Clinical and Experimental Dermatology (1981) 6, 477-483.

Correlation of circulating intercellular antibodytitres in pemphigus with disease activity

SANDRA N.CRESWELL*, MARTIN M.BLACK, BALBIR BHOGALAND MAUREEN V.H.SKEETHt

Department of Experimental Pathology, Institute of Dermatology, Lisle Street,Leicester Square, London WC2H jBJf

Accepted for publication 24 September 1980

Summary

Twenty-one cases of pemphigus were studied regarding the correlation of disease activity andtitre of circulating intercellular antibodies. The correlation was good in six, poor in seven,and fairly good in eight.

There was a tendency for antibody titres to parallel disease activity, but in general wefound it of little value in clinical management as a guide to therapy or predicting clinicalrelapses.

Pemphigus was the first bullous dermatosis in which immunofiuorescence studies showedspecific circulating antibodies that proved to be of diagnostic significance (Beautner & Jordon,1964; Beutner et al, 1965; Chorzelski, von Weiss & Lever, 1966b). These are IgG antibodiesdirected against the intercellular areas of stratified epithelia of skin and mucous membranes.Their pathogenic significance is now well established both from passive transfers studies inanimals (Chorzelski, Beutner & Jarzaboek, 1970; Sams & Jordon, 1971 ajb; Wood, Beutner &Chorzelski, 1972; Beutner & Chorzelski, 1973; Holubar et al, 1973), and induction of acantho-lysis in skin explants grown in pemphigus antibody containing sera (Bellose & Leone, 1956;Michel & Ko, 1974; Schiltz & Michel, I976a,b; Deng et al, 1977)-

Over the past few years there have been several papers reporting studies in pemphiguspatients with regard to the correlation between serum antibody titres and disease activity(Beutner et al, 1965; Chorzelski, Jablonska & Blaszczyk, 1966a; Chorzelski et al, 1966b;

* Present address: Royal Victoria Hospital, Grosvenor Road, Belfast BT12 6BB.1 Queen Elizabeth Hospital, Bridgetown, Barbados.

O3O7-6928/8i/O9OO-O477$O2.o0 lO 1981 Blackwell Scientific Publications 477

478 S.N.Cresswell et al.

Beutner, 1967; Anderson et al., 1970; Sams & Jordon, 1971; O'Loughlin, Goldman & Provost,1978; Weissmann et al, 1978; Chorzelski, Beutner & Jablonska, 1979; Judd & Lever, 1979;Judd & Mescon, 1979; Fitzpatrick & Newcomer, 1980).

At the Institute of Dermatology, London, we have had the opportunity to study serialtitres of intercellular antibodies in a number of pemphigus patients (over the past 8 years),and our experience is presented in this paper.

Materials and method

Twenty-two pemphigus patients (ten male, twelve female), aged between 17 and 64 years(mean 40 years), were followed over periods ranging from 28 to 420 weeks (mean 207). Sincepatients with pemphigus are referred from many other countries to the Institute of Derma-tology, 50% of our patients were of Asian or Middle Eastern origin. The patients of non-Caucasian origin were younger than the Caucasian patients in the study (average age 30 years).Eleven had pemphigus vulgaris, nine had pemphigus foiiaceus, one had pemphigus erythema-tosus and one had pemphigus vegetans.

In all the cases the diagnosis had been confirmed histologically and by direct immuno-fluorescence. One patient with pemphigus vulgaris had no circulating antibody during theperiod of follow-up (270 weeks) and so was excluded from the study.

The level of disease activity was graded as follows: mild, a few scattered lesions (-t-);moderate, several lesions (+ +); severe, extensive involvement of skin, mucous membranesor both (-1- + -f-). Serum was taken before treatment was started and approximately every 2months thereafter, and was examined by the standard method of indirect immunofluorescence(Beutner & Nisengard, 1973). Normal human skin was used as substrate, and commerciallyobtained fluorocein labelled rabbit anti-human IgG (F/P ratio 2:e M, diluted i :6o) was used(Wellcome Research Laboratories).

A total of 327 serum samples were examined. The number of sera examined per patientvaried between six and thirty-eight (mean flfteen). When analysing the data, only a two-foldchange in titre was considered significant.

Treatment varied between patients, but prednisone, gold, azothioprine, cyclophosphamideand topical steroids were all used in various doses and combinations. In general, the dosageof these agents was altered according to the clinical state and not solely on the antibody titreresults.

Graphs were constructed of disease activity versus antibody titre.

Results

Of the twenty-one patients studied, the correlation between antibody titre and disease activitywas good in six, fairly good in eight, but poor in seven. In the *fairly good' correlation group,two patients had a good correlation initially, but later it became poor. Examples of represen-tative patients are shown in Figs 1-3.

Circulating intercellular antibody titres 479

51 years, pemphigus vulgat is

2 5 0 1

Skin lesions

Mouth lesions

I M F r i t res

-1 r

0 20 40" 60 80 100 120 140 160 180Time in weeks

Figure i. Correlation of circulating intercellular antibody titre with disease activity—good.

In A.R. (see Fig. i) a relatively high dose of steroids failed to control disease activity, butthis was later achieved by gradually increasing the dose of azothioprine.

Twenty out of twenty-one (95%) patients had intercellular (IC) antibodies detectablewhen initially tested.

During the period of study, the IC antibody disappeared at some stage in nineteen/twenty-one (90%) patients; however, it was only possible to predict a clinical relapse in three patientsfrom a rise in antibody titre prior to an exacerbation.

A.K.S 23 years, pemphigus vulqans

Skm lesionsIMF titresMouth lesions

0

0 20 40 60 80 100 120 140 160 180 200 220 240 260 280 300Time in weeks

Figure 2. Correlation of circulating intercellular antibody titre with disease activity—initiallygood, then poor.

48o S.N.Cresswell el al.

M.W. J 3l years, pemphigus erythemotosis

0 20 40 60 80 100 120 140 160 160 200

Time in weeks

Figure 3. Correlation of circulating intercellular antibody titre with disease activity—poor.

Furthermore, a clinical relapse occurred in six/twenty-one patients without an associatedrise in antibody titre. However, in five out of these six patients the relapse only involvedthe oral mucosa.

Conversely, a rise in antibody titre occurred without relapse in five/twenty-one (23",,)patients (Table i). In one further patient the titre remained elevated in spite of clinicalremission.

Table i. Changes in clinical activity and intercellular antibody titre

Clinical relapse withoutincreased titre

Increased titre withoutclinical relapse

5 (mouth lesions)I (skin lesion)

6/21

5/21

The highest titre found was 1:1280, which occurred in five patients, four of whom hadsevere disease (-1- + -)-) and one moderate disease (+ +). Ofthe two patients who had milddisease (+ ) the highest titres were i :i6o and 11640. Although there was an overlap the highesttitres tended to be found in the most severely afFected patients.

Circulating intercellular antibody titres 481

Discussion

In pemphigus, intercellular antibodies can in most cases be detected in the serum by theindirect immunofluorescence technique at some stage of the disease process.

There has been continuing controversy as to whether or not the antibody titre correlateswith disease activity. The majority of workers have found a positive correlation between anti-body titre and disease severity. Chorzelski et al. (1966b) only performed single antibodydeterminations while Sams & Jordon (1971a) only examined three patients with pemphigus.Weissmann et al. (1978) found a positive correlation between steroid induced clinical improve-ment and fall in antibody titre and conversely a rise was associated with exacerbation. Theyalso found, as did ourselves, that those with most severe disease had the highest titres.

Judd & Lever (1979), in a series of sixty-three patients, did not find indirect immuno-fiuorescence reliable for evaluating disease activity. In patients with lesions and receivingtreatment 41",, showed a negative titre, whereas in patients free of lesions 45";̂ showedpositive titres. Similarly, Anderson et al. (1970) found no positive correlation and concludedthat the immunofiuorescence technique is not sufficiently sensitive to be used to gaugetherapy. The most important point to elucidate is whether or not serial titres are useful inpredicting relapses in the continuous follow-up of pemphigus patients who usually need to bemaintained on potentially harmful drugs for prolonged periods.

O'Loughlin et al. (1978), in a 6-year study of seventeen pemphigus patients, found thatapproximately one-third had a prolonged clinical and immunological remission after successfultherapy and they suggest that maintenance treatment may not be required to preserve theremission. They found monitoring serum antibody titres of value in regulating therapy. In arecent paper, Fitzpatrick & Newcomer (1980) found a statistically significant relationshipbetween titre and disease activity but did not find serial titres reliable as a guide to treatment orprognosis in pemphigus.

Our data agrees with that of Fitzpatrick & Newcomer (19B0) in that, although fourteen/twenty-two (63",,) of patients had a good or fairly good correlation between disease activityand antibody titre, in only three (14%) cases was it possible to predict a relapse from a previousrise in antibody titre.

Fluctuations in antibody titre without a similar change in level of disease activity occurredin five (23'/,,) cases, and an exacerbation occurred without a change in antibody titre in six(28",,) cases. Also, the correlation varied during the course of the disease in individualpatients (Fig. 2).

Although there was a tendency for intercellular antibody titre to parallel disease activity,in general we found it of little value in clinical management.

References

ANDERSON, H.J., NEWCOMER, V.D., LANDAU, J . W . & ROSENTHAL, L . H . (1970) Pemphigus and otherdiseases. Results of indirect intercellular immunofluorescence. Archives of Dermatology, io i ,538-546.

BELLOSE, A . G . & LEONE, V. (1956) Richerche sull'influenza esercitata da sieri di sogetti sani o affect,da pemfigo su pele umana normale e pempfigosa coltvata in vitro. Giornale italiano di derntatohgiae sifilografia) 97, 97-109.

482 S.N.Cresswell et al.

BEUTNER, E . H . (1967) Role of autoimmunity in chronic bullous diseases. Dermatology Digest, 6, 55-63.BEUTNER, E.H. & CHORZELSKI, T . P . (1973) Experimental studies on autosensitization in bullous diseases

on transfer of pemphigus. In: Immunopathology of the Skin: Labelled Antibody Studies (Ed. byE.H.Beutner, T.P.Chorzelski, S.F.Bean and R.E.Jordon), pp. 330. Dowden, Hutchinson and Ross,Stroudsburg, Pennsylvania.

BEUTNER, E.H. & JORDON, R . E . (1964) Demonstration of skin antibodies in sera of pemphigus vulgarispatients by indirect immunofluorescent staining. Proceedings of the Society for Experimental Biologyand Medicine, 117, 505-510.

BEUTNER, E.H. & NISENGARD, R . J . (1973) Defined immunofluorescence in clinical immunopathology.In: Immunopathology of the Skin: Labelled Antibody Studies (Ed. by E.H.Beutner, T.P.Chorzelski,S.F.Bean and R.E.Jordon), pp. 197-247. Dowden, Hutchinson and Ross, Stroudsburg,Pennsvlyvania.

BEUTNER, E.H., LEVER, W.F., WITEGSKY, E . , JORDON, R.E. & CHERTOCK, B . (1965) Autoantibodies in

pemphigus vulgaris—response to an intercellular substance of epidermis. Journal of the AmericanMedical Association, 192, 682-688.

CHORZELSKI, T.P., JABLONSKA, S. & BLASZCZYK, M . (1966a) Autoantibodies in pemphigus. Acta dermato-venereologica {Stockholm), 46, SuppI., 26-31.

CHORZELSKI, T.P., VON WEISS, J . F . & LEVER, W . F . (1966b) Clinical signiflcance of autoantibodies inpemphigus. Archives of Dermatology, 93, 570-576.

CHORZELSKI, T.P. BEUTNER, E.H. & JARZABEK, M . (1970) Passive transfer of pemphigus in experimentalanimals. International Archives of Allergy and Applied Immunology, 39, 106.

CHORZELSKI, T.P., BEUTNER, E.H. & JABLONSKA, S. (1979) Clinical significance of pemphigus auto-antibodies. In: Immunopathology of the Skin: Labelled Antibody Studies (Ed. by E.H.Beutner,T.P.Chorzelski, S.F.Bean and R.E. Jordon), pp. 183-196. Dowden, Hutchinson and Ross, Strouds-burg, Pennsylvania.

DENG, J . - S . , BEUTNER, E.H., SUYU, S. & CHORZELSKI, T.P. {i^'j'j) Pemphigus antibody action on skinexplants. Kinetics of acantholytic changes and stability of antigens in tissue cultures of normalmonkey skin explants. Archives of Dermatology, 113, 923-926.

FITZPATRICK, R.E. & NEWCOMER, V . D . (1980) The correlation of disease activity and antibody titres inpemphigus. Archives of Dermatology., 116, 285-290.

HoLUBAR, K., CHORZELSKI, T.P., GAUTO, M . & BEUTNER, E.H. (1973) Induction of intraepithelial lesionsin monkeys by intramucosal injections of pemphigus antibodies. International Archives of Allergy,44, 631-643.

JtJDD, K.P. & LEVER, W.F. (1979) Correlation of antibodies in skin and serum with disease severity inpemphigus. Archives of Dermatology, 115, 428-432.

JUDD, K.P. & MESCON, H . (1979) Comparison of different epithelial substrates useful for indirectimmunofluorescence testing of sera from patients with active pemphigus. Journal of InvestigativeDermatology, 72, 314-316.

MICHEL, B . & Ko, C.S. (1974) Effect of pemphigus and bullous pemphigoid sera and leukocytes onnormal skin in argon culture: an in vitro model for study of bullous diseases. Journal of InvestigativeDermatology, 62, 541-542.

O'LOUGHLIN, S., GOLDMAN, G . G . & PROVOST, T . T . (1978) Fate of pemphigus antibody followingsuccessful therapy. Archives of Dermatology, 114, ii6g-i']-jz.

SAMS, W.M., JR SE JORDON, R.E. (1971a) Correlation of pemphigoid and pemphigus antibody titres withactivity of disease. British Journal of Dermatology, 84, 7-13.

SAMS, W.M., JR & JORDON, R.E. (1971b) Pemphigus antibodies: their role in iA.\^Qa%c. Journal of Investi-gative Dermatology, 56, 474-479.

SCHiLTZ, J.R. & MICHEL, B . (1976a) Production of epidermal acantholysis in human skin in vitro by theIgG fraction from pemphigus serum. Journal of Investigative Dermatology, 67, 254-260.

ScHiLTZ, J.R. & MICHEL, B . (1976b) Effect of pemphigus autoantibodies on human epidermal cells inargon or suspension culture. Journal of Investigative Dermatology, 66, 279.

Circulating intercellular antibody titres 483

WEISSMANN, V., FEUERMAN, E.J., JOSHUA, H . & HAZAZ, B . (1978) The correlation between antibodytitres in sera of patients with pemphigus vulgaris and their clinical siaie. Journal of InvestigativeDermatology, 71, 197-109.

WOOD, G.W., BEUTNER, E.H. & CHORZELSKI, T.P. (1972) Studies in immunodermatology. 2. Productionof pemphigus-like lesions by intradermal injections of monkey with Brazilian pemphigus foliaceussera. International Archives of Allergy, 42, 556-564.