Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
15th National Conference of the IAOMFP, Chennai, 2006
Abstract
Abstracts from current literature
Acne in India: Guidelines for management - IAA Consensus Document
Addendum
Announcement
Art & Psychiatry
Article
Articles
Association Activities
Association Notes
Award Article
Book Review
Brief Report
Case Analysis
Case Letter
Case Letters
Case Notes
Case Report
Case Reports
Clinical and Laboratory Investigations
Clinical Article
Clinical Studies
Clinical Study
Commentary
Conference Oration
Conference Summary
Continuing Medical Education
Correspondence
Corrigendum
Cosmetic Dermatology
Cosmetology
Current Best Evidence
Current Issue
Current View
Derma Quest
Dermato Surgery
Dermatopathology
Dermatosurgery Specials
Dispensing Pearl
Do you know?
Drug Dialogues
e-IJDVL
Editor Speaks
Editorial
Editorial Remarks
Editorial Report
Editorial Report - 2007
Editorial report for 2004-2005
Errata
Erratum
Focus
Fourth All India Conference Programme
From Our Book Shelf
From the Desk of Chief Editor
General
Get Set for Net
Get set for the net
Guest Article
Guest Editorial
History
How I Manage?
IADVL Announcement
IADVL Announcements
IJDVL Awards
IJDVL AWARDS 2015
IJDVL Awards 2018
IJDVL Awards 2019
IJDVL Awards 2020
IJDVL International Awards 2018
Images in Clinical Practice
In Memorium
Inaugural Address
Index
Knowledge From World Contemporaries
Leprosy Section
Letter in Response to Previous Publication
Letter to Editor
Letter to the Editor
Letter to the Editor - Case Letter
Letter to the Editor - Letter in Response to Published Article
LETTER TO THE EDITOR - LETTERS IN RESPONSE TO PUBLISHED ARTICLES
Letter to the Editor - Observation Letter
Letter to the Editor - Study Letter
Letter to the Editor - Therapy Letter
Letter to the Editor: Articles in Response to Previously Published Articles
Letters in Response to Previous Publication
Letters to the Editor
Letters to the Editor - Letter in Response to Previously Published Articles
Letters to the Editor: Case Letters
Letters to the Editor: Letters in Response to Previously Published Articles
Medicolegal Window
Messages
Miscellaneous Letter
Musings
Net Case
Net case report
Net Image
Net Images
Net Letter
Net Quiz
Net Study
New Preparations
News
News & Views
Obituary
Observation Letter
Observation Letters
Oration
Original Article
ORIGINAL CONTRIBUTION
Original Contributions
Pattern of Skin Diseases
Pearls
Pediatric Dermatology
Pediatric Rounds
Perspective
Presedential Address
Presidential Address
Presidents Remarks
Quiz
Recommendations
Regret
Report
Report of chief editor
Report of Hon : Treasurer IADVL
Report of Hon. General Secretary IADVL
Research Methdology
Research Methodology
Resident page
Resident's Page
Resident’s Page
Residents' Corner
Residents' Corner
Residents' Page
Retraction
Review
Review Article
Review Articles
Reviewers 2022
Revision Corner
Self Assessment Programme
SEMINAR
Seminar: Chronic Arsenicosis in India
Seminar: HIV Infection
Short Communication
Short Communications
Short Report
Snippets
Special Article
Specialty Interface
Studies
Study Letter
Study Letters
Supplement-Photoprotection
Supplement-Psoriasis
Symposium - Contact Dermatitis
Symposium - Lasers
Symposium - Pediatric Dermatoses
Symposium - Psoriasis
Symposium - Vesicobullous Disorders
SYMPOSIUM - VITILIGO
Symposium Aesthetic Surgery
Symposium Dermatopathology
Symposium-Hair Disorders
Symposium-Nails Part I
Symposium-Nails-Part II
Systematic Review and Meta-Analysis
Systematic Reviews
Systematic Reviews and Meta-analyses
Systematic Reviews and Meta-analysis
Tables
Technology
Therapeutic Guideline-IADVL
Therapeutic Guidelines
Therapeutic Guidelines - IADVL
Therapeutics
Therapy
Therapy Letter
Therapy Letters
View Point
Viewpoint
What’s new in Dermatology
Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
15th National Conference of the IAOMFP, Chennai, 2006
Abstract
Abstracts from current literature
Acne in India: Guidelines for management - IAA Consensus Document
Addendum
Announcement
Art & Psychiatry
Article
Articles
Association Activities
Association Notes
Award Article
Book Review
Brief Report
Case Analysis
Case Letter
Case Letters
Case Notes
Case Report
Case Reports
Clinical and Laboratory Investigations
Clinical Article
Clinical Studies
Clinical Study
Commentary
Conference Oration
Conference Summary
Continuing Medical Education
Correspondence
Corrigendum
Cosmetic Dermatology
Cosmetology
Current Best Evidence
Current Issue
Current View
Derma Quest
Dermato Surgery
Dermatopathology
Dermatosurgery Specials
Dispensing Pearl
Do you know?
Drug Dialogues
e-IJDVL
Editor Speaks
Editorial
Editorial Remarks
Editorial Report
Editorial Report - 2007
Editorial report for 2004-2005
Errata
Erratum
Focus
Fourth All India Conference Programme
From Our Book Shelf
From the Desk of Chief Editor
General
Get Set for Net
Get set for the net
Guest Article
Guest Editorial
History
How I Manage?
IADVL Announcement
IADVL Announcements
IJDVL Awards
IJDVL AWARDS 2015
IJDVL Awards 2018
IJDVL Awards 2019
IJDVL Awards 2020
IJDVL International Awards 2018
Images in Clinical Practice
In Memorium
Inaugural Address
Index
Knowledge From World Contemporaries
Leprosy Section
Letter in Response to Previous Publication
Letter to Editor
Letter to the Editor
Letter to the Editor - Case Letter
Letter to the Editor - Letter in Response to Published Article
LETTER TO THE EDITOR - LETTERS IN RESPONSE TO PUBLISHED ARTICLES
Letter to the Editor - Observation Letter
Letter to the Editor - Study Letter
Letter to the Editor - Therapy Letter
Letter to the Editor: Articles in Response to Previously Published Articles
Letters in Response to Previous Publication
Letters to the Editor
Letters to the Editor - Letter in Response to Previously Published Articles
Letters to the Editor: Case Letters
Letters to the Editor: Letters in Response to Previously Published Articles
Medicolegal Window
Messages
Miscellaneous Letter
Musings
Net Case
Net case report
Net Image
Net Images
Net Letter
Net Quiz
Net Study
New Preparations
News
News & Views
Obituary
Observation Letter
Observation Letters
Oration
Original Article
ORIGINAL CONTRIBUTION
Original Contributions
Pattern of Skin Diseases
Pearls
Pediatric Dermatology
Pediatric Rounds
Perspective
Presedential Address
Presidential Address
Presidents Remarks
Quiz
Recommendations
Regret
Report
Report of chief editor
Report of Hon : Treasurer IADVL
Report of Hon. General Secretary IADVL
Research Methdology
Research Methodology
Resident page
Resident's Page
Resident’s Page
Residents' Corner
Residents' Corner
Residents' Page
Retraction
Review
Review Article
Review Articles
Reviewers 2022
Revision Corner
Self Assessment Programme
SEMINAR
Seminar: Chronic Arsenicosis in India
Seminar: HIV Infection
Short Communication
Short Communications
Short Report
Snippets
Special Article
Specialty Interface
Studies
Study Letter
Study Letters
Supplement-Photoprotection
Supplement-Psoriasis
Symposium - Contact Dermatitis
Symposium - Lasers
Symposium - Pediatric Dermatoses
Symposium - Psoriasis
Symposium - Vesicobullous Disorders
SYMPOSIUM - VITILIGO
Symposium Aesthetic Surgery
Symposium Dermatopathology
Symposium-Hair Disorders
Symposium-Nails Part I
Symposium-Nails-Part II
Systematic Review and Meta-Analysis
Systematic Reviews
Systematic Reviews and Meta-analyses
Systematic Reviews and Meta-analysis
Tables
Technology
Therapeutic Guideline-IADVL
Therapeutic Guidelines
Therapeutic Guidelines - IADVL
Therapeutics
Therapy
Therapy Letter
Therapy Letters
View Point
Viewpoint
What’s new in Dermatology
View/Download PDF

Translate this page into:

Letter in Response to Previous Publication
90 (
4
); 549-550
doi:
10.25259/IJDVL_481_2024
pmid:
38841926

Hypogammaglobulinemia-induced skin infections as a factor of post rituximab paradoxical flare in pemphigus

Department of Dermatology, Venereology and Leprosy, GCS Medical College Hospital and Research Centre, Ahmedabad, India

Corresponding author: Dr. Harshita R. Vyas, Department of Dermatology, Venereology and Leprosy, GCS Medical College Hospital and Research Centre, Ahmedabad, India. dr.harshitavyas@gmail.com

Licence
This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Vyas HR, Padhiyar JK, Patel NH, Patel JR. Hypogammaglobulinemia-induced skin infections as a factor of post rituximab paradoxical flare in pemphigus. Indian J Dermatol Venereol Leprol. 2024;90:549-50. doi: 10.25259/IJDVL_481_2024

Dear Editor,

We read the article ‘Clinical and immunological predictors of post-rituximab paradoxical pemphigus flare: A prospective cohort study’ with great interest and congratulate the authors for conducting this study, which is highly relevant in clinical practice.1 Earlier, the data on disease flare after rituximab (RTX) infusion in pemphigus was limited to isolated case reports, case series and retrospective analyses. This was a prospective, observational cohort study where 50 patients with pemphigus vulgaris and foliaceous were included, of which 10 cases (20%) developed disease flare. Eight cases developed a flare after the first dose of rituximab and two cases developed it after the second infusion. Out of the studied clinical and immunological factors, pemphigus disease area index (PDAI) score (>28) and anti-Dsg1 levels (>1137 RU/mL) were found to be statistically significantly associated with post-rituximab disease flare.

Prospective design is an advantage of this study. While going through the manuscript, certain points caught our attention that, in our humble opinion, require further clarification. As the authors have mentioned in the study flow chart, a total of 57 patients were screened but only 50 patients were included in the study. The authors have mentioned that three patients were shifted to corticosteroid pulse therapy, but the reason for this change in the treatment plan was not clarified. Four patients were not administered a second dose of RTX; again, the reason for this is not mentioned by the authors. Also, if these four patients were administered the first dose, they would fulfil the inclusion criteria for the study. The reason for their withdrawal from the study was not mentioned. We observed that although follow-up evaluations at week 2 and week 4 were part of the study design, authors failed to report the clinical characteristics at these time points.

Previously, in a retrospective analysis, Narayanan et al. have implicated more frequent secondary bacterial infections of pemphigus lesions as a risk factor for disease flare.2 Similarly, there was an almost simultaneous publication from our institute where a retrospective analysis of 44 patients with pemphigus vulgaris treated with rituximab was performed.3 Four cases (9%) developed a paradoxical flare of disease. A rather remarkable finding in our study, which was not reported by the authors of the above study was that all cases with disease flare were associated with secondary bacterial infection of skin lesions, documented with positive culture studies from skin swabs and fall in serum immunoglobulin G levels (≤7 g/L) from baseline. At the time of disease flare, in three out of four cases, gram-positive and gram-negative bacteria, i.e. Staphylococcus aureus and Pseudomonas, Klebsiella, and Proteus, respectively, were isolated and in one case, moderate growth of Staphylococcus aureus was noted. The identification of gram-negative bacteria is noteworthy as these organisms are typically not isolated from immunocompetent hosts and thus may denote underlying immunosuppression. This aspect has been overlooked by the investigators of the current study. Neither at baseline nor at the time of flare have microbial studies from the lesional skin been reported. The outcome of flares in terms of time taken for resolution, modalities, antimicrobials in particular, used for the management of flare, and the disease course after receiving a second dose of RTX was not discussed by the authors. Though authors have mentioned that one patient died of sepsis, the colonisation status of skin lesions in all other cases remains unreported.

RTX-induced hypogammaglobulinemia is a known adverse event, reported from studies in rheumatology literature as a delayed event.4 The study from our institute shows hypogammaglobulinemia as an immediate complication of RTX therapy. We propose hypogammaglobulinemia-induced skin infections and resultant epitope spreading as a probable explanation of paradoxical disease flare.

Undoubtedly, the present study along with other recent publications have started a serious conversation about this less explored and potentially fatal phenomenon in patients of pemphigus who are treated with RTX. Further investigations into the role of infections, hypogammaglobulinemia, and other known and unknown underlying factors responsible for this phenomenon are warranted. Translating this understanding into clinical practice, particularly in identifying at-risk populations would be highly relevant in predicting and preventing the paradoxical flare of disease activity following RTX treatment.

Declaration of patient consent

Patient’s consent not required as there are no patients in this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Use of artificial intelligence (AI)-assisted technology for manuscript preparation

The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.

References

  1. , , , , , . Clinical and immunological predictors of post-rituximab paradoxical pemphigus flare: A prospective cohort study. Indian J Dermatol Venereol Leprol 2024:1-6. doi: 10.25259/IJDVL_894_2023
    [CrossRef] [PubMed] [Google Scholar]
  2. , , . A retrospective case-control study of clinical factors associated with paradoxical exacerbation of pemphigus vulgaris following rituximab infusion. Int J Dermatol. 2020;59:e459-e460.
    [CrossRef] [PubMed] [Google Scholar]
  3. , , , , , . Paradoxical disease flare, skin infection and hypogammaglobulinaemia in patients with pemphigus vulgaris treated with rituximab. Clin Exp Dermatol. 2024;49:175-7.
    [CrossRef] [PubMed] [Google Scholar]
  4. , , , , . Association of immunoglobulin levels, infectious risk, and mortality with rituximab and hypogammaglobulinemia. JAMA Network Open. 2018;1:e184169.
    [CrossRef] [PubMed] [PubMed Central] [Google Scholar]

Fulltext Views
205

PDF downloads
28
View/Download PDF
Download Citations
BibTeX
RIS
Show Sections