DERMATOLOGICA SINICA 34 (2016) 205e208

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Dermatologica Sinica
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CASE REPORT

Analysis of human leukocyte antigen genotypes in pemphigus with

antidesmoglein antibody prole shift
Seiko Mitsui 1, 2, a, Koji Kamiya 2, 3, *, a, Yoshiki Tokura 3, Keiji Iwatsuki 2, Yumi Aoyama 2, 4
1
Department of Dermatology, Okayama City Hospital, Okayama, Japan
2
Department of Dermatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
3
Department of Dermatology, Hamamatsu University School of Medicine, Hamamatsu, Japan
4
Department of Dermatology, Kawasaki Hospital, Kawasaki Medical School, Okayama, Japan

a r t i c l e i n f o a b s t r a c t

Article history: In particular pemphigus cases, the phenotypic transition between pemphigus vulgaris and pemphigus
Received: Oct 29, 2015 foliaceus is observed with the change of antibody prole between anti-desmoglein (Dsg) 3 antibodies
Revised: Jan 25, 2016 and anti-Dsg1 antibodies. In this study, we examined human leukocyte antigen (HLA) genotypes of four
Accepted: Apr 29, 2016
pemphigus patients who presented with the phenotypic transition and/or antibody prole shift. Two out
of four patients possessed a DRB1*0405-DQB1*0401, and two out of four patients possessed a
Keywords:
DRB1*1405-DQB1*0503. These alleles might be associated with the development of phenotypic transi-
antidesmoglein 1 antibody
tion and antibody prole shift.
antidesmoglein 3 antibody
human leukocyte antigen
Copyright 2016, Taiwanese Dermatological Association.
pemphigus foliaceus Published by Elsevier Taiwan LLC. This is an open access article under the CC BY-NC-ND license (http://
pemphigus vulgaris creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction was found in ve out of seven patients with a transition from PV to

Pemphigus is an autoimmune blistering disease caused by auto-
antibodies against desmogleins (Dsgs).1 There are two major sub-
types, pemphigus vulgaris (PV) and pemphigus foliaceus (PF),
which are clinically distinct, but closely related autoimmune blis-
tering diseases caused by immunoglobulin G (IgG) antibodies
against Dsg3 and Dsg1, respectively. During the clinical course, the
phenotypic transition between PV and PF correlates well with the
change of antibody prole between anti-Dsg3 antibodies and anti-
Dsg1 antibodies in particular cases of pemphigus.2 The underlying
mechanism still remains to be elucidated, because these
pemphigus cases are relatively rare. We have shown that familial
pemphigus patients who presented with the phenotypic transition
between PV and PF with the change of antibody prole between
anti-Dsg3 antibodies and anti-Dsg1 antibodies shared human
leukocyte antigen (HLA)-DRB1*1405-DQA1*0104-DQB1*0503.3 In a
past HLA analysis of 195 Japanese pemphigus patients, DRB1*1405
Conicts of interest: The authors declare that they have no nancial or non-
nancial conicts of interest related to the subject matter or materials discussed
in this article.
* Corresponding author. Department of Dermatology, Hamamatsu University
School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu 431-3192, Japan.
E-mail address: m01023kk@jichi.ac.jp (K. Kamiya).
a
These authors contributed equally to this work.
PF.4 In this study, we examined HLA genotypes of four pemphigus
patients who presented with the phenotypic transition and/or
antibody prole shift.
Case Report
Patient 1
A 70-year-old Japanese man was admitted to our hospital because
of multiple bullae and erosions on the trunk and extremities
(Figure 1A). The lesions were also observed in the oral cavity
(Figure 1B). Dsg1 enzyme-linked immunosorbent assay (ELISA) and
Dsg3 ELISA (MBL, Nagoya, Japan) detected anti-Dsg1 antibodies and
anti-Dsg3 antibodies in the patient serum (Dsg1 ELISA index value
63.1; positive cut-off value 20.0, Dsg3 ELISA index value 278.0;
positive cut-off value 20.0, respectively). Histopathology of a bio-
psied specimen from the skin lesion disclosed suprabasal acan-
tholysis (Figure 1C). The patient was treated under the diagnosis of
severe PV with pemphigus disease area index (PDAI) score of 38.
The treatment with 50 mg/d of prednisolone (PSL) improved
mucosal lesions with the decrement of anti-Dsg3 antibodies (Dsg3
ELISA index value 113.8). However, skin lesions were exacerbated
(Figure 1D) with the increment of anti-Dsg1 antibodies (Dsg1 ELISA
index value 312.5). Intriguingly, histopathology showed acanthol-
ysis in the suprabasal layer and the upper layer of epidermis within

http://dx.doi.org/10.1016/j.dsi.2016.04.001
1027-8117/Copyright 2016, Taiwanese Dermatological Association. Published by Elsevier Taiwan LLC. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
206 S. Mitsui et al. / Dermatologica Sinica 34 (2016) 205e208

Figure 1 Clinical appearance and histopathological ndings. (A) Multiple bullae and erosions on the trunk; (B) oral erosions are observed at the initial examination; (C) histo-
pathology, showing suprabasal acantholysis (H&E staining,
200); (D) skin lesions are scattered on the trunk; (E) acantholysis in the suprabasal layer and the upper layer of
epidermis (arrows) (H&E staining,
200); (F) crusty and eroded lesions are refractory to the treatment; (G) subcorneal acantholysis (H&E staining,
200). H&E hematoxylin and
eosin.

the same specimen (Figure 1E). The dose of PSL was increased to
60 mg/d and double ltration plasmapheresis was performed.
These therapies improved the mucosal lesions and Dsg3 ELISA in-
dex values also decreased below the cut-off value. However, skin
lesions were refractory to the treatment with persistently high
levels of anti-Dsg1 antibodies (Dsg1 ELISA index value 69.8;
Figure 1F). Histopathology showed subcorneal blisters but not
suprabasal blisters (Figure 1G). The patient was followed up under
the diagnosis of PF. The phenotypic transition from PV to PF was
observed during the clinical course.
Patient 2
respectively. Histopathology showed subcorneal blisters with
acantholytic cells. The patient had been followed-up under the
diagnosis of PF. Oral PSL 30 mg/d and intravenous immunoglobulin
therapy were given because of the exacerbation of skin lesions.
Thereafter, the patient had been in a good condition with a main-
tenance dose of oral PSL 15 mg/d. Dsg1 ELISA index values and Dsg3
ELISA index values also decreased below the cut-off value. How-
ever, oral mucosal erosions relapsed with the increment of anti-
Dsg3 antibodies (Dsg3 ELISA index value 102.7). Skin lesions were
not observed and Dsg1 ELISA index values were below the cut-off
value. The phenotypic transition from PF to PV was observed in
this case.

A 40-year-old Japanese woman was admitted to our hospital Patient 4

because of oral erosions and accid blisters on the trunk. Dsg1
ELISA index value and Dsg3 ELISA index value were 77.6 and 34.5,
respectively. Histopathological examination disclosed suprabasal
acantholysis. The diagnosis of PV was made and oral PSL 55 mg/
d and intravenous immunoglobulin therapy were given with
therapeutic effect on both mucosal and skin lesions. Dsg1 ELISA
index values and Dsg3 ELISA index values also decreased below the
cut-off value. When the dose of oral PSL was reduced to 10 mg/d,
crusty and eroded lesions were again observed on the trunk. No
mucosal lesions were observed. Dsg1 ELISA index values increased
to 49.8, while Dsg3 ELISA index values did not exceed the cut-off
value. The phenotypic transition from PV to PF was observed dur-
ing the clinical course.
Patient 3
A 59-year-old Japanese man presented with accid blisters and
erythema on the trunk. There were no mucosal lesions. Dsg1 ELISA
index value and Dsg3 ELISA index value were 31.9 and 46.1,
A 68-year-old Japanese woman was referred to our hospital
because of multiple bullae and erosions on the trunk with high
levels of anti-Dsg1 antibodies (Dsg1 ELISA index value 90.0). There
were no mucosal lesions and Dsg3 ELISA index values were below
the cut-off value. From the clinical and histopathological ndings, a
diagnosis of PF was made. Skin lesions were successfully treated
with 10 mg/d of PSL and Dsg1 ELISA index values had been below
the cut-off value. When the dose of PSL was reduced to 5 mg/d,
Dsg3 ELISA index values, but not Dsg1 ELISA index values, increased
and showed persistently high levels (Dsg3 ELISA index value 94.5).
However, no skin and mucosal lesions were observed. The antibody
prole shift from anti-Dsg1 antibodies to anti-Dsg3 antibodies was
observed during the clinical course without clinical relapse.
Human leukocyte antigen typing
HLA genotyping was determined by polymerase chain reaction
restriction fragment length polymorphism (PCR-RFLP). Informed
 S. Mitsui et al. / Dermatologica Sinica 34 (2016) 205e208 207

Table 1 Clinical phenotypes, antibody proles and human leukocyte antigen (HLA) genotypes.

Case Clinical phenotype Antibody prole HLA

Before transition After transition

No Age (y), sex Before transition After transition Dsg1 ELISA Dsg3 ELISA Dsg1 ELISA Dsg3 ELISA DRB1* DQB1*

1 70, Male PV (mucocutaneous type) PF 63.1 278.0 69.8 < 20.0 *0405 *0301
*1406 *0401
2 40, Female PV (mucocutaneous type) PF 77.6 34.5 49.8 < 20.0 *1403 *0301
*1405 *0503
3 59, Male PF PV (mucosal dominant type) 31.9 46.1 < 20.0 102.7 *1454 *0502
*1502 *0601
4 68, Female PF Remission 90.0 < 20.0 < 20.0 94.5 *0405 *0401
*1405 *0503

Dsg desmoglein; ELISA enzyme-linked immunosorbent assay; HLA human leukocyte antigen; PF pemphigus foliaceus; PV pemphigus vulgaris.

consent was obtained from all patients. Clinical phenotypes, anti-
body proles and HLA genotypes are summarized in Table 1. HLA
genotyping dened HLA-DRB1*0405, *1403, *1405, *1406, *1454,
*1502 and HLA-DQB1*0301, *0401, *0502, *0503, *0601, respec-
tively. Two patients (Cases 1 and 4) possessed a DRB1*0405-
DQB1*0401. Two patients (Cases 2 and 4) possessed a
DRB1*1405-DQB1*0503.
Discussion
In this study, we rst analyzed the correlation between phenotypic
transition and antibody prole shift in four pemphigus patients. In
Cases 1 and 2, the phenotypic transition from PV to PF was
observed during the clinical course. The treatment suppressed the
production of anti-Dsg3 antibodies but not anti-Dsg1 antibodies. By
contrast, the treatment suppressed the production of anti-Dsg1
antibodies but not anti-Dsg3 antibodies in Case 3. Accordingly,
the phenotypic transition from PF to PV was observed in Case 3.
These observations suggest that the capacity for anti-Dsg1 antibody
production is different from that for anti-Dsg3 antibody produc-
tion. In addition, the capacity of antibody production differs among
pemphigus patients. Thus, the same steroid treatment regimen has
different effects on anti-Dsg1 antibody production and anti-Dsg3
antibody production in each patient, resulting in the phenotypic
transition of pemphigus.
In Case 3, although anti-Dsg3 antibodies were detected, clinical
manifestations of PV were not observed at the initial examination,
suggesting that anti-Dsg3 antibodies were of low pathogenicity at
this point. Similar to this case, nonpathogenic anti-Dsg3 antibodies
have been reported in particular PV cases.5e7 In Case 4, although
persistent high levels of anti-Dsg3 antibodies were observed, the
patient had maintained clinical remission. In this case, nonpatho-
genic anti-Dsg3 antibodies were detected by dissociation assay
(data not shown).6 Antibody prole shift from anti-Dsg1 antibodies
to anti-Dsg3 antibodies was observed.
We next analyzed HLA-DR and -DQ alleles. The association of
pemphigus with HLA class II has been demonstrated in different
ethnic populations.8 In this meta-analysis, results have shown that
DRB1*04, DRB1*08, and DRB1*14 are statistically signicant sus-
ceptibility factors for PV, while DRB1*03, DRB1*07, and DRB1*15
may be negatively associated with PV.8 DRB1*04 and DRB1*14
(DRB1*0403, *0404, *0406, *1401, *1405, *1406) are also associated
with Japanese patients with PV and PF,9e12 and DRB1*04 and
DRB1*14 were found in all cases of this study. In Japan, DRB1*1405
is frequently observed in pemphigus patients who presented with
the phenotypic transition between PV and PF.3e4 In our cases, two
patients (Cases 2 and 4) possessed a DRB1*1405-DQB1*0503.
DRB1*1405 is commonly associated with PV and PF, and all Japa-
nese patients with PV carrying DRB1*1405 have been reported to
possess DQB1*0503.9,12 Taken together, DRB1*1405-DQB1*0503
may confer susceptibility to both PV and PF. By contrast, two pa-
tients (Cases 1 and 4) possessed a DRB1*0405-DQB1*0401, which
might be associated with the phenotypic transition between PV
and PF.
A limitation of this study is small sample size. Although the
change of antibody prole between anti-Dsg3 antibodies and anti-
Dsg1 antibodies is strongly related to the phenotypic shift between
PV and PF, an obvious relationship between HLA genotypes and
antibody prole shift was not observed in this study. The function
of HLA in the pathogenesis of pemphigus still remains to be
elucidated. Other confounding factors seem to be involved in the
phenotypic transition and antibody prole shift. Further in-
vestigations are necessary to clarify the underlying mechanisms.
Acknowledgments
This work was supported by a grant from the Ministry of Health,
Labour and Welfare (Research for Intractable Diseases), and a
Ministry of Education, Culture, Sports, Science and Technology. SM
and KK contributed equally to this work. We would like to grate-
fully and sincerely thank Dr. Tomoko Miyake, Dr. Mariko Kawata,
Dr. Tetsuya Takiguchi, Dr. Mari Yamaguchi, and Dr. Yoshio Kawa-
kami for their assistance.
References
1. Stanley JR, Amagai M. Pemphigus, bullous impetigo, and the staphylococcal
scalded-skin syndrome. N Engl J Med 2006;355:1800e10.
2. Komai A, Amagai M, Ishii K, et al. The clinical transition between pemphigus
foliaceus and pemphigus vulgaris correlates well with the changes in autoan-
tibody prole assessed by an enzyme-linked immunosorbent assay. Br J Der-
matol 2001;144:1177e82.
3. Yamamoto T, Ikeda K, Sasaoka S, et al. Human leukocyte antigen genotypes and
antibody proles associated with familial pemphigus in Japanese. J Dermatol
2011;38:711e6.
4. Niizeki H. HLA-DRB1 typing of 195 Japanese patients with pemphigus. In:
Kitajima Y, editor. Annual Report of Intracutable Diseases (2007). Gifu, Japan: The
Ministry of Health, Labour and Welfare (Research for Intractable Diseases);
2008. p. 61e9.
5. Kamiya K, Aoyama Y, Shirafuji Y, et al. Detection of antibodies against the non-
calcium-dependent epitopes of desmoglein 3 in pemphigus vulgaris and their
pathogenic signicance. Br J Dermatol 2012;167:252e61.
6. Kamiya K, Aoyama Y, Shirafuji Y, et al. A higher correlation of the antibody
activities against the calcium-dependent epitopes of desmoglein 3 quantied
by ethylenediaminetetraacetic acid-treated enzyme-linked immunosorbent
assay with clinical disease activities of pemphigus vulgaris. J Dermatol Sci
2013;70:190e5.
7. Kamiya K, Aoyama Y, Yamaguchi M, Tokura Y, Iwatsuki K. Detection of auto-
antibodies against the calcium-dependent epitopes of desmoglein 3 by ethyl-
enediaminetetraacetic acid-treated enzyme-linked immunosorbent assay with
mammalian cell expression system. J Dermatol 2015;42:825e7.
8. Yan L, Wang JM, Zeng K. Association between HLA-DRB1 polymorphisms and
pemphigus vulgaris: a meta-analysis. Br J Dermatol 2012;167:768e77.
208 S. Mitsui et al. / Dermatologica Sinica 34 (2016) 205e208

9. Niizeki H, Inoko H, Mizuki N, et al. HLA-DQA1, -DQB1 and -DRB1 genotyping in
Japanese pemphigus vulgaris patients by the PCR-RFLP method. Tissue Antigens
1994;44:248e51.
10. Miyagawa S, Higashimine I, Iida T, Yamashina Y, Fukumoto T, Shirai T. HLA-
DRB1*04 and DRB1*14 alleles are associated with susceptibility to pemphigus
among Japanese. J Invest Dermatol 1997;109:615e8.
11. Yamashina Y, Miyagawa S, Kawatsu T, et al. Polymorphisms of HLA class II
genes in Japanese patients with pemphigus vulgaris. Tissue Antigens 1998;52:
74e7.
12. Miyagawa S, Amagai M, Niizeki H, et al. HLA-DRB1 polymorphisms and auto-
immune responses to desmogleins in Japanese patients with pemphigus. Tissue
Antigens 1999;54:333e40.