It is known that the major histocompatibility complex (MHC) has important relationships in increasing the susceptibility of autoimmune diseases. Although there are few papers that analyze the relationship between PNP and genetics, some studies in the Caucasian and Chinese population showed the relationships of the HLA class II alleles DRB1\*03 and HLA-Cw\*14 in the PNP's trigger [26, 27]. HLA-Cw\* 14 proved to be a more specific allele type of PNP. Its importance has been associated with PNP, regardless of whether it is a Castleman disease or other tumors, in addition to Castleman disease. [26]. However, to date, these studies are preliminary studies that suggest the association between genetic factors and PNP. To better understand this relationship, it is important to conduct studies with larger numbers of patients and that are affected by different tumors, as well as the

**Neoplasms Frequencies (%)** Non-Hodgkin's lymphoma 38.6 Chronic lymphocytic leukemia 18.4 Castleman disease 18.4 Sarcoma 8.6 Others 16

of this disease in the world population [3]. To date, about 500 cases have been reported in the literature, with PNP representing 3–5% of all cases of pemphigus in the population [6–8]. The vast majority of affected patients demonstrate lymphoproliferative disorders (LPD) [9]. Although this disease can affect children and adolescents, the most common age group is between 45 and 70 years of age and is

not correlated with place of origin, race, and sex [7, 10–14].

**3. Association with malignancy and genetic background**

**2. Epidemiology**

**128**

**Table 1.**

PNP even being a disease not yet known at the present time, it is known that both autoantibodies, as cell-mediated immunity, are involved [28]. Certainly, it deduces that the immune system is paramount in the pathophysiology of this disease.

#### **4.1 Autoantibodies**

PNP triggers immune changes with the production of autoantibodies capable of acting on various proteins in the body. The major target proteins of the autoantibodies are desmoglein 1 (DSG-1) and desmoglein 3 (DSG-3); desmocollins 1, 2, and 3; desmoplakins 1 and 2; BP230; BP130; and envoplakin, in addition to several other epitopes affected by autoantigens found in the individual [29]. These characteristics demonstrate the immunological complexity of the disease.

Proteins of the plakin family, such as desmoplakins 1 and 2, envoplakin, periplakin, plectin and BP230, demonstrate the major targets of autoantibodies [30]. In contrast, the proteins of the cadherin family are the second most affected, with proteins such as DSG-1 and DSG-3 and desmocollin [31]. It is known that the presence of autoantibodies to some proteins are not related to the clinical practice of the patients, although there is a study that has mentioned DSG-3 relation with genital involvement [32].

Other autoantibodies such as alpha-2 macroglobulin-like 1 (A2ML1), a broad-range protease inhibitor, have been shown to be important in some patients. This protein has been shown to increase in the oral mucosa, intestine, esophagus, and muscles. However, its true function in the epithelium is unknown [33, 34].

PNP studies with tumor resection demonstrate that tumors have the capacity to secrete autoantibodies capable of affecting the proteins of the epidermal region [35]. While knowing that most PNPs are involved in neoplastic and LPD diseases, triggering by solid tumors is still poorly understood and demonstrates other mechanisms involved in the production of autoantibodies to plakin proteins.

The involvement of the humoral immunity of PNP presents the desmoplakins 1 and 2, envoplakin, periplakin, BP230, A2ML1, and DSG-1 and DSG-3 as the main proteins of concern [1]. However, 16% of all affected do not demonstrate the presence of these autoantibodies, and this makes, in some cases, the accomplishment of the early diagnosis difficult. A study conducted in patients with PNP and who developed muscle weakness demonstrated autoantibodies against neuromuscular junction proteins and muscle tissue. These muscle-associated proteins were autoantibodies to anti-acetylcholinesterase receptors and anti-titin and anti-ryanodine receptor [36].

#### **4.2 Cellular immunity**

Cellular immunity has evidenced important roles in the immunophenotyping of PNP. Pathological analyses have demonstrated inflammatory infiltrates with the presence of CD8+ T cells, CD68+ monocytes, and non-major histocompatibility complex-restricted CD56+ in the subepidermal region [2, 37]. Besides that, in the places of affection, the increase in tumor necrosis factor, as well as interferon gamma, was evidenced [38]. These findings show the importance of cellular immunity in the pathogenesis of the disease, since they present abundantly in the sites of PNP involvement.

#### **5. Clinical features**

PNP presents several symptoms and clinical evolutions. The first symptoms as well as the progression of the disease are very varied from one patient to another. However, there are more frequent clinical features of these individuals.

#### **5.1 Oral lesions**

The oral mucosa is often affected in patients with PNP [3, 39, 40]. Oral symptoms may be the first symptoms in these patients, even before skin lesions [41]. The most common symptoms are oral and labial erosions with bleeding that may be associated with blisters, macules, papules, vesicles, and erythema (**Figure 1**). In addition, these patients may present a positive Nikolsky sign [41].

PNP lesions may be similar to oral manifestations of other diseases. Pemphigus vulgaris is a disease that initially triggers blisters and ulcers in the oral mucosa (especially on the cheeks) and may even reach the body. Erythema multiforme also affects the region of the oral mucosa with the appearance of erythema, edema, and some superficial erosions with formation of pseudomembrane. Lichen planus causes erythematous lesions where Wickham striae are present and may in rare cases develop erosions. In most cases of oral lichen planus, these are asymptomatic manifestations with few complications. Even though these diseases show some similarity to PNP, they are less aggressive, lethal, painful, and incapacitating, with less ability to spread to all mucosal and other body sites when compared to PNP [28, 42, 43].

#### **5.2 Secondary mucosal lesions**

Lesions can also affect regions such as the oropharynx, esophagus, stomach, duodenum, large intestine, conjunctiva, and anogenital region [2, 3, 7, 39, 41, 44, 45]. The involvement of the oropharynx and esophagus commonly triggers painful sensations and dysphagia [4]. The anogenital lesions demonstrate red-violet erythema in the glans or its surroundings (**Figure 2**). In some cases, lichen planus presents a possible differential diagnosis. However, unlike red-violet lesions, lichen planus forms linear white streaks that may arise in the glans, scrotum, and vulva, in addition to the presence of dyspareunia and pruritus [43]. In these patients, both necrosis and loss of epidermis are absent, unlike patients with PNP who present this clinical [43].

**131**

**5.3 Skin lesions**

**Figure 3.**

**Figure 2.**

*Red-violet lesion in the genital organ.*

*Extensive erosions and blisters in the dorsal region.*

*Paraneoplastic Pemphigus Is a Life-Threatening Disease DOI: http://dx.doi.org/10.5772/intechopen.84956*

About 70% of the patients present conjunctival lesions such as bilateral bulbar conjunctival hyperemia, diffuse papillary tarsal conjunctival reactions, conjunctival epithelium desquamation, forniceal shortening, painful ocular irritation, poor vision, conjunctival and corneal erosions, and pseudomembranous conjunctivitis [2, 46, 47].

Skin lesions usually appear soon after the onset of mucosal involvement [48]. The most affected sites are the dorsal region (**Figure 3**), head, and neck (**Figure 4**), in addition to the nearby extremities [4, 39, 49]. Patients with PNP started the study in very different ways, with the first signs being erythema, bullous and vesicular lesions, papules, skin scaling with Nikolsky sign, exfoliative erythema, and ulcers with hematic crust. Often, the first clinical sign on the skin is erythema that may progress with bullous and ulcerated lesions [24, 50]. Unlike adults, PNP in the skin of children appears in the form of lichenoid lesions, rather than bullous lesions.

Similar to PNP, bullous pemphigoid (BP) provides blistering with erythematous base or normal skin. However, BP lesions occur more frequently in the lower abdomen and lower limbs, and in most individuals, mucosal lesions are not affected [51]. In addition, pruritus is present in the vast majority of these patients, unlike PNP, which show painful

and disseminated lesions mainly in the upper body and mucosal regions [28, 51].

**Figure 1.** *Severe erosive mucositis with hematic crusting on the lips and oral mucosa.*

*Paraneoplastic Pemphigus Is a Life-Threatening Disease DOI: http://dx.doi.org/10.5772/intechopen.84956*

*Current Trends in Cancer Management*

**5.2 Secondary mucosal lesions**

PNP presents several symptoms and clinical evolutions. The first symptoms as well as the progression of the disease are very varied from one patient to another.

The oral mucosa is often affected in patients with PNP [3, 39, 40]. Oral symptoms may be the first symptoms in these patients, even before skin lesions [41]. The most common symptoms are oral and labial erosions with bleeding that may be associated with blisters, macules, papules, vesicles, and erythema (**Figure 1**). In

PNP lesions may be similar to oral manifestations of other diseases. Pemphigus vulgaris is a disease that initially triggers blisters and ulcers in the oral mucosa (especially on the cheeks) and may even reach the body. Erythema multiforme also affects the region of the oral mucosa with the appearance of erythema, edema, and some superficial erosions with formation of pseudomembrane. Lichen planus causes erythematous lesions where Wickham striae are present and may in rare cases develop erosions. In most cases of oral lichen planus, these are asymptomatic manifestations with few complications. Even though these diseases show some similarity to PNP, they are less aggressive, lethal, painful, and incapacitating, with less ability to spread

Lesions can also affect regions such as the oropharynx, esophagus, stomach, duodenum, large intestine, conjunctiva, and anogenital region [2, 3, 7, 39, 41, 44, 45]. The involvement of the oropharynx and esophagus commonly triggers painful sensations and dysphagia [4]. The anogenital lesions demonstrate red-violet erythema in the glans or its surroundings (**Figure 2**). In some cases, lichen planus presents a possible differential diagnosis. However, unlike red-violet lesions, lichen planus forms linear white streaks that may arise in the glans, scrotum, and vulva, in addition to the presence of dyspareunia and pruritus [43]. In these patients, both necrosis and loss of epidermis are absent, unlike patients with PNP who present this

However, there are more frequent clinical features of these individuals.

addition, these patients may present a positive Nikolsky sign [41].

to all mucosal and other body sites when compared to PNP [28, 42, 43].

*Severe erosive mucositis with hematic crusting on the lips and oral mucosa.*

**5. Clinical features**

**5.1 Oral lesions**

**130**

**Figure 1.**

clinical [43].

**Figure 2.** *Red-violet lesion in the genital organ.*

#### **Figure 3.** *Extensive erosions and blisters in the dorsal region.*

About 70% of the patients present conjunctival lesions such as bilateral bulbar conjunctival hyperemia, diffuse papillary tarsal conjunctival reactions, conjunctival epithelium desquamation, forniceal shortening, painful ocular irritation, poor vision, conjunctival and corneal erosions, and pseudomembranous conjunctivitis [2, 46, 47].

#### **5.3 Skin lesions**

Skin lesions usually appear soon after the onset of mucosal involvement [48]. The most affected sites are the dorsal region (**Figure 3**), head, and neck (**Figure 4**), in addition to the nearby extremities [4, 39, 49]. Patients with PNP started the study in very different ways, with the first signs being erythema, bullous and vesicular lesions, papules, skin scaling with Nikolsky sign, exfoliative erythema, and ulcers with hematic crust. Often, the first clinical sign on the skin is erythema that may progress with bullous and ulcerated lesions [24, 50]. Unlike adults, PNP in the skin of children appears in the form of lichenoid lesions, rather than bullous lesions.

Similar to PNP, bullous pemphigoid (BP) provides blistering with erythematous base or normal skin. However, BP lesions occur more frequently in the lower abdomen and lower limbs, and in most individuals, mucosal lesions are not affected [51]. In addition, pruritus is present in the vast majority of these patients, unlike PNP, which show painful and disseminated lesions mainly in the upper body and mucosal regions [28, 51].

#### **Figure 4.** *Confluent erosions with hematic crusts in the head and neck region.*

Already erythema multiforme shows prodromal symptoms such as fever and myalgia before the appearance of lesions on the mucosal and skin. Their skin lesions change in feature according to the course of the disease and resemble insect bites or hives that result in the well-known targetoid lesions that are common in this disease. Although cases of necrosis and blisters occur in the center of the lesions, this disease shows less aggression and fewer blisters and ulcers with hematic crusts than the patients affected by PNP [42].

Lichen planus affects flexor surfaces of the wrists, forearm, and legs. These lesions have round reticular white lines such as Wickham striae. They may arise in places that suffer trauma (Koebner's phenomenon), in addition to making the site pigmented after inflation, thus demonstrating clinical differences in cutaneous erosions seen in the course of PNP progression [43].

The graft versus host disease causes rash and maculopapular rash that present itching and can spread to the entire body, less in the scalp. In very severe cases, there may be some sites with necrosis at the base of epidermal rete pegs [52]. Generally, these severe cases are differentiated from the PNP both by the patient's clinical history and by skin biopsy that demonstrate distinct histopathological characteristics.

#### **5.4 Pulmonary manifestations**

Approximately 92.8% of the cases described in the literature show pulmonary involvement [3]. The pulmonary clinical signs of PNP are dyspnea, obstructive pulmonary disease, and bronchiolitis obliterans. The resolution of pulmonary problems is of extreme importance, since it is the main cause of death in individuals with PNP [53]. The patients with the greatest pulmonary involvement are Chinese children and patients with Castleman disease [53]. Studies show that 71% of the patients had bronchiolitis obliterans organizing pneumonia, and they give worse prognosis even if treatment of the neoplasia occurs [12, 54].

#### **6. Histopathological examination**

The pathological analyses demonstrate many varied aspects, since they show them peculiar characteristics according to the evaluated lesions [55]. When

**133**

**Figure 5.**

dermal junctions in band [28, 55].

**7. Immunological studies**

*Paraneoplastic Pemphigus Is a Life-Threatening Disease DOI: http://dx.doi.org/10.5772/intechopen.84956*

analyzing the biopsy of blisters, we found acantholysis with inflammatory infiltrates (**Figure 5**) [55]. However, when it presents inflammatory maculopapular lesions, the most common findings are lichenoid interface dermatitis [55]. In the presence of lesions with the presence of blisters and maculopapular lesions, mixed characteristics of each type of lesion may occur in the pathology. The findings with dyskeratosis and suprabasal acantholysis are one of the most important characteristics that lead to the definitive diagnosis of PNP [6]. Dyskeratosis is an abnormal formation of epidermal keratinization, whereas acantholysis is the loss of adhesion between skin cells [28]. These findings may help in the diagnosis even when there is no possibility of performing direct immunofluorescence (DIF) or when they are negative [39, 55]. DIF is a laboratory technique capable of detecting the deposition of autoantibodies and immune cells in the sites affected by the disease. The use of DIF demonstrates an extremely important technique for the diagnosis of PNP, since it can analyze both specific autoantibodies and cytotoxic cells of the human immune system, such as CD8+ T cells that act by attacking several layers with keratin and demonstrating intracellular staining of cementum and/or marking of epidermal

*Histopathological examination of the biopsy specimen showing keratinocyte apoptosis and*

*acantholysis (hematoxylin and eosin, original magnification × 100).*

The use of DIF demonstrates great importance in the diagnosis of PNP even though approximately 50% of the cases show negative [3]. This technique shows a staining in IgG deposition intracellular chicken wire pattern (linear formation of autoantibodies deposition) along the dermoepidermal junction in both the linear form, as granulate [15]. The presence of IgG deposition in the dermoepidermal region

is very characteristic of the PNP; however, only 25% presents this pattern [56].

alerting to PNP investigation, since it shows high specificity [56].

The use of indirect immunofluorescence (IIF) shows involvement of the epidermis by the deposition of IgG in the intercellular regions. Other techniques used as cytoplasmic fluorescence (intracellular staining) demonstrate a prominent basal staining. IIF marking is extremely strong in the layers of the epithelium, and this,

*Paraneoplastic Pemphigus Is a Life-Threatening Disease DOI: http://dx.doi.org/10.5772/intechopen.84956*

#### **Figure 5.**

*Current Trends in Cancer Management*

than the patients affected by PNP [42].

**Figure 4.**

**5.4 Pulmonary manifestations**

**6. Histopathological examination**

erosions seen in the course of PNP progression [43].

*Confluent erosions with hematic crusts in the head and neck region.*

prognosis even if treatment of the neoplasia occurs [12, 54].

Already erythema multiforme shows prodromal symptoms such as fever and myalgia before the appearance of lesions on the mucosal and skin. Their skin lesions change in feature according to the course of the disease and resemble insect bites or hives that result in the well-known targetoid lesions that are common in this disease. Although cases of necrosis and blisters occur in the center of the lesions, this disease shows less aggression and fewer blisters and ulcers with hematic crusts

Lichen planus affects flexor surfaces of the wrists, forearm, and legs. These lesions have round reticular white lines such as Wickham striae. They may arise in places that suffer trauma (Koebner's phenomenon), in addition to making the site pigmented after inflation, thus demonstrating clinical differences in cutaneous

The graft versus host disease causes rash and maculopapular rash that present itching and can spread to the entire body, less in the scalp. In very severe cases, there may be some sites with necrosis at the base of epidermal rete pegs [52]. Generally, these severe cases are differentiated from the PNP both by the patient's clinical history and by skin biopsy that demonstrate distinct histopathological characteristics.

Approximately 92.8% of the cases described in the literature show pulmonary involvement [3]. The pulmonary clinical signs of PNP are dyspnea, obstructive pulmonary disease, and bronchiolitis obliterans. The resolution of pulmonary problems is of extreme importance, since it is the main cause of death in individuals with PNP [53]. The patients with the greatest pulmonary involvement are Chinese children and patients with Castleman disease [53]. Studies show that 71% of the patients had bronchiolitis obliterans organizing pneumonia, and they give worse

The pathological analyses demonstrate many varied aspects, since they show

them peculiar characteristics according to the evaluated lesions [55]. When

**132**

*Histopathological examination of the biopsy specimen showing keratinocyte apoptosis and acantholysis (hematoxylin and eosin, original magnification × 100).*

analyzing the biopsy of blisters, we found acantholysis with inflammatory infiltrates (**Figure 5**) [55]. However, when it presents inflammatory maculopapular lesions, the most common findings are lichenoid interface dermatitis [55]. In the presence of lesions with the presence of blisters and maculopapular lesions, mixed characteristics of each type of lesion may occur in the pathology. The findings with dyskeratosis and suprabasal acantholysis are one of the most important characteristics that lead to the definitive diagnosis of PNP [6]. Dyskeratosis is an abnormal formation of epidermal keratinization, whereas acantholysis is the loss of adhesion between skin cells [28]. These findings may help in the diagnosis even when there is no possibility of performing direct immunofluorescence (DIF) or when they are negative [39, 55]. DIF is a laboratory technique capable of detecting the deposition of autoantibodies and immune cells in the sites affected by the disease. The use of DIF demonstrates an extremely important technique for the diagnosis of PNP, since it can analyze both specific autoantibodies and cytotoxic cells of the human immune system, such as CD8+ T cells that act by attacking several layers with keratin and demonstrating intracellular staining of cementum and/or marking of epidermal dermal junctions in band [28, 55].

#### **7. Immunological studies**

The use of DIF demonstrates great importance in the diagnosis of PNP even though approximately 50% of the cases show negative [3]. This technique shows a staining in IgG deposition intracellular chicken wire pattern (linear formation of autoantibodies deposition) along the dermoepidermal junction in both the linear form, as granulate [15]. The presence of IgG deposition in the dermoepidermal region is very characteristic of the PNP; however, only 25% presents this pattern [56].

The use of indirect immunofluorescence (IIF) shows involvement of the epidermis by the deposition of IgG in the intercellular regions. Other techniques used as cytoplasmic fluorescence (intracellular staining) demonstrate a prominent basal staining. IIF marking is extremely strong in the layers of the epithelium, and this, alerting to PNP investigation, since it shows high specificity [56].

Other serological methods may also be used, such as immunoprecipitation, immunoblot and anti-EP enzyme-linked immunosorbent assay (ELISA) [57–59]. Studies evidenced 95 and 100% sensitivity in radioactive and nonradioactive immunoprecipitation techniques, respectively, and this demonstrates that immunoprecipitation is the most serologically sensitive test for PNP diagnosis [57, 60, 61]. Currently the immunoprecipitation is considered gold standard in the diagnosis of PNP, that is, the main criterion to diagnose [62, 63].

#### **8. Diagnosis**

The criteria for diagnosis according to Anhalt et al. in 1990 are based on five criteria, such as clinical characteristics, histopathological analysis, direct and indirect immunofluorescence, and immunoprecipitation [1]. These criteria have been modified and adapted. In 1993, researchers included to perform the diagnosis the presence of three main criteria or two major and two minor [63]. Already in 2002, Mimouni et al. reviewed the Anhalt criteria and considered four minimum criteria of high confidence in diagnosis (**Table 2**) [12]. DIF is a nonessential criterion because of its low sensitivity. As for IIF on rat bladder epithelia and monkey esophagus, they were considered useful for tracking and detecting PNP [57, 64]. Negative IIF cannot exclude PNP, and other techniques such as immunoblotting and immunoprecipitation should be used to confirm or rule out a diagnosis.

#### **Table 2.**

*Minimum criteria for diagnosis.*

#### **9. Differential diagnosis**

The diagnosis of PNP can be complex and difficult to perform because there are several similar diseases (**Table 3**). PNP and pemphigus vulgaris (PV) are very similar clinically, but some details differentiate them. PNP develops with inflammatory papules or macules that progress to blisters, while PV presents bullous lesions with a reddish background. Molecularly, the PNP presents some antibodies specific for this disease, such as the presence of anti-A2ML1, anti-envoplakin, and anti-periplakin, and demonstrates patterns of IgG deposition on cell surfaces with accumulation in the basement membrane zone [57, 64–66]. Even though bullous autoimmune diseases resemble each other, PNP differentiates it by the presence of antibody that stains the mouse bladder. In bullous pemphigoid (PB), BP230 and BP180 can be found, as well as in PNP. However, the use of DIF differentiates them by the IgG deposition patterns found in the PNP. The involvement by morbilliform-like erythema, toxic epidermal necrolysis, and Stevens-Johnson syndrome can also be confused with PNP. However, the detection of antibodies, pathological analysis of the lesions, and the patient's clinic can differentiate these diseases [1, 10, 39, 57, 64–66].

Despite some cases that both clinically and histologically resemble each other, it is important to perform other techniques to rule out differential diagnoses. The use of otorhinolaryngological examination is very important to differentiate the diseases

**135**

**10. Treatment**

*Differential diagnosis.*

Pemphigus vulgaris

Bullous pemphigoid

Erythema multiforme

**Table 3.**

Toxic epidermal necrolysis

Stevens-Johnson syndrome

*Paraneoplastic Pemphigus Is a Life-Threatening Disease DOI: http://dx.doi.org/10.5772/intechopen.84956*

**Disease Causers Pathophysiology**

hypersensitivity by infection,

Drug reaction that affects more than 30% of the body

Drug reaction that affects less than 10% of the body

viruses and drugs

Lichen planus Autoimmune reaction Autoantigens anti-keratinocyte and

Autoimmune reaction Autoantigens anti-desmoglein 1,3

Autoimmune reaction Autoantigens anti-BP180 and anti-BP230

antinuclear

leukotrienes

tumor necrosis factor-α

and increased granulysin

and increased granulysin

Infiltration of cytotoxic T cell and increased

Infiltration of cytotoxic T cell, natural killer,

Infiltration of cytotoxic T cell, natural killer,

eosinophils, and increased histamine and

that affect the mucous membranes. Well-done physical examination of the oral cavity, histopathological analysis characteristics, cutaneous involvement, and the presence

Drug eruption Drug reaction Perivascular infiltration by lymphocytes,

Effective treatment for PNP is still a major puzzle because of its rarity. Although several drugs are used in the literature, PNP has shown great resistance when compared to other forms of pemphigus [50, 68]. When there is suspicion or evidence of PNP, the performance of the six steps described on 2011 by Frew et al. may provide better management of individuals (**Table4**) [69]. Stabilization of patients, according to the first step, is the most important step, since it is the major cause of death in patients [69]. Currently, the first-line treatment for PNP is still high doses of corticosteroids [70]. This treatment improves the cutaneous lesions, but the mucosal involvement is little altered. The use of other drugs also shows little efficacy in the lesions of the

Several studies have shown that the combination of drugs has been effective and safe. These associations were prednisolone used with other therapies, such as mycophenolate mofetil, cyclosporine A, azathioprine, plasmapheresis, and intravenous immunoglobulin [72–77]. Even though treatment is more effective, mucosal

The use of monoclonal antibody has been effective in the treatment of PNP in some case reports described in the literature. Administration of rituximab, an anti-CD20, has shown good PNP therapy due to B-cell lymphoma [78, 79]. This therapy

infusions for 4 weeks of corticosteroid and administration of other immunosup-

The use of alemtuzumab, a humanized monoclonal antibody that binds to CD52, has been reported. Reported in the treatment of PNP remission in patients whose presence of chronic lymphoid leukemia [80]. Alemtuzumab has been used in a patient with resistance to other drugs such as corticosteroids, intravenous immunoglobulin,

weekly for 4 weeks followed by eight weekly

mucosa, this resistance being the characteristic of the disease [69, 71].

involvement is still resistant to such combined therapies [71].

is based on an infusion of 375 mg/m2

pressive drugs such as cyclosporine A [69].

of IIF strongly suggest for the diagnosis of PNP [40, 44, 67].

#### **Table 3.**

*Current Trends in Cancer Management*

**8. Diagnosis**

**9. Differential diagnosis**

*Minimum criteria for diagnosis.*

**Table 2.**

can differentiate these diseases [1, 10, 39, 57, 64–66].

PNP, that is, the main criterion to diagnose [62, 63].

Other serological methods may also be used, such as immunoprecipitation, immunoblot and anti-EP enzyme-linked immunosorbent assay (ELISA) [57–59]. Studies evidenced 95 and 100% sensitivity in radioactive and nonradioactive immunoprecipitation techniques, respectively, and this demonstrates that immunoprecipitation is the most serologically sensitive test for PNP diagnosis [57, 60, 61]. Currently the immunoprecipitation is considered gold standard in the diagnosis of

The criteria for diagnosis according to Anhalt et al. in 1990 are based on five criteria, such as clinical characteristics, histopathological analysis, direct and indirect immunofluorescence, and immunoprecipitation [1]. These criteria have been modified and adapted. In 1993, researchers included to perform the diagnosis the presence of three main criteria or two major and two minor [63]. Already in 2002, Mimouni et al. reviewed the Anhalt criteria and considered four minimum criteria of high confidence in diagnosis (**Table 2**) [12]. DIF is a nonessential criterion because of its low sensitivity. As for IIF on rat bladder epithelia and monkey esophagus, they were considered useful for tracking and detecting PNP [57, 64]. Negative IIF cannot exclude PNP, and other techniques such as immunoblotting and

The diagnosis of PNP can be complex and difficult to perform because there are several similar diseases (**Table 3**). PNP and pemphigus vulgaris (PV) are very similar clinically, but some details differentiate them. PNP develops with inflammatory papules or macules that progress to blisters, while PV presents bullous lesions with a reddish background. Molecularly, the PNP presents some antibodies specific for this disease, such as the presence of anti-A2ML1, anti-envoplakin, and anti-periplakin, and demonstrates patterns of IgG deposition on cell surfaces with accumulation in the basement membrane zone [57, 64–66]. Even though bullous autoimmune diseases resemble each other, PNP differentiates it by the presence of antibody that stains the mouse bladder. In bullous pemphigoid (PB), BP230 and BP180 can be found, as well as in PNP. However, the use of DIF differentiates them by the IgG deposition patterns found in the PNP. The involvement by morbilliform-like erythema, toxic epidermal necrolysis, and Stevens-Johnson syndrome can also be confused with PNP. However, the detection of antibodies, pathological analysis of the lesions, and the patient's clinic

Despite some cases that both clinically and histologically resemble each other, it is important to perform other techniques to rule out differential diagnoses. The use of otorhinolaryngological examination is very important to differentiate the diseases

immunoprecipitation should be used to confirm or rule out a diagnosis.

2. Histologic features of acantholysis or lichenoid or interface dermatitis

4. The presence of an underlying neoplasm, especially lymphoproliferative tumors

3. Demonstration of antiplakin autoantibodies

1. Clinical features of severe and protracted mucosal involvement and polymorphic cutaneous eruptions

**134**

*Differential diagnosis.*

that affect the mucous membranes. Well-done physical examination of the oral cavity, histopathological analysis characteristics, cutaneous involvement, and the presence of IIF strongly suggest for the diagnosis of PNP [40, 44, 67].

#### **10. Treatment**

Effective treatment for PNP is still a major puzzle because of its rarity. Although several drugs are used in the literature, PNP has shown great resistance when compared to other forms of pemphigus [50, 68]. When there is suspicion or evidence of PNP, the performance of the six steps described on 2011 by Frew et al. may provide better management of individuals (**Table4**) [69]. Stabilization of patients, according to the first step, is the most important step, since it is the major cause of death in patients [69].

Currently, the first-line treatment for PNP is still high doses of corticosteroids [70]. This treatment improves the cutaneous lesions, but the mucosal involvement is little altered. The use of other drugs also shows little efficacy in the lesions of the mucosa, this resistance being the characteristic of the disease [69, 71].

Several studies have shown that the combination of drugs has been effective and safe. These associations were prednisolone used with other therapies, such as mycophenolate mofetil, cyclosporine A, azathioprine, plasmapheresis, and intravenous immunoglobulin [72–77]. Even though treatment is more effective, mucosal involvement is still resistant to such combined therapies [71].

The use of monoclonal antibody has been effective in the treatment of PNP in some case reports described in the literature. Administration of rituximab, an anti-CD20, has shown good PNP therapy due to B-cell lymphoma [78, 79]. This therapy is based on an infusion of 375 mg/m2 weekly for 4 weeks followed by eight weekly infusions for 4 weeks of corticosteroid and administration of other immunosuppressive drugs such as cyclosporine A [69].

The use of alemtuzumab, a humanized monoclonal antibody that binds to CD52, has been reported. Reported in the treatment of PNP remission in patients whose presence of chronic lymphoid leukemia [80]. Alemtuzumab has been used in a patient with resistance to other drugs such as corticosteroids, intravenous immunoglobulin,

#### **Table 4.**

*Management of the patient with suspected PNP.*

and cyclosporine A. In this patient, intravenous 30 mg was infused three times a week for 3 months. Even though there was improvement in both skin and mucosal lesions, the patient continued maintenance treatment with 500 mg of mycophenolate mofetil and 5 mg of prednisone [80]. Although there are several treatment alternatives, new therapies that reduce the resistance of PNP to drugs are still fundamental. Daclizumab, a monoclonal antibody against T-cell interleukin-2, has been shown to be a promising therapy [81].

It is known that in order to avoid large amounts of autoantibodies released into the bloodstream during tumor excision surgery, it is necessary to block blood flow and prevent compression of neoplastic tissue. In addition, the use of intravenous immunoglobulin before and during operations has demonstrated a significant reduction in mortality caused by bronchiolitis obliterans. Even after complete tumor resolution, immunoglobulin administration is required until 2 years to provide remission of autoimmunity triggered by PNP [82, 83].

In addition to the treatment of neoplasia and PNP, other ducts must be performed. When there is loss of skin integrity or immunosuppression, antimicrobial therapy is recommended early to prevent sepsis. Medications for pain control are also useful, since patients have pain in regions with ulceration and erosions [50].

Although there are several treatments stipulated in the literature, there are still no known drugs that reduce the mortality of patients, since the PNP proves highly resistant to more aggressive therapies. However, it is known that management, diagnosis, and early treatment are indispensable methods for a better response of the patients in the prescribed procedures.

#### **11. Prognosis**

The prognosis of PNP is extremely poor. Mortality can reach 90% of the cases in the first year, 41% of mortality in the second year, and 38% of death in the third year with the disease [84]. Commonly, death is triggered by systemic complications such as bronchiolitis obliterans, sepsis, and bleeding in the gastrointestinal tract [6, 50]. It is known that regardless of the cure or control of the neoplasia, the PNP progresses, demonstrating itself autonomous to the triggering factor [6, 10, 11, 13, 50]. Patients who exhibit morbilliform erythema and necrosis of skin biopsy keratinocytes demonstrate a worse overall survival [84]. In some cases, the removal of Castleman disease and benign thymoma has shown better results than other underlying diseases [84, 85].

Even with a high mortality rate, the prognosis depends very much on the proper management of the patient, such as monitoring of vital signs, control of oral and skin lesions, treatment of the triggering disease, and prevention of sepsis and bronchitis obliterans. For this, it is essential to follow the patient closely and treat the disease aggressively [50].

**137**

*Paraneoplastic Pemphigus Is a Life-Threatening Disease DOI: http://dx.doi.org/10.5772/intechopen.84956*

at key points by multidisciplinary teams.

immunologists, psychologists, nurses, and social workers.

of Health Sciences Barretos, São Paulo, Brazil.

A2ML1 alpha-2 macroglobulin-like 1

DIF direct immunofluorescence

IIF indirect immunofluorescence LPD lymphoproliferative disorders PNP paraneoplastic pemphigus

The author has declared no conflicts of interest.

Studies have mentioned severe losses in the quality of life of patients with pemphigus. The main criteria that impair the quality of life were the greater severity of the disease, anxiety, and depression. However, there was no clear measurement of gender, age, type of pemphigus, duration of disease, skin involvement, disease activity, itching, burning sensation in the skin, or treatment in use [86]. There is still a great need in the standardization and validation of PNP-specific questionnaires, as this proves to be extremely important in order to know and enable actions

PNP demonstrates a great challenge for physicians, since it presents several clinical aspects and varied degrees of bodily involvement. Early diagnosis, management of the patient, treatment of the underlying neoplasia, and aggressive treatment for PNP are of paramount importance for the best prognosis of the patient, since it is an extremely lethal disease. For this, more studies are needed to better understand the disease and cooperation between multidisciplinary teams involving dermatologists, oncologists, hematologists, otorhinolaryngologists, surgeons, ophthalmologists,

The author would like to acknowledge the help of Dr. Paulo Prata and the School

**12. Quality of life**

**13. Conclusions**

**Acknowledgements**

**Conflict of interest**

**Appendices and nomenclature**

BP bullous pemphigoid

DSG desmoglein

### **12. Quality of life**

*Current Trends in Cancer Management*

1. Stabilization of vital parameters

3. Diagnosis of PNP

5. Treatment of PNP

2. Assessment of any underlying malignancy

4. Removal and therapy for the triggering tumor

*Management of the patient with suspected PNP.*

therapy [81].

**Table 4.**

erosions [50].

**11. Prognosis**

underlying diseases [84, 85].

the disease aggressively [50].

and cyclosporine A. In this patient, intravenous 30 mg was infused three times a week for 3 months. Even though there was improvement in both skin and mucosal lesions, the patient continued maintenance treatment with 500 mg of mycophenolate mofetil and 5 mg of prednisone [80]. Although there are several treatment alternatives, new therapies that reduce the resistance of PNP to drugs are still fundamental. Daclizumab, a monoclonal antibody against T-cell interleukin-2, has been shown to be a promising

It is known that in order to avoid large amounts of autoantibodies released into the bloodstream during tumor excision surgery, it is necessary to block blood flow and prevent compression of neoplastic tissue. In addition, the use of intravenous immunoglobulin before and during operations has demonstrated a significant reduction in mortality caused by bronchiolitis obliterans. Even after complete tumor resolution, immunoglobulin administration is required until 2 years to

In addition to the treatment of neoplasia and PNP, other ducts must be performed. When there is loss of skin integrity or immunosuppression, antimicrobial therapy is recommended early to prevent sepsis. Medications for pain control are also useful, since patients have pain in regions with ulceration and

Although there are several treatments stipulated in the literature, there are still no known drugs that reduce the mortality of patients, since the PNP proves highly resistant to more aggressive therapies. However, it is known that management, diagnosis, and early treatment are indispensable methods for a better response of

The prognosis of PNP is extremely poor. Mortality can reach 90% of the cases in the first year, 41% of mortality in the second year, and 38% of death in the third year with the disease [84]. Commonly, death is triggered by systemic complications such as bronchiolitis obliterans, sepsis, and bleeding in the gastrointestinal tract [6, 50]. It is known that regardless of the cure or control of the neoplasia, the PNP progresses, demonstrating itself autonomous to the triggering factor [6, 10, 11, 13, 50]. Patients who exhibit morbilliform erythema and necrosis of skin biopsy keratinocytes demonstrate a worse overall survival [84]. In some cases, the removal of Castleman disease and benign thymoma has shown better results than other

Even with a high mortality rate, the prognosis depends very much on the proper management of the patient, such as monitoring of vital signs, control of oral and skin lesions, treatment of the triggering disease, and prevention of sepsis and bronchitis obliterans. For this, it is essential to follow the patient closely and treat

provide remission of autoimmunity triggered by PNP [82, 83].

the patients in the prescribed procedures.

**136**

Studies have mentioned severe losses in the quality of life of patients with pemphigus. The main criteria that impair the quality of life were the greater severity of the disease, anxiety, and depression. However, there was no clear measurement of gender, age, type of pemphigus, duration of disease, skin involvement, disease activity, itching, burning sensation in the skin, or treatment in use [86]. There is still a great need in the standardization and validation of PNP-specific questionnaires, as this proves to be extremely important in order to know and enable actions at key points by multidisciplinary teams.

### **13. Conclusions**

PNP demonstrates a great challenge for physicians, since it presents several clinical aspects and varied degrees of bodily involvement. Early diagnosis, management of the patient, treatment of the underlying neoplasia, and aggressive treatment for PNP are of paramount importance for the best prognosis of the patient, since it is an extremely lethal disease. For this, more studies are needed to better understand the disease and cooperation between multidisciplinary teams involving dermatologists, oncologists, hematologists, otorhinolaryngologists, surgeons, ophthalmologists, immunologists, psychologists, nurses, and social workers.

### **Acknowledgements**

The author would like to acknowledge the help of Dr. Paulo Prata and the School of Health Sciences Barretos, São Paulo, Brazil.

### **Conflict of interest**

The author has declared no conflicts of interest.

#### **Appendices and nomenclature**

*Current Trends in Cancer Management*

#### **Author details**

Richard Lucas Konichi-Dias School of Health Sciences, Dr. Paulo Prata-FACISB, Barretos, Sao Paulo, Brazil

\*Address all correspondence to<EMAIL_ADDRESS>
© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

**139**

*Paraneoplastic Pemphigus Is a Life-Threatening Disease DOI: http://dx.doi.org/10.5772/intechopen.84956*

> review on pathogenesis, clinical presentation and novel therapeutic approaches. Clinical Reviews in Allergy

and Immunology. 2018;**54**:1-25

[10] Sehgal VN, Srivastava G. Paraneoplastic pemphigus/

[11] Cervini AB, Tosi V, Kim SH, et al. Paraneoplastic pemphigus or paraneoplastic autoimmune multiorgan syndrome. Report of 2 cases in children and a review of the literature. Actas Dermo-Sifiliográficas. 2010;**101**:879-886

paraneoplastic autoimmune multiorgan syndrome. International Journal of Dermatology. 2009;**48**:162-169

[12] Mimouni D, Anhalt GJ, Lazarova Z, et al. Paraneoplastic pemphigus in children and adolescents. British Journal of Dermatology. 2002;**147**:725-732

[13] Lane JE, Woody C, Davis LS, et al. Paraneoplastic autoimmune multiorgan syndrome (paraneoplastic pemphigus) in a child: Case report and review of the literature. Pediatrics.

[14] Geller S, Gat A, Harel A, et al. Childhood pemphigus foliaceus with exclusive immunoglobulin G autoantibodies to desmocollins.

[15] Amber KT, Valdebran M, Grando SA. Paraneoplastic autoimmune multiorgan

syndrome (PAMS): Beyond the single phenotype of paraneoplastic pemphigus. Autoimmunity Reviews.

[16] Kaplan I, Hodak E, Ackerman L, et al. Neoplasms associated with paraneoplastic pemphigus: A review with emphasis on non-hematologic malignancy and oral mucosal manifestations. Oral Oncology.

2004;**114**:e513-e516

Pediatric Dermatology.

2016;**33**:e10-e13

2018;**17**:1002-1010

2004;**40**:553-562

[1] Anhalt GJ, Kim SC, Stanley JR, et al. Paraneoplastic pemphigus. An autoimmune mucocutaneous disease associated with neoplasia. The New England Journal of Medicine.

[2] Nguyen VT, Ndoye A, Bassler KD,

manifestations, and immunopathological mechanisms of the epithelial variant of paraneoplastic autoimmune

multiorgan syndrome: A reappraisal of paraneoplastic pemphigus. Archives of

[3] Paolino G, Didona D, Magliulo G, et al. Paraneoplastic pemphigus: Insight into the autoimmune pathogenesis, clinical features and therapy. International Journal of Molecular Sciences.

2017;**18**:2532. DOI: 10.3390/ijms18122532

pemphigus. The Journal of Investigative Dermatology. Symposium Proceedings.

[5] Sinha AA. Paraneoplastic pemphigus: Autoimmune-cancer nexus in the skin. Anti-Cancer Agents in Medicinal

Manuelyan K. Autoimmune blistering dermatoses as systemic diseases. Clinics in Dermatology. 2014;**32**:364-375

[7] Czernik A, Camilleri M, Pittelkow MR, et al. Paraneoplastic autoimmune multiorgan syndrome: 20 years after. International Journal of Dermatology.

[8] Sticherling M, Erfurt-Berge C. Autoimmune blistering diseases of the skin. Autoimmunity Reviews.

[9] Pollmann R, Schmidt T, Eming R, et al. Pemphigus: A comprehensive

Dermatology. 2001;**137**:193-206

[4] Anhalt GJ. Paraneoplastic

Chemistry. 2015;**15**:1215-1223

[6] Vassileva S, Drenovska K,

2004;**9**:29-33

2011;**50**:905-914

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et al. Classification, clinical

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*Paraneoplastic Pemphigus Is a Life-Threatening Disease DOI: http://dx.doi.org/10.5772/intechopen.84956*

#### **References**

*Current Trends in Cancer Management*

**138**

**Author details**

Richard Lucas Konichi-Dias

provided the original work is properly cited.

School of Health Sciences, Dr. Paulo Prata-FACISB, Barretos, Sao Paulo, Brazil

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

\*Address all correspondence to<EMAIL_ADDRESS>
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[2] Nguyen VT, Ndoye A, Bassler KD, et al. Classification, clinical manifestations, and immunopathological mechanisms of the epithelial variant of paraneoplastic autoimmune multiorgan syndrome: A reappraisal of paraneoplastic pemphigus. Archives of Dermatology. 2001;**137**:193-206

[3] Paolino G, Didona D, Magliulo G, et al. Paraneoplastic pemphigus: Insight into the autoimmune pathogenesis, clinical features and therapy. International Journal of Molecular Sciences. 2017;**18**:2532. DOI: 10.3390/ijms18122532

[4] Anhalt GJ. Paraneoplastic pemphigus. The Journal of Investigative Dermatology. Symposium Proceedings. 2004;**9**:29-33

[5] Sinha AA. Paraneoplastic pemphigus: Autoimmune-cancer nexus in the skin. Anti-Cancer Agents in Medicinal Chemistry. 2015;**15**:1215-1223

[6] Vassileva S, Drenovska K, Manuelyan K. Autoimmune blistering dermatoses as systemic diseases. Clinics in Dermatology. 2014;**32**:364-375

[7] Czernik A, Camilleri M, Pittelkow MR, et al. Paraneoplastic autoimmune multiorgan syndrome: 20 years after. International Journal of Dermatology. 2011;**50**:905-914

[8] Sticherling M, Erfurt-Berge C. Autoimmune blistering diseases of the skin. Autoimmunity Reviews. 2012;**11**:226-230

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review on pathogenesis, clinical presentation and novel therapeutic approaches. Clinical Reviews in Allergy and Immunology. 2018;**54**:1-25

[10] Sehgal VN, Srivastava G. Paraneoplastic pemphigus/ paraneoplastic autoimmune multiorgan syndrome. International Journal of Dermatology. 2009;**48**:162-169

[11] Cervini AB, Tosi V, Kim SH, et al. Paraneoplastic pemphigus or paraneoplastic autoimmune multiorgan syndrome. Report of 2 cases in children and a review of the literature. Actas Dermo-Sifiliográficas. 2010;**101**:879-886

[12] Mimouni D, Anhalt GJ, Lazarova Z, et al. Paraneoplastic pemphigus in children and adolescents. British Journal of Dermatology. 2002;**147**:725-732

[13] Lane JE, Woody C, Davis LS, et al. Paraneoplastic autoimmune multiorgan syndrome (paraneoplastic pemphigus) in a child: Case report and review of the literature. Pediatrics. 2004;**114**:e513-e516

[14] Geller S, Gat A, Harel A, et al. Childhood pemphigus foliaceus with exclusive immunoglobulin G autoantibodies to desmocollins. Pediatric Dermatology. 2016;**33**:e10-e13

[15] Amber KT, Valdebran M, Grando SA. Paraneoplastic autoimmune multiorgan syndrome (PAMS): Beyond the single phenotype of paraneoplastic pemphigus. Autoimmunity Reviews. 2018;**17**:1002-1010

[16] Kaplan I, Hodak E, Ackerman L, et al. Neoplasms associated with paraneoplastic pemphigus: A review with emphasis on non-hematologic malignancy and oral mucosal manifestations. Oral Oncology. 2004;**40**:553-562

[17] Shahidi-Dadras M, Abdollahimajd F, Barzkar N, et al. Paraneoplastic pemphigus with underlying retroperitoneal inflammatory myofibroblastic tumor: A case report and review of the literature. Indian Dermatology Online Journal. 2017;**8**:478-481

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[21] Gill H, Trendell-Smith NJ, Loong F, et al. Paraneoplastic pemphigus due to CD8-positive cytotoxic T-cell lymphoma. British Journal of Haematology. 2010;**149**:464

[22] Ghigliotti G, Di Zenzo G, Cozzani E, et al. Paraneoplastic autoimmune multi-organ syndrome: Association with retroperitoneal Kaposi's sarcoma. Acta Dermato-Venereologica. 2016;**96**:261-262

[23] Hong WJ, Lee SE, Chang S-E, et al. Paraneoplastic pemphigus associated with metastatic lymphoepitheliomalike carcinoma originating from the thyroid gland. The British Journal of Dermatology. 2015;**172**:831-834

[24] Ohzono A, Sogame R, Li X, et al. Clinical and immunological findings in 104 cases of paraneoplastic pemphigus. The British Journal of Dermatology. 2015;**173**:1447-1452

[25] Verrini A, Cannata G, Cozzani E, et al. A patient with immunological features of paraneoplastic pemphigus in the absence of a detectable malignancy. Acta Dermato-Venereologica. 2002;**82**:382-384

[26] Liu Q, Bu D-F, Li D, et al. Genotyping of HLA-I and HLA-II alleles in Chinese patients with paraneoplastic pemphigus. The British Journal of Dermatology. 2008;**158**:587-591

[27] Martel P, Loiseau P, Joly P, et al. Paraneoplastic pemphigus is associated with the DRB1\*03 allele. Journal of Autoimmunity. 2003;**20**:91-95

[28] Kasperkiewicz M, Ellebrecht CT, Takahashi H, et al. Pemphigus. Nature Reviews Disease Primers. 2017;**3**:17026

[29] Okahashi K, Oiso N, Ishii N, et al. Paraneoplastic pemphigus associated with Castleman disease: Progression from mucous to mucocutaneous lesions with epitope-spreading phenomena. The British Journal of Dermatology. 2017;**176**:1406-1409

[30] Gloghini A, Colombatti A, Bressan G, et al. Basement membrane components in lymphoid follicles: Immunohistochemical demonstration and relationship to the follicular dendritic cell network. Human Pathology. 1989;**20**:1001-1007

[31] Futei Y, Amagai M, Hashimoto T, et al. Conformational epitope mapping and IgG subclass distribution of desmoglein 3 in paraneoplastic pemphigus. Journal of the American Academy of Dermatology. 2003;**49**:1023-1028

[32] Ohyama M, Amagai M, Hashimoto T, et al. Clinical phenotype and antidesmoglein autoantibody profile in paraneoplastic pemphigus. Journal of the American Academy of Dermatology. 2001;**44**:593-598

**141**

*Paraneoplastic Pemphigus Is a Life-Threatening Disease DOI: http://dx.doi.org/10.5772/intechopen.84956*

[41] Wieczorek M, Czernik A.

Dermatology. 2016;**9**:291-295

2012;**51**:889-902

2011;**84**:53-60

Paraneoplastic pemphigus: A short review. Clinical, Cosmetic and Investigational

[42] Sokumbi O, Wetter DA. Clinical features, diagnosis, and treatment of erythema multiforme: A review for the practicing dermatologist. International Journal of Dermatology.

[43] Usatine RP, Tinitigan M. Diagnosis and treatment of lichen planus. American Family Physician.

[44] Healy WJ, Peters S, Nana-Sinkam SP. A middle-aged man presenting with unexplained mucosal erosions and progressive dyspnoea. Case Reports.

mucosal lichen planus associated with primary hepatocellular carcinoma. The Journal of Dermatology.

[46] Meyers SJ, Varley GA, Meisler DM,

American Journal of Ophthalmology.

[47] Broussard KC, Leung TG, Moradi A, et al. Autoimmune bullous diseases with skin and eye involvement: Cicatricial pemphigoid, pemphigus vulgaris, and pemphigus paraneoplastica. Clinics in

[48] Bialy-Golan A, Brenner S, Anhalt GJ.

et al. Conjunctival involvement in paraneoplastic pemphigus.

Dermatology. 2016;**34**:205-213

Paraneoplastic pemphigus: Oral involvement as the sole manifestation.

[49] Mutasim DF, Pelc NJ, Anhalt GJ.

Dermatologic Clinics. 1993;**11**:473-481

Acta Dermato-Venereologica.

Paraneoplastic pemphigus.

1996;**76**:253-254

2015;**2015**:bcr2014208677

2006;**33**:842-845

1992;**114**:621-624

[45] Yokokura H, Demitsu T, Kakurai M, et al. Paraneoplastic pemphigus mimicking erosive

[33] Schepens I, Jaunin F, Begre N, et al. The protease inhibitor alpha-2-macroglobulin-like-1 is the p170 antigen recognized by paraneoplastic pemphigus autoantibodies in human.

PLoS One. 2010;**5**:e12250

[34] Galliano M-F, Toulza E, Gallinaro H, et al. A novel protease inhibitor of the alpha2-macroglobulin family expressed in the human epidermis. The Journal of Biological Chemistry. 2006;**281**:5780-5789

[35] Wang L, Bu D, Yang Y, et al. Castleman's tumours and production of autoantibody in paraneoplastic pemphigus. Lancet. 2004;**363**:525-531

[36] Wang R, Li J, Wang M, et al. Prevalence of myasthenia gravis and associated autoantibodies in paraneoplastic pemphigus and their correlations with symptoms and prognosis. The British Journal of Dermatology. 2015;**172**:968-975

[37] Wade MS, Black MM. Paraneoplastic pemphigus:

Quiz 9-10

of Dermatology. 2005;**46**:1-8.

A brief update. The Australasian Journal

[38] Reich K, Brinck U, Letschert M, et al. Graft-versus-host disease-like immunophenotype and apoptotic keratinocyte death in paraneoplastic pemphigus. The British Journal of Dermatology. 1999;**141**:739-746

[39] Konichi-Dias RL, Ramos AF, de Almeida Santos Yamashita ME, et al. Paraneoplastic pemphigus associated with chronic lymphocytic leukemia: A case report. Journal of Medical Case

[40] Kelly S, Schifter M, Fulcher DA, et al. Paraneoplastic pemphigus: Two cases of intra-abdominal malignancy presenting solely as treatment refractory

oral ulceration. The Journal of Dermatology. 2015;**42**:300-304

Reports. 2018;**12**:252

*Paraneoplastic Pemphigus Is a Life-Threatening Disease DOI: http://dx.doi.org/10.5772/intechopen.84956*

[33] Schepens I, Jaunin F, Begre N, et al. The protease inhibitor alpha-2-macroglobulin-like-1 is the p170 antigen recognized by paraneoplastic pemphigus autoantibodies in human. PLoS One. 2010;**5**:e12250

*Current Trends in Cancer Management*

Barzkar N, et al. Paraneoplastic pemphigus with underlying retroperitoneal inflammatory myofibroblastic tumor: A case report and review of the literature. Indian Dermatology Online Journal.

[18] Lim JM, Lee SE, Seo J, et al. Paraneoplastic pemphigus associated with a malignant thymoma: A case of persistent and refractory oral ulcerations following thymectomy. Annals of Dermatology. 2017;**29**:219-222

Treatment. 2013;**45**:70-73

2016;**129**:1501-1502

[20] Wang Y-Z, Gao Z-Y, Lei F-M, et al. A case report on paraneoplastic pemphigus associated colonic carcinoma. Chinese Medical Journal.

[21] Gill H, Trendell-Smith NJ, Loong F,

[23] Hong WJ, Lee SE, Chang S-E, et al. Paraneoplastic pemphigus associated with metastatic lymphoepitheliomalike carcinoma originating from the thyroid gland. The British Journal of Dermatology. 2015;**172**:831-834

[24] Ohzono A, Sogame R, Li X, et al. Clinical and immunological findings in 104 cases of paraneoplastic pemphigus. The British Journal of Dermatology.

et al. Paraneoplastic pemphigus due to CD8-positive cytotoxic T-cell lymphoma. British Journal of

Haematology. 2010;**149**:464

[22] Ghigliotti G, Di Zenzo G, Cozzani E, et al. Paraneoplastic autoimmune multi-organ syndrome: Association with retroperitoneal Kaposi's sarcoma. Acta Dermato-Venereologica. 2016;**96**:261-262

[19] Cho JH, Kim NJ, Ko SM, et al. A case report of paraneoplastic pemphigus associated with esophageal squamous cell carcinoma. Cancer Research and

2017;**8**:478-481

[17] Shahidi-Dadras M, Abdollahimajd F,

[25] Verrini A, Cannata G, Cozzani E, et al. A patient with immunological features of paraneoplastic pemphigus in the absence of a detectable malignancy.

Acta Dermato-Venereologica.

[26] Liu Q, Bu D-F, Li D, et al. Genotyping of HLA-I and HLA-II alleles in Chinese patients with paraneoplastic pemphigus. The British Journal of Dermatology.

[27] Martel P, Loiseau P, Joly P, et al. Paraneoplastic pemphigus is associated with the DRB1\*03 allele. Journal of Autoimmunity. 2003;**20**:91-95

[28] Kasperkiewicz M, Ellebrecht CT, Takahashi H, et al. Pemphigus. Nature Reviews Disease Primers. 2017;**3**:17026

[29] Okahashi K, Oiso N, Ishii N, et al. Paraneoplastic pemphigus associated with Castleman disease: Progression from mucous to mucocutaneous lesions with epitope-spreading phenomena. The British Journal of Dermatology.

2002;**82**:382-384

2008;**158**:587-591

2017;**176**:1406-1409

[30] Gloghini A, Colombatti A, Bressan G, et al. Basement membrane components in lymphoid follicles: Immunohistochemical demonstration and relationship to the follicular dendritic cell network. Human Pathology. 1989;**20**:1001-1007

[31] Futei Y, Amagai M, Hashimoto T, et al. Conformational epitope mapping and IgG subclass distribution of desmoglein 3 in paraneoplastic pemphigus. Journal of the American

[32] Ohyama M, Amagai M, Hashimoto T, et al. Clinical phenotype and antidesmoglein autoantibody profile in paraneoplastic pemphigus. Journal of the American Academy of Dermatology.

Academy of Dermatology.

2003;**49**:1023-1028

2001;**44**:593-598

**140**

2015;**173**:1447-1452

[34] Galliano M-F, Toulza E, Gallinaro H, et al. A novel protease inhibitor of the alpha2-macroglobulin family expressed in the human epidermis. The Journal of Biological Chemistry. 2006;**281**:5780-5789

[35] Wang L, Bu D, Yang Y, et al. Castleman's tumours and production of autoantibody in paraneoplastic pemphigus. Lancet. 2004;**363**:525-531

[36] Wang R, Li J, Wang M, et al. Prevalence of myasthenia gravis and associated autoantibodies in paraneoplastic pemphigus and their correlations with symptoms and prognosis. The British Journal of Dermatology. 2015;**172**:968-975

[37] Wade MS, Black MM. Paraneoplastic pemphigus: A brief update. The Australasian Journal of Dermatology. 2005;**46**:1-8. Quiz 9-10

[38] Reich K, Brinck U, Letschert M, et al. Graft-versus-host disease-like immunophenotype and apoptotic keratinocyte death in paraneoplastic pemphigus. The British Journal of Dermatology. 1999;**141**:739-746

[39] Konichi-Dias RL, Ramos AF, de Almeida Santos Yamashita ME, et al. Paraneoplastic pemphigus associated with chronic lymphocytic leukemia: A case report. Journal of Medical Case Reports. 2018;**12**:252

[40] Kelly S, Schifter M, Fulcher DA, et al. Paraneoplastic pemphigus: Two cases of intra-abdominal malignancy presenting solely as treatment refractory oral ulceration. The Journal of Dermatology. 2015;**42**:300-304

[41] Wieczorek M, Czernik A. Paraneoplastic pemphigus: A short review. Clinical, Cosmetic and Investigational Dermatology. 2016;**9**:291-295

[42] Sokumbi O, Wetter DA. Clinical features, diagnosis, and treatment of erythema multiforme: A review for the practicing dermatologist. International Journal of Dermatology. 2012;**51**:889-902

[43] Usatine RP, Tinitigan M. Diagnosis and treatment of lichen planus. American Family Physician. 2011;**84**:53-60

[44] Healy WJ, Peters S, Nana-Sinkam SP. A middle-aged man presenting with unexplained mucosal erosions and progressive dyspnoea. Case Reports. 2015;**2015**:bcr2014208677

[45] Yokokura H, Demitsu T, Kakurai M, et al. Paraneoplastic pemphigus mimicking erosive mucosal lichen planus associated with primary hepatocellular carcinoma. The Journal of Dermatology. 2006;**33**:842-845

[46] Meyers SJ, Varley GA, Meisler DM, et al. Conjunctival involvement in paraneoplastic pemphigus. American Journal of Ophthalmology. 1992;**114**:621-624

[47] Broussard KC, Leung TG, Moradi A, et al. Autoimmune bullous diseases with skin and eye involvement: Cicatricial pemphigoid, pemphigus vulgaris, and pemphigus paraneoplastica. Clinics in Dermatology. 2016;**34**:205-213

[48] Bialy-Golan A, Brenner S, Anhalt GJ. Paraneoplastic pemphigus: Oral involvement as the sole manifestation. Acta Dermato-Venereologica. 1996;**76**:253-254

[49] Mutasim DF, Pelc NJ, Anhalt GJ. Paraneoplastic pemphigus. Dermatologic Clinics. 1993;**11**:473-481 [50] Yong AA, Tey HL. Paraneoplastic pemphigus. The Australasian Journal of Dermatology. 2013;**54**:241-250

[51] Khandpur S, Verma P. Bullous pemphigoid. Indian Journal of Dermatology, Venereology and Leprology. 2011;**77**:450

[52] Ferrara JLM, Levine JE, Reddy P, et al. Graft-versus-host disease. Lancet. 2009;**373**:1550-1561

[53] Maldonado F, Pittelkow MR, Ryu JH. Constrictive bronchiolitis associated with paraneoplastic autoimmune multi-organ syndrome. Respirology. 2009;**14**:129-133

[54] Mar WA, Glaesser R, Struble K, et al. Paraneoplastic pemphigus with bronchiolitis obliterans in a child. Pediatric Dermatology. 2003;**20**:238-242

[55] Zimmermann J, Bahmer F, Rose C, et al. Clinical and immunopathological spectrum of paraneoplastic pemphigus. Journal der Deutschen Dermatologischen Gesellschaft. 2010;**8**:598-606

[56] Poot AM, Siland J, Jonkman MF, et al. Direct and indirect immunofluorescence staining patterns in the diagnosis of paraneoplastic pemphigus. The British Journal of Dermatology. 2016;**174**:912-915

[57] Joly P, Richard C, Gilbert D, et al. Sensitivity and specificity of clinical, histologic, and immunologic features in the diagnosis of paraneoplastic pemphigus. Journal of the American Academy of Dermatology. 2000;**43**:619-626

[58] Hashimoto T, Amagai M, Ning W, et al. Novel non-radioisotope immunoprecipitation studies indicate involvement of pemphigus vulgaris antigen in paraneoplastic pemphigus. Journal of Dermatological Science. 1998;**17**:132-139

[59] Probst C, Schlumberger W, Stöcker W, et al. Development of ELISA for the specific determination of autoantibodies against envoplakin and periplakin in paraneoplastic pemphigus. Clinica Chimica Acta. 2009;**410**:13-18

[60] Poot AM, Diercks GFH, Kramer D, et al. Laboratory diagnosis of paraneoplastic pemphigus. The British Journal of Dermatology. 2013;**169**:1016-1024

[61] Kelly S, Culican S, Silvestrini RA, et al. Comparative study of five serological assays for the diagnosis of paraneoplastic pemphigus. Pathology. 2015;**47**:58-61

[62] Hashimoto T, Amagai M, Watanabe K, et al. Characterization of paraneoplastic pemphigus autoantigens by immunoblot analysis. The Journal of Investigative Dermatology. 1995;**104**:829-834

[63] Camisa C, Helm TN. Paraneoplastic pemphigus is a distinct neoplasiainduced autoimmune disease. Archives of Dermatology. 1993;**129**:883-886

[64] Helou J, Allbritton J, Anhalt GJ. Accuracy of indirect immunofluorescence testing in the diagnosis of paraneoplastic pemphigus. Journal of the American Academy of Dermatology. 1995;**32**:441-447

[65] Cozzani E, Dal Bello MG, Mastrogiacomo A, et al. Antidesmoplakin antibodies in pemphigus vulgaris. The British Journal of Dermatology. 2006;**154**:624-628

[66] Kazerounian S, Mahoney MG, Uitto J, et al. Envoplakin and periplakin, the paraneoplastic pemphigus antigens, are also recognized by pemphigus foliaceus autoantibodies. The Journal of Investigative Dermatology. 2000;**115**:505-507

[67] van der Waal RI, Pas HH, Anhalt GJ, et al. Paraneoplastic pemphigus as the

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[68] Lee SE, Hashimoto T, Kim S-C. No mucosal involvement in a patient with paraneoplastic pemphigus associated with thymoma and myasthenia gravis. The British Journal of Dermatology.

[69] Frew JW, Murrell DF. Current management strategies in paraneoplastic pemphigus (paraneoplastic autoimmune multiorgan syndrome). Dermatologic

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[72] Gergely L, Váróczy L, Vadász G, et al. Successful treatment of B cell chronic lymphocytic leukemiaassociated severe paraneoplastic pemphigus with cyclosporin A. Acta Haematologica. 2003;**109**:202-205

[73] Williams JV, Marks JG, Billingsley EM. Use of mycophenolate mofetil in the treatment of paraneoplastic pemphigus. The British Journal of Dermatology.

[74] Hertzberg MS, Schifter M, Sullivan J, et al. Paraneoplastic pemphigus in two patients with B-cell non-Hodgkin's lymphoma: Significant responses to cyclophosphamide and prednisolone. American Journal of Hematology.

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1998;**34**:567-570

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2000;**142**:506-508

2000;**63**:105-106

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presenting symptom of a lymphoma of the tongue. Oral Oncology. 1998;**34**:567-570

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Dermatology. 2013;**54**:241-250

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spectrum of paraneoplastic pemphigus. Journal der Deutschen Dermatologischen Gesellschaft.

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Ning W, et al. Novel non-radioisotope immunoprecipitation studies indicate involvement of pemphigus vulgaris antigen in paraneoplastic pemphigus. Journal of Dermatological Science.

2000;**43**:619-626

1998;**17**:132-139

2010;**8**:598-606

[54] Mar WA, Glaesser R, Struble K, et al. Paraneoplastic pemphigus with bronchiolitis obliterans in a child. Pediatric Dermatology. 2003;**20**:238-242

[55] Zimmermann J, Bahmer F, Rose C, et al. Clinical and immunopathological

[56] Poot AM, Siland J, Jonkman MF,

immunofluorescence staining patterns in the diagnosis of paraneoplastic pemphigus. The British Journal of Dermatology. 2016;**174**:912-915

[57] Joly P, Richard C, Gilbert D, et al. Sensitivity and specificity of clinical, histologic, and immunologic features in the diagnosis of paraneoplastic pemphigus. Journal of the American

[50] Yong AA, Tey HL. Paraneoplastic pemphigus. The Australasian Journal of [59] Probst C, Schlumberger W, Stöcker W, et al. Development of ELISA for the specific determination of autoantibodies against envoplakin and periplakin in paraneoplastic pemphigus. Clinica Chimica Acta. 2009;**410**:13-18

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[61] Kelly S, Culican S, Silvestrini RA, et al. Comparative study of five serological assays for the diagnosis of paraneoplastic pemphigus. Pathology.

[62] Hashimoto T, Amagai M, Watanabe K, et al. Characterization of paraneoplastic pemphigus autoantigens by immunoblot analysis. The Journal of Investigative Dermatology. 1995;**104**:829-834

[63] Camisa C, Helm TN. Paraneoplastic pemphigus is a distinct neoplasiainduced autoimmune disease. Archives of Dermatology. 1993;**129**:883-886

[64] Helou J, Allbritton J, Anhalt GJ. Accuracy of indirect immunofluorescence testing in the diagnosis of paraneoplastic pemphigus. Journal of the American Academy of Dermatology. 1995;**32**:441-447

[65] Cozzani E, Dal Bello MG, Mastrogiacomo A, et al. Antidesmoplakin antibodies in

pemphigus vulgaris. The British Journal of Dermatology. 2006;**154**:624-628

[67] van der Waal RI, Pas HH, Anhalt GJ, et al. Paraneoplastic pemphigus as the

[66] Kazerounian S, Mahoney MG, Uitto J, et al. Envoplakin and periplakin, the paraneoplastic pemphigus antigens, are also recognized by pemphigus foliaceus autoantibodies. The Journal of Investigative Dermatology.

2000;**115**:505-507

et al. Laboratory diagnosis of paraneoplastic pemphigus. The British Journal of Dermatology.

2013;**169**:1016-1024

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[69] Frew JW, Murrell DF. Current management strategies in paraneoplastic pemphigus (paraneoplastic autoimmune multiorgan syndrome). Dermatologic Clinics. 2011;**29**:607-612

[70] Martínez De Pablo MI, Iranzo P, Mascaró JM, et al. Paraneoplastic pemphigus associated with non-Hodgkin B-cell lymphoma and good response to prednisone. Acta Dermato Venereologica. 2005;**85**:233-235

[71] Vezzoli P, Berti E, Marzano AV. Rationale and efficacy for the use of rituximab in paraneoplastic pemphigus. Expert Review of Clinical Immunology. 2008;**4**:351-363

[72] Gergely L, Váróczy L, Vadász G, et al. Successful treatment of B cell chronic lymphocytic leukemiaassociated severe paraneoplastic pemphigus with cyclosporin A. Acta Haematologica. 2003;**109**:202-205

[73] Williams JV, Marks JG, Billingsley EM. Use of mycophenolate mofetil in the treatment of paraneoplastic pemphigus. The British Journal of Dermatology. 2000;**142**:506-508

[74] Hertzberg MS, Schifter M, Sullivan J, et al. Paraneoplastic pemphigus in two patients with B-cell non-Hodgkin's lymphoma: Significant responses to cyclophosphamide and prednisolone. American Journal of Hematology. 2000;**63**:105-106

[75] Tan-Lim R, Bystryn JC. Effect of plasmapheresis therapy on circulating levels of pemphigus antibodies. Journal of the American Academy of Dermatology. 1990;**22**:35-40

[76] Izaki S, Yoshizawa Y, Kitamura K, et al. Paraneoplastic pemphigus: Potential therapeutic effect of plasmapheresis. The British Journal of Dermatology. 1996;**134**:987-989

[77] Granata G, Greco A, Iannella G, et al. Posterior reversible encephalopathy syndrome—Insight into pathogenesis, clinical variants and treatment approaches. Autoimmunity Reviews. 2015;**14**:830-836

[78] Hertl M, Zillikens D, Borradori L, et al. Recommendations for the use of rituximab (anti-CD20 antibody) in the treatment of autoimmune bullous skin diseases. Journal der Deutschen Dermatologischen Gesellschaft. 2008;**6**:366-373

[79] Hainsworth JD, Burris HA, Morrissey LH, et al. Rituximab monoclonal antibody as initial systemic therapy for patients with low-grade non-Hodgkin lymphoma. Blood. 2000;**95**:3052-3056

[80] Hohwy T, Bang K, Steiniche T, et al. Alemtuzumab-induced remission of both severe paraneoplastic pemphigus and leukaemic bone marrow infiltration in a case of treatment-resistant B-cell chronic lymphocytic leukaemia. European Journal of Haematology. 2004;**73**:206-209

[81] Lee SE, Kim S-C. Paraneoplastic pemphigus. Dermatologica Sinica. 2010;**28**:1-14

[82] Zhu X, Zhang B. Paraneoplastic pemphigus. The Journal of Dermatology. 2007;**34**:503-511

[83] Anhalt GJ. Paraneoplastic pemphigus. Advances in Dermatology. 1997;**12**:77-96. Discussion 97

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*Current Trends in Cancer Management*

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[86] Rencz F, Gulácsi L, Tamási B, et al. Health-related quality of life and its determinants in pemphigus: A systematic review and meta-analysis. The British Journal of Dermatology.

2015;**173**:1076-1080

**144**

### *Edited by Liliana Streba, Dan Ionut Gheonea and Michael Schenker*

The field of cancer diagnosis, prognosis, and treatment is constantly advancing. From novel biomarkers to cutting-edge imaging solutions, changing chemotherapy protocols and novel immune-targeting agents, medical teams develop and test new ways to manage this ever-growing threat to the modern age.

Imaging has been a reliable method for initial diagnosis and later surveillance of premalignant and cancerous lesions of the digestive tract.

This book project aims to characterize the main diagnostic procedures and novel medical and surgical treatments, as well as provide an updated view on current guidelines, premalignant lesions management, and minimally invasive curative techniques.

Published in London, UK © 2019 IntechOpen © Ugreen / iStock

Current Trends in Cancer Management

Current Trends in

Cancer Management

*Edited by Liliana Streba,*

*Dan Ionut Gheonea and Michael Schenker*


*<IP_ADDRESS> Seismic activity*

It is also important to monitor seismic activity in and around these areas. In a region which is active in terms of seismicity, fractures, faults, and subsidence dissolution caves/areas in gypsum units, and changes in underground water levels should be monitored because new deformations may develop over time and new dissolution caves/areas may also occur (**Figures 1a** and **5b, c**).

New problems will be added to the existing problems if all these natural and environmental factors that have an impact on the sustainability of the environment and the quality of life of all kinds of living beings are not determined, and hazards, risks and other problems that may arise are not kept under control in time. Therefore, the attempts of regional or local authorities to maintain environmentalist works, as well as at the dimension of countries, and the compliance with the EIA/SEIA reports in constructions are important for the sustainability of the quality of life.


3.1.4. Agrochemicals

Regular use of pesticides in irrigated crops is also likely to lead to the occurrence of these residues in irrigation water and food crops, especially in regions where regulation and training in proper application of these substances is lacking. Application of large quantities of agrichemicals and improper management can create a substantial effect on the environment. The leaching and runoff of agrochemicals is a potential source of groundwater and surface water contamination [95,96]. The occurrence of agrichemical residues in vegetables has been documented [97] and their uptake by crops is well studied [98,99] and regulated. Leaching of nitrate from fertilizer over application to groundwater below is well reported, and accumulation of reactive nitrogen is also thought to initiate mobilization of other geogenic contaminants [15].