|Year : 2016 | Volume
| Issue : 2 | Page : 43-50
Usefulness of enzyme-linked immunosorbent assay in the diagnosis of pemphigus and bullous pemphigoid in upper Egypt: correlation with intensity score
Azza Mahfouz Abdel-Megaid1, Hisham D Gaber1, Amal T Abo-elghiet2, Sohir K Sayed3, Asma O Ahmed3, Aya Y Badran1
1 Department of Dermatology, Venereology and Andrology, Faculty of Medicine, Assiut University, Assiut, Egypt
2 Department of Histology, Faculty of Medicine, Assiut University, Assiut, Egypt
3 Department of Clinical Pathology, Faculty of Medicine, Assiut University, Assiut, Egypt
|Date of Submission||30-Jul-2016|
|Date of Acceptance||05-Oct-2016|
|Date of Web Publication||21-Mar-2017|
Hisham D Gaber
Department of Dermatology, Venereology and Andrology, Faculty of Medicine, Assiut University, Assiut 08844423
Source of Support: None, Conflict of Interest: None
Background The availability of complementary DNA clones for pemphigus and pemphigoid antigens has led to the production of recombinant proteins representing epitopes of native antigens Dsg1, Dsg3, BP180 and BP230, and to the development of related enzyme-linked immunosorbent assay (ELISA) systems.
Objective The aim of this study was to evaluate the diagnostic value of Dsg1, Dsg3, BP180 and BP230 ELISAs in upper Egypt patients, and to assess its correlation with the severity of diseases.
Patients and methods Forty-six patients with pemphigus and bullous pemphigoid were enrolled. The diagnosis was confirmed by means of histopathology and direct immunofluorescence. Autoantibodies against Dsg1, Dsg3, BP180 and BP230 were assayed using ELISA in the serum of pemphigus and bullous pemphigoid patients. In pemphigus vulgaris, anti-Dsg1 and anti-Dsg3 antibody titre were raised above the cutoff value in 88.5 and 96.1% of patients, respectively. A strong positive correlation between the titre of anti-Dsg1 and Dsg3 and the total Autoimmune Bullous Skin Disorder Intensity Score (ABSIS) in (mucocutaneous) pemphigus patients (P<0.001) was detected. Moreover, a strong positive correlation between the titre of anti-BP180 and anti-BP230 and the total ABSIS score was found (P<0.001).
Conclusion ELISA can be considered an important step in the laboratory diagnosis of pemphigus and bullous pemphigoid, especially as it is a simple, noninvasive and fast manoeuvre. Anti-Dsg1 Ab and anti-Dsg3 Ab ELISA values are correlated with the disease activity of pemphigus. Anti-BP180 and anti-BP230 Ab ELISA values are correlated with the disease activity of bullous pemphigoid.
Keywords: bullous pemphigoid, enzyme-linked immunosorbent assay, pemphigus
|How to cite this article:|
Abdel-Megaid AM, Gaber HD, Abo-elghiet AT, Sayed SK, Ahmed AO, Badran AY. Usefulness of enzyme-linked immunosorbent assay in the diagnosis of pemphigus and bullous pemphigoid in upper Egypt: correlation with intensity score. Egypt J Dermatol Venerol 2016;36:43-50
|How to cite this URL:|
Abdel-Megaid AM, Gaber HD, Abo-elghiet AT, Sayed SK, Ahmed AO, Badran AY. Usefulness of enzyme-linked immunosorbent assay in the diagnosis of pemphigus and bullous pemphigoid in upper Egypt: correlation with intensity score. Egypt J Dermatol Venerol [serial online] 2016 [cited 2020 May 28];36:43-50. Available from: http://www.ejdv.eg.net/text.asp?2016/36/2/43/202638
| Introduction|| |
Autoimmune bullous diseases (AIBD) are clinically characterized by chronic mucocutaneous blistering, leading to severe morbidity and increased mortality . Blister formation is directly or indirectly caused by autoantibodies binding to structural proteins of the skin . These structures are responsible for cell-to-cell and cell-to-matrix junction . Depending on the location of the blister and the targeted autoantigens, AIBD can be classified as pemphigus and pemphigoid disease, epidermolysis bullosa acquisita and dermatitis herpetiformis . The most frequent AIBD are pemphigus and bullous pemphigoid, with incidences varying considerably between geographical regions .
Pemphigus includes a group of severe autoimmune diseases. The two main classic types of pemphigus have been identified as pemphigus vulgaris (PV) and pemphigus foliaceus (PF) . The main characteristics of the pemphigus disease are the presence of autoantibody against cell-to-cell junctions and intraepidermal bullae. The pathogenic immunogloblin G (IgG) autoantibodies are directed against transmembrane desmosomal proteins called desmogleins (Dsg) .
Pemphigoid has two major forms: bullous pemphigoid (BP) and pemphigoid of the mucous membranes. In BP, skin blisters are common and oral lesions are rare, and when the oral lesions occur they are transient with few symptoms . Bullous pemphigoid is characterized by subepidermal bullae and associated with circulating and tissue-bound autoantibodies directed against two hemidesmosomal components of the basement membrane: BP180 (BPAg2, type XVII collagen) and BP230 (BPAg1) .
There is a great need for rapidly establishing the diagnosis of these disorders as they may run a severe and potentially life-threatening course . In many cases, bullous diseases cannot be differentiated clinically and need the help of histopathological examination and immunofluorescence study . The cell staining pattern using direct immunofluorescence (DIF) or indirect immunofluorescence (IIF) is virtually identical, making it difficult to distinguish between PV and PF .
The availability of complementary DNA clones for pemphigus and pemphigoid antigens has led to the production of recombinant proteins representing epitopes of native antigens Dsg1, Dsg3, BP180 and BP230, and to the development of related enzyme-linked immunosorbent assay (ELISA) systems .
ELISA has several advantages: large numbers of samples can be analysed in a relatively short time; and the data are objectives as the optical density of each well can be read automatically and expressed as a numerical value . Other advantages of ELISA are as follows: provides information on antigen identity and can allow PV and PF to be distinguished; provides reproducible, quantitative data, which can be beneficial in guiding patient management; and it is simple and can be easily applied .
During the last decade, efforts to evaluate the clinical extent and severity of pemphigus, to better estimate the therapeutic efficacy of different modalities, have led to the establishment of scoring systems. The Autoimmune Bullous Skin Disorder Intensity Score (ABSIS) is a clinical score introduced by Pfütze et al.  to achieve improved evaluation and monitoring of the status of both oral and cutaneous lesions in patients with pemphigus. Total ABSIS score consists of ABSIS score for skin involvement, mucosal extent score and mucosal severity score . There are other scoring systems used to evaluate the extent and severity of pemphigus (e.g. pemphigus disease area index), but we used the ABSIS in this study because we find it more convenient for our study .
The aim of this study was to evaluate the diagnostic value of Dsg1, Dsg3, BP180 and BP230 autoantibodies detected using ELISA in the diagnosis of pemphigus and bullous pemphigoid in upper Egypt, and to correlate the titre of these autoantibodies with the activity of the disease using the ABSIS.
| Patients and methods|| |
This descriptive study was conducted at the Department of Dermatology, Venereology and Andrology, Assiut University Hospital, during the period from 2013 to 2015. Written informed consent was obtained from patients included in the study, and the study was approved by the Faculty of Medicine Ethics Committee, Assiut University.
The study included 46 patients, after exclusion of patients on corticosteroids and/or any immunosuppressive agent at, or 1 month before, the time of the study (most of the cases were new cases, and some of them were on no treatment 1 month before the study), to correlate the actual clinical score and antibody titre. The patients were diagnosed clinically, histopathologically and with DIF as having pemphigus disease (n=36) and bullous pemphigoid (n=10). Of the 36 patients with pemphigus disease, 26 patients were diagnosed as having PV, seven patients as having PF and three patients as having pemphigus herpetiformis (PH). The 10 patients diagnosed as having BP included three male (30%) and seven female patients (70%).
Clinical information was obtained by means of brief history taking, and general and dermatological examination. Biopsy specimens were obtained from all cases and sent for histopathological examinations including haematoxylin and eosin (H&E) and DIF (IgG, IgM, IgA and C3).
Each patient was scored using the ABSIS with a maximum score of 206. It consists of skin involvement score and oral involvement score. The skin involvement score uses the rule of ninth, which is used in burn measurement, to assess the percentage of involvement of blisters and erosions on the skin combined with a weighting factor for the stage of the blistering and erosions [skin involvement total score=% body surface area (BSA)×weighting factor=0–150 points]. Erosive, exudative lesions obtain a weighting factor of 1.5; erosive, dry lesions have a weighting factor of 1.0; and re-epithelized lesions have a weighting factor of 0.5. Oral involvement is based on two scores: the extent (presence of lesions) the disease and the severity (discomfort during eating and drinking) of the disease. The extent is given a score of 0 or 1 (absence or presence, respectively) for 11 different parts of the mouth. The severity of oral lesions is assessed by evaluating the amount of pain/bleeding associated with certain foods. The maximum scores for oral involvement are 11 for extent and 45 for severity .
- Extent (1 for presence of lesions, and 0 for absence of any lesion). Total score ranges from 0 to 11.
- Severity (discomfort during eating/drinking).
Five milliliters of blood was drawn from each patient. Blood samples were left to clot for 30 min at 37°C and then centrifuged at 3000 rpm for 10 min. The separated serum was immediately divided into aliquots and kept at −20°C for further investigation.
Enzyme-linked immunosorbent assay tests for Dsg3, Dsg1, BP180 and BP230
All serum samples were tested in the Clinical Pathology Departments, Assiut University Hospital, to assess Dsg3, Dsg1, BP180 and BP230 antibody titre using commercial ELISA kits (ELISA, anti-BP180-NC16A-ELISA, anti-BP230-CF-ELISA, anti-Dsg1-ELISA and anti-Dsg3-ELISA; all manufactured by Euroimmun Medizinische Labordiagnostika AG, Lubeck, Deutschland) ,. The serum samples were diluted to 1 : 100 in accordance with the manufacturer’s instructions, and the manufacturer’s cutoff value of 20 RU/ml was used. All four markers had the same principle.
The ELISA test kit provides a semiquantitative or quantitative in-vitro assay for human autoantibodies of the immunoglobulin class IgG against Dsg1, Dsg3, BP180 or BP230. The test kit contains six microtitre strips each with eight individual break-off reagent wells coated with Dsg1, Dsg3, BP180 or BP230. In the first reaction step, diluted patient samples are incubated in the wells. In the case of positive samples, specific IgG antibodies will bind to the antigens. To detect the bounded antibodies, a second incubation is carried out using an enzyme-labelled anti-human IgG (enzyme conjugate) catalyzing a colour reaction.
All analyses were performed with the SPSS 20.0 software (IBM_SPSS. Statistical Package for Social Science. Ver.21. Standard version. Copyright © SPSS Inc., 2011–2012. NY, USA. 2012). Categorical variables were described as number and percentage, whereas continuous variables were described as mean and SD. Continuous variables were tested for normal distribution using the Kolmogorov–Smirnov test. Pearson correlation coefficient was used to assess the association between ABSIS score and desmoglein levels. A two-tailed test was used. P value less than 0.05 was considered statistically significant.
| Results|| |
Among patients with pemphigus, PV was the most frequent disease in 26/36 patients (72.7%), followed by PF in 7/36 (19.4%), and lastly PH in 3/36 (8.3%). The age of this group ranged from 21 to 73 years, with a mean of 46.94±14.6 years. In this group, male sex was more frequent among patients having PV and PF, whereas all patients who had PH were female ([Table 1]).
As regards ELISA results in patients with PV, anti-Dsg3 titre was raised above the cutoff value in 25 patients (96.1%), whereas 23 patients (88.5%) showed raised anti-Dsg1 titre. Only one patient who was diagnosed clinically, pathologically and using DIF as having PV showed negative results for both anti-Dsg3 and anti-Dsg1 ([Table 2]). All PV patients were negative for anti-BP180 and anti-BP230 titre.
|Table 2 Enzyme-linked immunosorbent assay result in patients with pemphigus (n=36)|
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In PF and PH, the anti-Dsg1 level was raised in all cases (100%), whereas, anti-Dsg3, BP180 and BP230 titre were not raised above the cutoff ([Table 2]).
Skin and oral severity of pemphigus patients were studied using the ABSIS score after they had been divided into three subgroups as regards the location of lesions at baseline: cutaneous lesions (n=26), mucosal lesions (n=20) and both cutaneous and mucosal lesions (n=26). Correlation between the score and the titre of the anti-Dsg1 and Dsg3 values was made ([Table 3]).
|Table 3 Correlation of the anti-Dsg1 titre with the activity of pemphigus disease using Autoimmune Bullous Skin Disorder Intensity Score|
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There was a positive significant correlation between the titre of anti-Dsg1 and the total ABSIS (mucocutaneous) in PV patients (r=0.646, P<0.001). Moreover, a positive significant correlation between the titre of anti-Dsg1 and both the cutaneous ABSIS score and mucous membrane score in PV patients (P<0.001 for each).
However, no significant correlation was found between the titre of anti-Dsg1 and the total ABSIS in PF or PH ([Table 3] and [Figure 1]). Patients with PF and PH had no mucous membrane affection.
|Figure 1 Correlation of the anti-Dsg1 antibodies titre using enzyme-linked immunosorbent assay (ELISA) with the activity of pemphigus vulgaris (PV) using Autoimmune Bullous Skin Disorder Intensity Score (ABSIS) score.|
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As regards anti-Dsg3, we found a positive correlation between the titre of anti-Dsg3 and the total ABSIS (mucocutaneous) of PV patients (r=0.725, P<0.001). Moreover, there was a positive significant correlation between the titre of anti-Dsg3 and both the mucous membrane and the skin score (P<0.001 for each) ([Table 4] and [Figure 2]). Patients with PF and PH had negative anti-Dsg3 titre (not raised above the cutoff).
|Table 4 Correlation of the anti-Dsg3 titre with the activity of pemphigus vulgaris using Autoimmune Bullous Skin Disorder Intensity Score|
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|Figure 2 Correlation of the anti-desmoglein-3 antibodies titre using enzyme-linked immunosorbent assay (ELISA) with the activity of pemphigus vulgaris (PV) using Autoimmune Bullous Skin Disorder Intensity Score (ABSIS) score.|
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In BP, using ELISA we found that 7/10 patients (70%) had elevated anti-BP180 titre, whereas 2/10 patients (20%) showed raised anti-BP230 titre. There was one male patient, clinically, pathologically and with DIF diagnosed as having BP, but ELISA result were incompatible with this diagnosis, as his serum was negative for anti-BP180 and anti-BP230.
A strong positive correlation between the titre of anti-BP180, anti-BP230 and the total ABSIS was found (r=0.904, P<0.001; r=1, P<0.000, respectively) ([Table 5] and [Figure 3] and [Figure 4]). All BP patients showed no mucous membrane involvement.
|Table 5 Correlation of the anti-BP180 and anti-BP230 antibody titre with the activity of the disease using Autoimmune Bullous Skin Disorder Intensity Score|
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|Figure 3 Correlation of the anti-BP180 titre with the activity of the disease using Autoimmune Bullous Skin Disorder Intensity Score (ABSIS) score.|
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|Figure 4 Correlation of the anti-BP230 titre with the activity of the disease using Autoimmune Bullous Skin Disorder Intensity Score (ABSIS) score.|
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| Discussion|| |
ELISA is a useful adjunctive in the diagnosis of AIBD. Although clinicians can usually differentiate these disorders on the basis of clinical features, histopathology, DIF and IIF, there are times when the diagnosis is equivocal .
Several ELISA systems using recombinant fragments of BP180, BP230, or Dsg1 and Dsg3 have become commercially available and are highly valuable diagnostic tools in the diagnosis of autoimmune bullous skin diseases .
It is considered a sensitive, easy and quick reading tool for the diagnosis of the main autoimmune blistering diseases: pemphigus and bullous pemphigoid. Moreover, autoantibody titre correlates with disease severity, and is useful to monitor treatment response .
As regards the frequency of immunobullous diseases in our study, we found that PV was the most frequent disease (56.5%), followed by BP (21.7%). Similarly, Khannan and Bhat  found that PV was the most common immunobullous disease observed in 34% of cases, followed by bullous pemphigoid (BP) in 26% of patients.
PV patients are divided into the mucosal-dominant type (predominantly oral erosions with limited skin involvement) and the mucocutaneous type (extensive skin involvement in addition to oral lesions). If serum is positive for anti-Dsg3 but negative for anti-Dsg1, it indicates mucosal-dominant pemphigus; if it is positive for anti-Dsg3 and anti-Dsg1 it indicates mucocutaneous PV. If serum is positive for anti-Dsg1 but negative for anti-Dsg3, it indicates PF .
In the present study, among patients with PV, anti-Dsg3 antibody titre was detected in 25/26 PV patients (96.2%), whereas 23/26 patients (88.5%) showed raised anti-Dsg1 titre. This is in agreement with the findings of Andreadis et al. , who reported that some patients with PV have only anti-Dsg3 IgG, whereas other patients have both anti-Dsg3 and anti-Dsg1 IgG. A similar study was conducted by Khandpur et al. , who found that, of the 54 cases, 53 (98.15%) had elevated anti-Dsg3 titre, whereas 45 (83.3%) showed raised anti-Dsg1 titre.
In this study, among patients with PF, the anti-Dsg1 level was raised in seven cases (100%), whereas anti-Dsg3 was not detected. This result is in accordance with that of Andreadis et al. , who found that patients with PF have only anti-Dsg1 IgG. In another study conducted by Schmidt et al. , autoantibodies against Dsg1 were detected in 48 (96%) of 50 PF sera.
In our study, there was a positive significant correlation between the titre of anti-Dsg1 and the total ABSIS (mucocutaneous) in PV patients. Moreover, there was a positive significant correlation between the titre of anti-Dsg1 and both the cutaneous ABSIS and mucous membrane score in PV patients for each. This is in agreement with the findings of Mortazavi et al. , who found a strong positive correlation between the titre of anti-Dsg1, and the skin and oral severity of pemphigus patients. They stated that the anti-Dsg3 and especially anti-Dsg1 autoantibody levels could be good indicators of severity of PV and may be of great benefit in the management and monitoring of patients with PV. Another study by Patsatsi et al.  found a weak positive significant correlation between the titre of anti-Dsg1 and the total ABSIS score.
Moreover, in this study, there was a strong positive correlation between the titre of anti-Dsg3 and the total ABSIS in PV patients. In accordance with our results, Harman et al.  have reported a relationship between anti-Dsg3 autoantibody levels measured using ELISA and the severity score of cutaneous and oral involvement in PV. In another study conducted by Ng et al. , they found a positive correlation between the clinical phenotype of patients and the recognition of anti-desmo-3 and/or desmo-1 in patients’ sera. Further, Mortazavi et al.  found that anti-Dsg3 value increases with oral severity, although this was not statistically significant.
In summary, pemphigus activity is associated with a wide range of anti-Dsg1 and anti-Dsg3 antibody values, and abnormal values of anti-Dsg antibodies are not always associated with disease activity. Furthermore, high levels of anti-Dsg antibodies were detected in the sera of several patients with PV and PF who were in complete remission and were not taking any medication. There is as yet no consensus concerning the value of anti-Dsg1 and anti-Dsg3 antibodies or the IIF test to monitor disease activity in patients with pemphigus.
As regards BP, in the present study, anti-BP180 was raised above the cutoff value in seven (70%) patients, whereas two (20%) patients showed raised anti-BP230 titre: Another study was done by Chan et al.  showed positive results of ELISA for the anti-BP 180 antibodies in 96% of cases. In a larger study by Sakuma-Oyama et al. , 102 patients with BP showed similar results, with a percentage of 89%. Feng et al.  also found that 19 of the 20 (95%) patients exhibited elevated serum levels of autoantibodies to BP180 using ELISA.
In the present study, anti-BP230 was raised above the cutoff value in 20% of patients. However, in a study by Wieland et al. , they found that anti-BP230 was raised above the cutoff value in 82% of patients.
In the current study, we found a strong positive correlation between the titre of both anti-BP180 and anti-BP230 values and the total ABSIS, respectively.
In the study conducted by Tsuji-Abe et al.  and Izumi et al. , they reported a direct correlation between the BP180 ELISA scores and the grade of disease severity. They stated that the BP180 ELISA index correlated well with clinical severity, especially in long-term follow-up. Moreover, Feng et al.  found a correlation between BP180 and disease activity. Similar results were reported in another study by Lee et al. , who found a strong positive correlation between BP180 ELISA scores and the grade of disease severity; however, contradictory to our results, the BP230 ELISA scores did not show any significant relationship with the clinical characteristics of BP.
In bullous pemphigoid, measurement of circulating autoantibodies against BP180 and BP230 with ELISA is helpful for diagnosis and may be used for disease monitoring and guiding management decisions .
| Conclusion|| |
The anti-Dsg3 and anti-Dsg1 autoantibody levels could be good indicators of severity of PV and may be of great benefit in the management and monitoring of patients with PV. ELISA can be considered an important step in the laboratory diagnosis of pemphigus and bullous pemphigoid, especially as it is a simple, noninvasive and fast manoeuvre.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]