Bullous Pemphigoid With a Dual Pattern of Glomerular Immune Complex Disease

Ewout J. Hoorn*, Noor E. Taams, Tiina Hurskainen, Mahdi Salih, Jan J. Weening, Marcel F. Jonkman, Hendri H. Pas, Marco W. J. Schreurs

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review

5 Citations (Scopus)

Abstract

A 75-year-old man presented with a blistering skin disease and nephrotic syndrome. Bullous pemphigoid was diagnosed by linear immunoglobulin G (IgG) and C3 staining along the basement membrane zone of a skin biopsy specimen and by the presence of circulating IgG recognizing the 180-kDa bullous pemphigoid antigen (BP180; type XVII collagen). A kidney biopsy specimen showed endocapillary inflammation without crescents. Direct immunofluorescence showed strong IgG and C3 staining in a combined granular and linear pattern along the glomerular basement membrane. Electron microscopy showed subepithelial deposits. In serum, no antibodies against the Goodpasture antigen (type IV collagen) or phospholipase A(2) receptor were detected. Indirect immunofluorescence studies using the patient's serum showed a strikingly linear but not granular IgG pattern along the epithelial basement membranes of monkey esophagus and kidney. Although type XVII collagen was recently identified in the glomerulus, the patient's serum did not produce a 180-kDa band on immunoblot of kidney tissue and still stained glomeruli of BP180 knockout mice by indirect immunofluorescence. The patient was treated with prednisone and azathioprine, which resulted in complete remission of skin and kidney manifestations. Although bullous pemphigoid has been reported previously in association with anti-glomerular basement membrane disease or membranous nephropathy, this case demonstrates both elements in 1 patient. This concurrence and the linear pattern on indirect immunofluorescence support the possibility of cross-reactive or parallel autoantibodies to basement membranes with a secondary membranous component. (C) 2016 by the National Kidney Foundation, Inc.

Original languageEnglish
Pages (from-to)302-306
Number of pages5
JournalAmerican Journal of Kidney Diseases
Volume67
Issue number2
DOIs
Publication statusPublished - Feb-2016

Keywords

  • Bullous pemphigoid
  • 180-kDa BP antigen
  • type XVII collagen
  • glomerular basement membrane (GBM)
  • anti-GBM disease
  • membranous nephropathy
  • autoantibody
  • nephrotic syndrome
  • renal biopsy
  • COLLAGEN
  • NEPHROPATHY
  • DIAGNOSIS
  • BLISTERS
  • PATIENT

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