Letters to the Editor
domain antibodies may not correlate with disease severity in anti-laminin gamma-1 pemphigoid.
CONFLICT OF INTEREST:
There is no conflict of interest.
Shin-ichi ANSAI,1 Shiho HASHIZUME,1 Seiji KAWANA,2 Chiharu TATEISHI,3 Hiroshi KOGA,4 Takashi HASHIMOTO4 1
Division of Dermatology, Nippon Medical School Musashi Kosugi-Hospital, Kawasaki, 2Department of Dermatology, Nippon Medical School, Tokyo, 3 Department of Dermatology, Osaka City University School of Medicine, Osaka, and 4Department of Dermatology, Kurume University School of Medicine, and Kurume Univerisity Institute of Cutaneous Cell Biology, Kurume, Japan
REFERENCES 1 Chen KR, Shimizu S, Miyakawa S, Ishiko A, Shimizu H, Hashimoto T. Coexistence of psoriasis and an unusual IgG-mediated subepidermal bullous dermatosis: identification of a novel 200-kDa lower lamina lucida target antigen. Br J Dermatol 1995; 134: 340–346. 2 Zillikens D, Kawahara Y, Ishiko A et al. A novel subepidermal blistering disease with autoantibodies to a 200-kDa antigen of the basement membrane zone. J Invest Dermatol 1996; 106: 1333–1338. 3 Dainichi T, Kurono S, Ohyama B et al. Anti-laminin gamma-1 pemphigoid. Proc Natl Acad Sci U S A 2009; 106: 2800–2805. 4 Chan LS, Vanderlugt CJ, Hashimoto T et al. Epitope spreading: lessons from autoimmune skin diseases. J Invest Dermatol 1998; 110: 103–109. 5 Di Zenzo G, Thoma-Uszynski S, Calabresi V et al. Demonstration of epitope-spreading phenomena in bullous pemphigoid: results of a prospective multicenter study. J Invest Dermatol 2011; 131: 2271–2280.
doi: 10.1111/1346-8138.12625
Pustular psoriasis occurring after total colectomy for ulcerative colitis and relieved by administration of infliximab Dear Editor, Association between pustular psoriasis and ulcerative colitis treated without antagonists of TNFa is very rare.1 We report here a case of pustular psoriasis that occurred after total colectomy for ulcerative colitis and the results of treatment with infliximab. A 20-year-old female visited our hospital in June 2012 because of skin eruptions of more than 1 year’s duration (Fig. 1a). She had undergone total colectomy for intractable ulcerative colitis in November 2010. Ileorectostomy and ileostomy were performed laparoscopically and the transient stoma was closed 4 months later. Rectal mucosa was totally removed and no residual lesion was found on the rectum. Systemic administration of several drugs for bowel disease, including corticosteroid, azathioprine and tacrolimus, had ceased in January 2011. One month later, pustular eruptions appeared on her face and extremities. She had no history of psoriasis but had pustules and diffuse erythema on her trunk and extremities. Biopsies revealed subcorneal pustules, spongiform pustules and infiltration of neutrophils in the dermis (Fig. 1b and c). Abnormal laboratory results included 3.6 mg/dL CRP and 79% neutrophils in a total of 6940/mm3 white blood cells. Differential diagnosis included pustulosis associated with ulcerative colitis but, in such cases, pustules surrounded by an erythematous halo are scattered and no spongiform pustules are observed.2 A diagnosis was made of pustular psoriasis. Oral prednisolone (30 mg/day for 40 days) was administered with benefit but tapering was problematic. Administration of infliximab (200 mg, 5 mg/kg) was initiated
(a)
(c) (b)
Figure 1. (a) Many scattered and aggregated pustules, surrounded by dark red erythema on the left thigh; (b) biopsy specimen revealing subcorneal pustules; and (c) spongiosis around a pustule. because of potential future pregnancy. Eruptions disappeared and did not recur during 1.5 years of subsequent bimonthly treatment with infliximab. We know of only one published case of pustular psoriasis associated with ulcerative colitis1. In that case, a 38-year-old female, suffering from ulcerative colitis for 5 years, had developed pustular psoriasis during tapering of corticosteroid. In our case, although periods of pustular psoriasis and ulcerative
Correspondence: Sakuhei Fujiwara, M.D., Department of Dermatology, Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hasama-machi, Yufu, Oita 879-5593, Japan. Email: [email protected]
© 2014 Japanese Dermatological Association
1033
Letters to the Editor
colitis did not overlap, pustular eruption occurred several months after colectomy and 1 month after cessation of drugs, including corticosteroid, azathioprine and tacrolimus, for ulcerative colitis. This history strongly suggests that the two diseases were associated. Our patient was treated for ulcerative colitis only once with antagonists of TNFa, 1 month before colectomy. According to a review by eHealthMe, among 10 917 people with ulcerative colitis, 7 had pustular psoriasis and females, younger than 30 years old, were preponderant. Mutation of the IL-36 receptor antagonist gene (IL-36RN) has been reported in pustular psoriasis without psoriasis vulgaris, and mutation or variants of the caspase recruitment domain family, member 14, gene (CARD14) were reported in pustular psoriasis with psoriasis vulgaris. Upon informed consent, we extracted genomic DNA from our patient’s peripheral blood and amplified exons of IL-36RN and exons 2, 3 and 4 of CARD14, including exon-intron boundaries, by the polymerase chain reaction, as described previously.3,4 Sequencing of the products revealed no mutations in either gene. Association between psoriasis and ulcerative colitis is very rare but a common pathway contributing to both diseases might exist. IL23R and IL12B might possibly be mutated genes in such a pathway.5
CONFLICT OF INTEREST:
None declared.
Kanami SAITO,1 Akiko ITO,1 Kazushi ISHIKAWA,1 Hiromitsu SHIMADA,1 Naoko TAKEO,1 Yutaka HATANO,1 Kazumitsu SUGIURA,2 Masashi AKIYAMA,2 Masafumi INOMATA,3 Seigo KITANO,3 Sakuhei FUJIWARA1 Departments of 1Dermatology, 3Gastroenterological Surgery, Faculty of Medicine, Oita University, Yufu, Oita, 2Department of Dermatology, Nagoya University Graduate School of Medicine, Nagoya, Japan doi: 10.1111/1346-8138.12629
REFERENCES 1 Shimizu A, Kamada N, Matsue H. Generalized pustular psoriasis associated with ulcerative colitis. J Clin Exp Dermatol Res 2013; 4(4): doi:10.4172/2155-9554.1000192 zquez J, Almagro M, Del Pozo J, Fonseca E. Neutrophilic pustulo2 Va sis and ulcerative colitis. J Eur Acad Dermatol Venereol 2003; 17(1): 77–79. 3 Sugiura K, Takemoto A, Yamaguchi M, et al. The majority of generalized pustular psoriasis without psoriasis vulgaris is caused by deficiency of interleukin-36 receptor antagonist. J Invest Dermatol 2013; 133: 2514–2521. 4 Sugiura K, Muto M, Akiyama M. CARD14 c.526G>C (p.Asp176His) is a significant risk factor for generalized pustular psoriasis with psoriasis vulgaris in the Japanese cohort. J Invest Dermatol 2014; 134: 1755–1757. 5 Capon F, Di Meglio P, Szaub J, et al. Sequence variants in the genes for the interleukin-23 receptor (IL23R) and its ligand (IL12B) confer protection against psoriasis. Hum Genet 2007; 122(2): 201–206.
Antitumor necrosis factor alpha inhibitor-induced dermatomyositis and interstitial lung disease with anti-PL12 autoantibody: Signs of antisynthetase syndrome Dear Editor, Cases of antitumor necrosis factor-a (anti-TNF-a)-induced dermatomyositis (DM)/polymyositis (PM) have been described.1 We report a case of anti-TNF-a-induced DM and interstitial lung disease (ILD) with anti-PL12 autoantibody as signs of antisynthetase syndrome (ASS). A 41-year-old woman was referred to us to apply an antiTNF-a agent for methotrexate-resistant rheumatoid arthritis (RA). Before injection of adalimumab, chest X-ray had not detected signs of ILD and anti-cyclic citrullinated peptide antibody had been within normal range (2.4 U/mL; normal,
domain antibodies may not correlate with disease severity in anti-laminin gamma-1 pemphigoid.
CONFLICT OF INTEREST:
There is no conflict of interest.
Shin-ichi ANSAI,1 Shiho HASHIZUME,1 Seiji KAWANA,2 Chiharu TATEISHI,3 Hiroshi KOGA,4 Takashi HASHIMOTO4 1
Division of Dermatology, Nippon Medical School Musashi Kosugi-Hospital, Kawasaki, 2Department of Dermatology, Nippon Medical School, Tokyo, 3 Department of Dermatology, Osaka City University School of Medicine, Osaka, and 4Department of Dermatology, Kurume University School of Medicine, and Kurume Univerisity Institute of Cutaneous Cell Biology, Kurume, Japan
REFERENCES 1 Chen KR, Shimizu S, Miyakawa S, Ishiko A, Shimizu H, Hashimoto T. Coexistence of psoriasis and an unusual IgG-mediated subepidermal bullous dermatosis: identification of a novel 200-kDa lower lamina lucida target antigen. Br J Dermatol 1995; 134: 340–346. 2 Zillikens D, Kawahara Y, Ishiko A et al. A novel subepidermal blistering disease with autoantibodies to a 200-kDa antigen of the basement membrane zone. J Invest Dermatol 1996; 106: 1333–1338. 3 Dainichi T, Kurono S, Ohyama B et al. Anti-laminin gamma-1 pemphigoid. Proc Natl Acad Sci U S A 2009; 106: 2800–2805. 4 Chan LS, Vanderlugt CJ, Hashimoto T et al. Epitope spreading: lessons from autoimmune skin diseases. J Invest Dermatol 1998; 110: 103–109. 5 Di Zenzo G, Thoma-Uszynski S, Calabresi V et al. Demonstration of epitope-spreading phenomena in bullous pemphigoid: results of a prospective multicenter study. J Invest Dermatol 2011; 131: 2271–2280.
doi: 10.1111/1346-8138.12625
Pustular psoriasis occurring after total colectomy for ulcerative colitis and relieved by administration of infliximab Dear Editor, Association between pustular psoriasis and ulcerative colitis treated without antagonists of TNFa is very rare.1 We report here a case of pustular psoriasis that occurred after total colectomy for ulcerative colitis and the results of treatment with infliximab. A 20-year-old female visited our hospital in June 2012 because of skin eruptions of more than 1 year’s duration (Fig. 1a). She had undergone total colectomy for intractable ulcerative colitis in November 2010. Ileorectostomy and ileostomy were performed laparoscopically and the transient stoma was closed 4 months later. Rectal mucosa was totally removed and no residual lesion was found on the rectum. Systemic administration of several drugs for bowel disease, including corticosteroid, azathioprine and tacrolimus, had ceased in January 2011. One month later, pustular eruptions appeared on her face and extremities. She had no history of psoriasis but had pustules and diffuse erythema on her trunk and extremities. Biopsies revealed subcorneal pustules, spongiform pustules and infiltration of neutrophils in the dermis (Fig. 1b and c). Abnormal laboratory results included 3.6 mg/dL CRP and 79% neutrophils in a total of 6940/mm3 white blood cells. Differential diagnosis included pustulosis associated with ulcerative colitis but, in such cases, pustules surrounded by an erythematous halo are scattered and no spongiform pustules are observed.2 A diagnosis was made of pustular psoriasis. Oral prednisolone (30 mg/day for 40 days) was administered with benefit but tapering was problematic. Administration of infliximab (200 mg, 5 mg/kg) was initiated
(a)
(c) (b)
Figure 1. (a) Many scattered and aggregated pustules, surrounded by dark red erythema on the left thigh; (b) biopsy specimen revealing subcorneal pustules; and (c) spongiosis around a pustule. because of potential future pregnancy. Eruptions disappeared and did not recur during 1.5 years of subsequent bimonthly treatment with infliximab. We know of only one published case of pustular psoriasis associated with ulcerative colitis1. In that case, a 38-year-old female, suffering from ulcerative colitis for 5 years, had developed pustular psoriasis during tapering of corticosteroid. In our case, although periods of pustular psoriasis and ulcerative
Correspondence: Sakuhei Fujiwara, M.D., Department of Dermatology, Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hasama-machi, Yufu, Oita 879-5593, Japan. Email: [email protected]
© 2014 Japanese Dermatological Association
1033
Letters to the Editor
colitis did not overlap, pustular eruption occurred several months after colectomy and 1 month after cessation of drugs, including corticosteroid, azathioprine and tacrolimus, for ulcerative colitis. This history strongly suggests that the two diseases were associated. Our patient was treated for ulcerative colitis only once with antagonists of TNFa, 1 month before colectomy. According to a review by eHealthMe, among 10 917 people with ulcerative colitis, 7 had pustular psoriasis and females, younger than 30 years old, were preponderant. Mutation of the IL-36 receptor antagonist gene (IL-36RN) has been reported in pustular psoriasis without psoriasis vulgaris, and mutation or variants of the caspase recruitment domain family, member 14, gene (CARD14) were reported in pustular psoriasis with psoriasis vulgaris. Upon informed consent, we extracted genomic DNA from our patient’s peripheral blood and amplified exons of IL-36RN and exons 2, 3 and 4 of CARD14, including exon-intron boundaries, by the polymerase chain reaction, as described previously.3,4 Sequencing of the products revealed no mutations in either gene. Association between psoriasis and ulcerative colitis is very rare but a common pathway contributing to both diseases might exist. IL23R and IL12B might possibly be mutated genes in such a pathway.5
CONFLICT OF INTEREST:
None declared.
Kanami SAITO,1 Akiko ITO,1 Kazushi ISHIKAWA,1 Hiromitsu SHIMADA,1 Naoko TAKEO,1 Yutaka HATANO,1 Kazumitsu SUGIURA,2 Masashi AKIYAMA,2 Masafumi INOMATA,3 Seigo KITANO,3 Sakuhei FUJIWARA1 Departments of 1Dermatology, 3Gastroenterological Surgery, Faculty of Medicine, Oita University, Yufu, Oita, 2Department of Dermatology, Nagoya University Graduate School of Medicine, Nagoya, Japan doi: 10.1111/1346-8138.12629
REFERENCES 1 Shimizu A, Kamada N, Matsue H. Generalized pustular psoriasis associated with ulcerative colitis. J Clin Exp Dermatol Res 2013; 4(4): doi:10.4172/2155-9554.1000192 zquez J, Almagro M, Del Pozo J, Fonseca E. Neutrophilic pustulo2 Va sis and ulcerative colitis. J Eur Acad Dermatol Venereol 2003; 17(1): 77–79. 3 Sugiura K, Takemoto A, Yamaguchi M, et al. The majority of generalized pustular psoriasis without psoriasis vulgaris is caused by deficiency of interleukin-36 receptor antagonist. J Invest Dermatol 2013; 133: 2514–2521. 4 Sugiura K, Muto M, Akiyama M. CARD14 c.526G>C (p.Asp176His) is a significant risk factor for generalized pustular psoriasis with psoriasis vulgaris in the Japanese cohort. J Invest Dermatol 2014; 134: 1755–1757. 5 Capon F, Di Meglio P, Szaub J, et al. Sequence variants in the genes for the interleukin-23 receptor (IL23R) and its ligand (IL12B) confer protection against psoriasis. Hum Genet 2007; 122(2): 201–206.
Antitumor necrosis factor alpha inhibitor-induced dermatomyositis and interstitial lung disease with anti-PL12 autoantibody: Signs of antisynthetase syndrome Dear Editor, Cases of antitumor necrosis factor-a (anti-TNF-a)-induced dermatomyositis (DM)/polymyositis (PM) have been described.1 We report a case of anti-TNF-a-induced DM and interstitial lung disease (ILD) with anti-PL12 autoantibody as signs of antisynthetase syndrome (ASS). A 41-year-old woman was referred to us to apply an antiTNF-a agent for methotrexate-resistant rheumatoid arthritis (RA). Before injection of adalimumab, chest X-ray had not detected signs of ILD and anti-cyclic citrullinated peptide antibody had been within normal range (2.4 U/mL; normal,
