. V. Leiden.
282 23- Roitt, I. M. & Doniach (1969): WHO-Manual for auto-immune serology. WHO, Geneva. 24. Sams, y . M., Jr. & Jordon, R. E. (1971): Correlation of pemphigoid and pemphigus antibody titer with activity of disease. Brit. J. Derm. 84, 7. 25. Sams, W. M. & Jordon, R. E. (1971): Pemphigus antibodies: their role in disease. J. invest. Derm. 56, 474. 26. Seah, P. P., Fry, L., Hoffbrand, A. V. & Holborow, E. J. (1971) : Tissue antibodies in dermatitis herpetiformis and adult coeliac disease. Lancet i, 83427. Whittingham, S., MacKay, I. R. & Irwin, J. (1966) : Autoimmune hepatitis. Lancet i, 1333. Authors' address:
Dr. Ernesto Mendes, M.D. Secgao de Alergia - sala 7109 Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo Caixa postal 8091 oiooo — Sao Paulo Brazil
From the Sec?ao de Alergia e Imunopatologia, Departamento de Clinica Medica do Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paula, e Escola Paulista de Medicina, Sao Paulo, Brasil.
AUTOIMMUNITY IN PATIENTS WITH PEMPHIGUS FOLIACEUS By ERNESTO MENDES & RAIMUNDO MARTINS DE CASTRO
The chronic, nonhereditary buUous diseases are usually classified as: Pemphigus vulgaris. Pemphigus foliaceus, BuUous pemphigus, Dermatitis hepetiformis, benign chronic bullous dermatosis and Pemphigus erythematosus. Patients with Pemphigus foliaceus were found to have antibodies reacting specifically with antigens present only in the subcorneal intercellular substance of the epidermis (8), while patients with bullous pemphigoid have antibodies for the basement membrane zone, both suggesting an autoimmune mechanism (11). On the other hand, it is usual to find different autoantibodies in the so-called autoimmune diseases, and for this reason the present study was designed to investigate the presence of other autoantibodies in patients with Pemphigus foliaceus. MATERIAL
AND
METHODS
Sera from 28 patients with Pemphigus foliaceus were examined. The diagnosis of Pemphigus foliaceus was based on conventional clinical and histological criteria. The age of the patients ranged between 20 and 55 years. In order to demonstrate autoantibodies, the following techniques were used: i) antibody to smooth muscle, according to the technique described by Johnson et al. (18); 2) antimitochondrial antibodies, according to the technique of Doniach et al. (14) ; 3) antibody to parietal cells, according to Roitt & Doniach (23) ; 4) antinuclear antibodies, according to Roitt & Doniach (23) ; 5) antiglomerular components, according to Whittingham et al. (27); 6) thyreoglobuHn
276 antibody, using the hemagglutination technique, according to Boyden (7) ; 7) rheumatoid factor, using Hyland Lab. Latex Test; 8) anti-salivary ducts, according to Bertram & Halberg (5) and Feltkamp & van Rossum (16). The search for , antibodies against salivary ducts, thyreoglobulin and rheumatoid factor was made in only 10 patients.
RESULTS
The results are summarized in Table i. Antibodies to parietal cells were demonstrated In six patients (21.4 per ecnt), and In two of them antibodies against mitochondria were also found. Antibody against smooth muscle was found in one patient. The clinical reevaluation of the patients with antibodies to parietal cells, mitochondria and smooth muscle showed no other pathological reasons for these autoantibodies.
DISCUSSION
In the 28 sera studied, the high proportion of parietal cell antibody and the presence of mitochondrial antibody in two suggest autoimmune mechanisms in Pemphigus foliaceus. Indirect evidence of the autoimmune mechanisms of pemphigus derives from the coexistence of this disease with other autoimmune syndromes, such as Myasthenia gravis and thymona and Lupus erythematosus (10). The coexistence of pemphigus with discoid Lupus erythematosus has also been described and the condition is known as the Senear-Usher syndrome. The occurrence of nuclear antibodies and pemphigus antibodies has been noted in Pemphigus erythematosus and buUous pemphigoid (19). The coexistence of pemphigus with other autoimmune diseases points to the existence of immunological defects which may predispose to autoimmune responses. On the other hand, there are some observations which do not support this view; identical antibodies have been found in the serum of burn patients, suggesting that the pemphigus antibody may be secondary to some other primary event (13). Pemphigus-like antibodies have also been de-
277 TABLE I. Serum Antibodies in 28 Patients with Pemphigus foliaceus. No. serum I 2
3 4 5 6 7 8 9 IO II 12
13 14 15 i6 17 i8 19 2O 21 22
24 25 26 27 28
* N P M Ms
= = = —
Autoantibodies*
N
P
M
Ms
G
— — — — — — — — — — — — — — — — — — — — — —
— — — —
— — — — -1— — — — — —
— — — — — — — —
— — — — — — — — — — — — — — — — — — — — —
— — — — —
— — + — —
+ — — — — + — + — — — — — — — — +
antinuclear antiparietal cell antimitochondrial antimuscle
+ — — — — — — — — — — — — — —*
+ — — — — — — — — — — — —
I — — — —
S
T
L
—~
~~
" ~
•
—
—
"'"" "
—
G S T L
•
•
I I — — _ _
' • • • "
"
= = =: =
"
" '
antiglomerular components antisalivary ducts antithyreoglobulin latex test
278 scribed in cases of morbilliform eruption to penicillin, and in unclassified lesions which macroscopically seem to be of erythema multiform type (i, 15). For this reason, it is still not clear whether these antibodies are the cause of the disease or whether they arise as a result of the tissue damage. The direct role of pemphigus antibody in the pathogenesis of the disease is not conclusive (25). Transfusion of human pemphigus plasma into monkeys and rabbits failed to produce disease, in spite of a small local lesion and strong binding of antibody to the epidermal intercellular space (17). Both pemphigus and buUous pemphigoid antibodies appear to be directly associated with the evolution of these diseases. They arise during active phases of the disease and fall during remission. Rising titers usually precede the appearance of lesions. Nevertheless, in some active cases there may be no demonstrable circulating buUous pemphigoid antibodies, while sera of some reactive cases have high titers (24). Pemphigus foUaceus is frequent in some regions of Brazil {South America pemphigus) and epidermiological data strongly suggest an unknown infection origin (virus?) (9). In this case the Pemphigus foliaceus autoantibodies should be considered secondary to some other primary event; this is so far highly speculative. Our findings have some points in common with other investigations on buUous dermatosis, with special reference to Dermatitis herpetiformis. Dick et al. (12) found antibodies reacting with the basement membrane and reported the occurrence of thyroid and gastric parietal cell antibodies in patients with Dermatitis herpetiformis. Seah et al. (26) reported the occurrence of circulating anti-connective tissue antibodies in patients with Dermatitis herpetiformis, possibly directed against reticulum antigens and a variety of different autoantibodies, such as antinuclear antibodies, parietal cell antibodies, thyroid microsomal antibodies and mitochondrial antibodies, and did not find thyreoglobulin and smooth muscle antibodies. Mitochondrial antibody was found by Andersen & Hale (2) in two cases of pemphigus, one of which was Pemphi-
279 gus erythematosus. Two of our patients had antimitochondrial antibodies and parietal cell antibodies. According to the literature, parietal cell antibodies occur in up to 95 per cent of patients between 30-60 years with pernicious anemia, and in about 80 per cent of patients over 60. There is a 60 per cent incidence of parietal cell antibodies in females with gastritis and about 30 per cent in patients with autoimmune thyroid disease. Gastric parietal cell antibodies are found in varying percentages in normal subjects: 2 per cent under 20 years and 8 per cent under 60 years. Our findings of 21.4 per cent in patients with Pemphigus foUaceus, without other pathological reasons for their presence, were considered significant. High levels of IgE were found in the blister fluids as well as in the sera of buUous pemphigoid patients (4) and the serum IgE level was high (3). It seems that both IgE and IgG respond to the antigen of the basement membrane, and the immune complexes thus formed participate in the formation of the eosinophil chemotatic factor in the lesion, thus explaining the large amount of eosinophils present in the skin. The role of complement is being studied and its presence has been detected by direct immunofluorescence staining only in patients not undergoing steroid treatment. In treated patients complement was not demonstrable, even in the active stage of the disease (20). On the contrary, the studies of the complement system in buUous pemphigoid are suggestive of local activation and utilization of complement (21). Complement activation by an alternative pathway has been suggested. By analogy and based on the immune complex deposit theory in patients with Dermatitis herpetiformis (22), one could speculate that antibodies found in Pemphigus foliaceus could induce immune complexes which would be transported as soluble substances in the blood circulation. Since kidney function in Pemphigus foliaceus is generally not disturbed, the immune complexes should be less than 19S in size. Probably, for immunological and non immunological reasons, the immune complexes would be deposited at a specific point in the skin. Chemotatic factors could induce the migration of cells.
28O
mainly neutrophils and eosinophils, responsible in part for the elicitation of the lesions. SUMMARY
The presence of conventional autoantibodies in the sera from 28 patients with Pemphigus foliaceus {South American pemphigus) was investigated. Gastric parietal cell antibody was found in six patients (21.4 per cent); and in two of them mitochondrial antibody was also detected. Antibody to smooth muscle was found m one patient. Based on the above results, the role of autoimmunity in Pemphigus foliaceus was discussed. Nuclear and rheumatoid factors were not detected, and antibodies against glomerular components, salivary duct and thyreoglobulin were not found. ACKNOWLEDGEMENTS We are indebted to Dr. Clovis Jose Lage, Director of Pemphigus Hospital, for selecting the patients, to Dr. Jose Daniel Lopes for the immunofluorescent studies and discussions, and Lucia Musenek for technical aid. REFERENCES 1. Ablin, R. J. (1969) : Immunopathologic studies of experimental pemphiguslike auto-antibodies and bullous-like lesions. J. invest. Derm. 53, 463. 2. Anderson, P. & Hale, W. L. (1973) : Immunopathology of human antibodies on monkey esophagus. In Beutner, E. H. et al. (eds.) : Immunopathology of the skin, pp. 271-286. Dowden, Hutchinson & Ross, Inc., Pennsylvania. 3. Arbesman, C. E., Wypych, J. I., Reisman, R. E. & Beutner, E. H. (1974): IgE levels in sera of patients with pemphigus or bullous pemphigoid. Arch. Derm, no, 378. 4. Baba, T., Sonozaki, H., Seki, K., Uchiyama, M., Ikesawa, Y. & Torisu, M. (1976): An eosinophil chemotatic factor present in blister fluids of bullous pemphigoid patients. J. Immunol. 116, 112. 5. Bertram, U. & Halberg, P. (1964) : A specific antibody against epithelium of salivary ducts in sera from patients with Sjogren's syndrome. Acta allergol. ig, 458. 7. Boyden, S. V. (1951): The adsorption of protein on erythrocytes treated
28l tannic acid and subsequent hemagglutination by antiproteinsera. J. exp. Med. ^3, 107. 8. Bystrin, J. C , Abel, E. & De Feo, C. (1974): Pemphigus foliaceus—subcorneal intercellular antibodies of unique specificity. Arch. Derm, no, 857. 9. Castro, R. M. & Proenga, N. (1972): South American pemphigus foliaceus. The Glaxo Volume 36, 17. 10. Chorzelski, T. P., Jablonska, S. & Blaszczyk, M. (1968) : Immunopathologic investigation in the Senear-Usher syndrome. Coexistence of pemphigus with lupus erythematosus. Brit. J. Derm. 80, 211. 11. Chorzelski, T. P., Jablonska, S. & Beutner, E. H. (1973): Clinical significance of pemphigus antibodies. In Beutner, E. H., Chorzelski, T. P., Bean, S. F. & Jordon, R. E. (eds.) : Immunopathology of the skin-labeled antibody studies, pp. 25-43. Dowden, Hutchinson & Ross, Inc., Pennsylvania. 12. Dick, H. M., Fraser, N. G. & Murray, D. (1969): Immunofluorescent antibody studies in dermatitis herpetiformis. Brit. J. Derm. 81, 692. 13. Dobmeier, L. J., Sams, W. M., Jr. & Beutner, E. H. (1971) : Intercellular antibodies in a patient without clinical pemphigus. Ann. N.Y. Acad. Sci. 177. 218. 14. Doniach, D., Roitt, I. M., Walker, J. G. & Sherlock, S. (1966): Tissue antibodies in primary biliary cirrhosis, active chronic (lupoid) hepatitis, cryptogenic cirrhosis and other liver diseases and their clinical implications. Clin. exp. Immunol. / , 237. 15. Fellner, M. J. & Prutkin, L. (1970) : Morbilliform eruption caused by penicillin. J. invest. Derm. ss> 39o. 16. Feltkamp, T. E. & van Rossum, A. L. (1968) : Antibodies to salivary duct cells, and other autoantibodies in patients with Sjogren's syndrome and other idiopathic autoimmune diseases. Clin. exp. Immunol. 3, 1. 17. Holubar, J., Chorzelski, T. P., Gauto, M. & Beutner, E. H. (1973) : Studies in immunodermatology. III. Induction of intraepithelial lesions in monkeys by intramucosal injections of pemphigus antibodies. Int. Arch. Allergy 44, 631. 18. Johnson, G. D., Holborow, E. J. & Glynn, L. E. (1965) : Antibody to smooth muscle in patients with liver disease. Lancet ii: 878. 19. Jordon, R. E., Muller, S. A., Hale, W. L. & Beutner, E. H. (1969) : Bullous pemphigoid associated with systemic lupus erythematosus. Arch. Derm, pp, 1720. Jordon, R. E., Sams, W. M., Jr. & Beutner, E. H. (1969): Complement immunofluorescent staining in bullous pemphigoid. J. Lab. clin. Med. 74, 548. 21. Katz, S. J., Inderbitzin, T. M. & Halprin, K. M. (1970) : Serum complement (C3) levels in patients with autoimmune bullous skin diseases. Arch. Derm. 102, 368. 22. Meer, J. B. van der (1972): Dermatitis herpetiformis: a specific (immunopathological?) entity. Battelie and Terp., Publ., W. V. Leiden.
282 23- Roitt, I. M. & Doniach (1969): WHO-Manual for auto-immune serology. WHO, Geneva. 24. Sams, y . M., Jr. & Jordon, R. E. (1971): Correlation of pemphigoid and pemphigus antibody titer with activity of disease. Brit. J. Derm. 84, 7. 25. Sams, W. M. & Jordon, R. E. (1971): Pemphigus antibodies: their role in disease. J. invest. Derm. 56, 474. 26. Seah, P. P., Fry, L., Hoffbrand, A. V. & Holborow, E. J. (1971) : Tissue antibodies in dermatitis herpetiformis and adult coeliac disease. Lancet i, 83427. Whittingham, S., MacKay, I. R. & Irwin, J. (1966) : Autoimmune hepatitis. Lancet i, 1333. Authors' address:
Dr. Ernesto Mendes, M.D. Secgao de Alergia - sala 7109 Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo Caixa postal 8091 oiooo — Sao Paulo Brazil
