Case Report/Case Series |

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

Tanya Sezin, MSc1,2; Ella Egozi, MD1,2; Wissam Hillou, MD1,2; Emily Avitan-Hersh, MD1,2; Reuven Bergman, MD1,2
[+] Author Affiliations
1Department of Dermatology, Rambam Health Care Campus, Haifa, Israel
2Bruce and Ruth Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel
JAMA Dermatol. 2013;149(7):858-862. doi:10.1001/jamadermatol.2013.741.
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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 circulating autoantibodies against BP180 and/or BP230 antigens. A case of anti–laminin-332 mucous membrane pemphigoid (MMP) that developed shortly after a diphtheria tetanus vaccination is described, with a review of the literature on postvaccination BP.

Observations  A 29-year-old man developed an acute eruption of oral and cutaneous blisters and erosions 2 days after receiving a diphtheria tetanus vaccination. The histopathological, immunohistochemical, immunofluorescent, ELISA, and immunoblotting assay results were compatible with anti–laminin-332 MMP. The serum autoantibodies reacted with the α3 and β3 subunits of laminin-332. The disease was controlled by administering a combination of glucocorticosteroids and dapsone.

Conclusions and Relevance  The development of acute MMP shortly after a diphtheria tetanus vaccination may have been serendipitous, a result of a nonspecific bystander activation of the immune system, or due to structural mimicry between domains of the toxoid molecule and a subunit of laminin-332.

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Figure 1.
Tense Blisters, Flaccid Blisters, and Erosions

A, Nose; B, groin; C, oral mucosa.

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Figure 2.
Analysis of a Skin Blister Biopsy Specimen

A, Specimen showing a subepidermal blister with complete epidermal-dermal separation (hematoxylin-eosin [H&E], original magnification ×100). B, Scant mononuclear infiltrate in the dermal floor of the blister (H&E, original magnification ×200). C, Immunohistochemical staining demonstrating collagen IV at the dermal floor (original magnification ×100). D, Human 1M sodium chloride–split skin indirect immunofluorescence showing linear deposits of IgG at the dermal floor (original magnification ×400).

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Figure 3.
Immunoblotting With Purified Human Laminin-332 as an Antigenic Substrate

Immunoblotting showing 130-kDa and 145-kDa bands (arrows), corresponding to β3 and α3 subunits, respectively, of human laminin-332 in serum samples from a patient (A) and a healthy control (B). M indicates marker.

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