Aberrant expression and secretion of heat shock protein 90 in patients with bullous pemphigoid.

The cell stress chaperone heat shock protein 90 (Hsp90) has been implicated in inflammatory responses and its inhibition has proven successful in different mouse models of autoimmune diseases, including epidermolysis bullosa acquisita. Here, we investigated expression levels and secretory responses of Hsp90 in patients with bullous pemphigoid (BP), the most common subepidermal autoimmune blistering skin disease. In comparison to healthy controls, the following observations were made: (i) Hsp90 was highly expressed in the skin of BP patients, whereas its serum levels were decreased and inversely associated with IgG autoantibody levels against the NC16A immunodominant region of the BP180 autoantigen, (ii) in contrast, neither aberrant levels of circulating Hsp90 nor any correlation of this protein with serum autoantibodies was found in a control cohort of autoimmune bullous disease patients with pemphigus vulgaris, (iii) Hsp90 was highly expressed in and restrictedly released from peripheral blood mononuclear cells of BP patients, and (iv) Hsp90 was potently induced in and restrictedly secreted from human keratinocyte (HaCaT) cells by BP serum and isolated anti-BP180 NC16A IgG autoantibodies, respectively. Our results reveal an upregulated Hsp90 expression at the site of inflammation and an autoantibody-mediated dysregulation of the intracellular and extracellular distribution of this chaperone in BP patients. These findings suggest that Hsp90 may play a pathophysiological role and represent a novel potential treatment target in BP

Management and treatment outcome of DRESS patients in Europe : An international multicentre retrospective study of 141 cases

BackgroundDrug reaction with eosinophilia and systemic symptoms (DRESS) is a rare but potentially fatal drug hypersensitivity reaction. ObjectiveTo explore treatment approaches across Europe and their impact on the disease course, as well as prognostic factors and culprit drugs. MethodsIn this retrospective European multicentric study, we included patients with probable or certain DRESS (RegiSCAR score >= 4) between January 2016 and December 2020. Independent associations between clinical parameters and the risk of intensive care unit admission and mortality at three months were assessed using a multivariable-adjusted logistic regression model. ResultsA total of 141 patients from 8 tertiary centres were included. Morbilliform exanthem was the most frequent cutaneous manifestation (78.0%). The mean affected body surface area (BSA) was 67%, 42% of the patients presented with erythroderma, and 24.8% had mucosal involvement. Based on systemic involvement, 31.9% of the patients had a severe DRESS. Anticonvulsants (24.1%) and sulphonamides (22.0%) were the most frequent causative agents. In all, 73% of the patients were treated with systemic glucocorticoids, and 25.5% received topical corticosteroids as monotherapy. Few patients received antiviral drugs or anti-IL5. No patients received intravenous immunoglobulins. The overall mortality was 7.1%. Independent predictors of mortality were older age (>= 57.0 years; fully adjusted OR, 9.80; 95% CI, 1.20-79.93; p = 0.033), kidney involvement (fully adjusted OR, 4.70; 95% CI, 1.00-24.12; p = 0.049), and admission in intensive care unit (fully adjusted OR, 8.12; 95% CI, 1.90-34.67; p = 0.005). Relapse of DRESS and delayed autoimmune sequelae occurred in 8.5% and 12.1% of patients, respectively. ConclusionsThis study underlines the need for diagnostic and prognostic scores/markers as well as for prospective clinical trials of drugs with the potential to reduce mortality and complications of DRESS.Peer reviewe

High expression of Hsp90 and its compromised secretion by peripheral blood mononuclear cells of bullous pemphigoid patients.

<p>Hsp90 was detected in whole cell lysates of freshly isolated peripheral blood mononuclear cells (PBMCs) as well as in conditioned medium of PBMC cultures of bullous pemphigoid (BP) patients and healthy controls by enzyme-linked immunosorbent assay. (<b>a</b>) The mean intracellular Hsp90 content of PBMCs was comparatively higher in BP patients. (<b>b</b>) The mean extracellular Hsp90 content of PBMC cultures was comparatively lower in BP patients after 18-hour stimulation with LPS/CpG and TNF-α. Values are mean ± SEM of 5 BP patients and 5 controls. *<i>P</i><0.05.</p

Decreased Hsp90 serum levels and their inverse association with anti-BP180 NC16A autoantibodies in bullous pemphigoid patients.

<p>Circulating Hsp90 was evaluated in serum of bullous pemphigoid (BP) patients and controls (healthy subjects and pemphigus vulgaris [PV] patients) by enzyme-linked immunosorbent assay. (<b>a</b>) Mean serum Hsp90 levels were comparatively lower in BP patients than in healthy controls. (<b>b</b>) Intraindividual serum levels of Hsp90 in BP patients showed an increase after a mean follow-up time of 29 weeks of immunosuppressive treatment. (<b>c</b>) Rising levels of circulating Hsp90 were paralleled by a reduction in individual serum anti-BP180 NC16A IgG autoantibodies. (<b>d</b>) A significant inverse correlation was observed between Hsp90 serum levels and circulating BP autoantibodies. (<b>e</b>) Mean serum Hsp90 levels were comparable between PV patients and corresponding healthy controls. (<b>f</b>) Intraindividual serum levels of Hsp90 in PV patients showed no consistent trend towards an increase or decrease, while serum (<b>g</b>) anti-desmoglein 3 (Dsg3) and (<b>h</b>) 1 (Dsg1) IgG autoantibodies declined after a mean follow-up time of 41 weeks of immunosuppressive treatment. (<b>i, j</b>) No significant correlation between Hsp90 serum levels and circulating PV autoantibodies could be recorded. Values are mean ± SEM of 12 BP patients, 10 PV patients and 12–29 healthy controls. *<i>P</i><0.05, ***<i>P</i><0.001.</p

High expression of Hsp90 in the epidermis of bullous pemphigoid patients.

<p>Hsp90 expression was analyzed in perilesional skin biopsies of bullous pemphigoid (BP) patients and in skin sections of healthy controls by fluorescent immunohistochemistry. (<b>a, b</b>) Representative immunofluorescent and DAPI-counterstained (in blue) skin samples showed a stronger intracellular Hsp90 expression (in green) mainly localized to the epidermal layer of the skin of a BP patient compared to control skin. Magnification: x200. (<b>c, d</b>) Higher magnification (x600) of the respective skin samples. (<b>e</b>) Relative mean epidermal Hsp90 fluorescence intensity by densitometry measurements. Values are mean ± SEM of 6 BP patients and 6 controls. ***<i>P</i><0.001.</p

Potent induction of Hsp90 expression in and its compromised release from keratinocytes by BP serum and isolated anti-BP180 NC16A IgG, respectively.

<p>(<b>a</b>) Human keratinocyte (HaCaT) cells were incubated with normal human serum (NHS) of healthy donors and serum of bullous pemphigoid (BP) patients over 24 hours. With increasing serum concentration a comparatively stronger intracellular upregulation of Hsp90 was induced by BP serum as measured by enzyme-linked immunosorbent assay (ELISA) with HaCaT cell lysates. Values are mean ± SEM of 2 independent experiments of 3 BP patients and 3 controls. *<i>P</i><0.05. (<b>b</b>) This finding was not dependent on the presence of BP autoantibodies, as a 24-hour stimulation of HaCaT cells with total BP IgG or affinity-purified anti-BP180 NC16A IgG from a BP patient failed to reproduce such effect when compared with NHS IgG from a healthy donor as measured by ELISA with HaCaT cell lysates. Values are mean ± SEM of 4 independent experiments. (<b>c</b>) Total BP IgG or affinity-purified anti-BP180 NC16A IgG from a BP patient, but not BP180 NC16A-depleted IgG, significantly inhibited the secretion of Hsp90 compared to NHS IgG from a healthy donor as measured by ELISA with conditioned medium of 24-hour stimulated HaCaT cells. Values are mean ± SEM of 4 independent experiments. *<i>P</i><0.05, ***<i>P</i><0.001.</p

No contribution of TGF-α, protein phosphatase 5 or protein kinase A to decreased levels of secreted Hsp90.

<p>Expression of (<b>a</b>) TGF-α, (<b>b</b>) protein phosphatase 5 (PP5) and (<b>c</b>) protein kinase A (PKA) was analyzed in serum (TGF-α) and peripheral blood mononuclear cells (PBMC) lysates (PP5 and PKA) of bullous pemphigoid (BP) patients and healthy controls by enzyme-linked immunosorbent assay and western blotting, respectively, and revealed no significant difference between both study groups. (<b>d</b>) Mean PP5 and PKA concentrations were expressed relative to the β-Actin level using densitometry measurements of immunoblots. Values are mean ± SEM of 3–9 BP patients and 3–6 controls.</p

Management of Adult Patients With Drug Reaction With Eosinophilia and Systemic Symptoms: A Delphi-Based International Consensus.

IMPORTANCE Drug reaction with eosinophilia and systemic symptoms (DRESS) is a rare but potentially fatal drug hypersensitivity reaction. To our knowledge, there is no international consensus on its severity assessment and treatment. OBJECTIVE To reach an international, Delphi-based multinational expert consensus on the diagnostic workup, severity assessment, and treatment of patients with DRESS. DESIGN, SETTING, AND PARTICIPANTS The Delphi method was used to assess 100 statements related to baseline workup, evaluation of severity, acute phase, and postacute management of DRESS. Fifty-seven international experts in DRESS were invited, and 54 participated in the survey, which took place from July to September 2022. MAIN OUTCOMES/MEASURES The degree of agreement was calculated with the RAND-UCLA Appropriateness Method. Consensus was defined as a statement with a median appropriateness value of 7 or higher (appropriate) and a disagreement index of lower than 1. RESULTS In the first Delphi round, consensus was reached on 82 statements. Thirteen statements were revised and assessed in a second round. A consensus was reached for 93 statements overall. The experts agreed on a set of basic diagnostic workup procedures as well as severity- and organ-specific further investigations. They reached a consensus on severity assessment (mild, moderate, and severe) based on the extent of liver, kidney, and blood involvement and the damage of other organs. The panel agreed on the main lines of DRESS management according to these severity grades. General recommendations were generated on the postacute phase follow-up of patients with DRESS and the allergological workup. CONCLUSIONS AND RELEVANCE This Delphi exercise represents, to our knowledge, the first international expert consensus on diagnostic workup, severity assessment, and management of DRESS. This should support clinicians in the diagnosis and management of DRESS and constitute the basis for development of future guidelines