Case report of bullous pemphigoid in a 65 year old woman

Abstract

The unique thing about this case is that it is the first reported case of bullous pemphigoid in the elderly that has been clinically diagnosed with histologic findings highly suggestive of this blistering disorder although an immunofluorescence could not be done due to unavailability in the centre. Patient was managed successfully and discharged home with improvement on subsequent hospital visits. This case report shows how diagnosis of an immunobullous disease was made and managed in a resource poor setting. A descriptive summary of 65-year old black Nigerian woman with bullous pemphigoid covering history, physical examination and management. The main diagnosis was bullous pemphigoid in a recently diagnosed type 2 diabetic. Patient was placed on corticosteroids as well as immunosuppressive agents and diabetes was managed with subcutaneous insulin and oral hypoglycemics with appropriate wound care. Patient showed remarkable improvement after management and was discharged home with subsequent follow up in the clinics. Bullous Pemphigoid (BP) can be diagnosed clinically with a high index of suspicion with the aid of skin biopsy and histology, and can be managed successfully even in a resource poor centre where immunofluorescence facilities are lacking.

Case report on localized bullous pemphigoid in two young females

“…It is known that BP tends to occur in those that are elderly as seen in the literature, however this case report showed two cases of females that are younger when compared to case report by Otike-Odibi et al from similar region that reported generalized BP in an older adult and that of Noorily and Ren that reported LBP in an 80 year old man. 5,6 The limbs have been commonly implicated in LBP as reported by Wang et al and as well as other case reports. 2,3,6,7 Hasegawa et al had a case of recurrent of lesions on the palms and soles in an elderly patient that had it initially on the right lower leg.…”

“…7 DIF and IIF are recognized as gold standards in making diagnosis and excluding other causes of autoimmune blistering disorders as reported by Kitajima et al 11 DIF and IIF availability is currently limited in the setting of this case report hence skin punch biopsy is recommended in addition to clinical history of recurrent ulcers with or without blistering with intense pruritus to make diagnosis. 5 Oral prednisolone was used for the two patients and their was improvement as seen in other case reports. [2][3][4] Potent topical steroids such as 0.05% clobetasol propionate ointment has also been used with good response and is recommended as reported in other case reports.…”

“…4,7,8 BP has been known to have these risk factors such as non-bullous chronic inflammatory diseases such as psoriasis and lichen planus, drugs such as non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen, captopril and oral antidiabetic agents such as vildagliptin, ultraviolet radiation and vaccination. 1,5 LBP has also been associated with stoma sites as seen in the reports by Stander et al and Salomon et al 8,10 The first patient had obvious bullae and ulcers while the second didn't have any obvious bullae. Initial clinical diagnoses did not consider BP in both cases.…”

“…[1][2][3][4] Punch biopsy and histology is available in our setting and can be used to make a diagnosis. 5 LBP diagnostic criteria has been proposed by Corbella-Bagot et al which includes having any three of these four : bullous eruption at any localized site with a possible trigger which has not progressed to generalized form within three months of occurrence(clinical criteria), positive IgG antibodies against the epidermal side of basement membrane zone (BMZ) by indirect immunofluorescence (IIF) and/or positive IgG antibodies reacting with BP180 and/or BP230 by ELISA, IIF, immunoblot, or immunoprecipitation (serologic criteria); subepidermal blister with the presence of eosinophils (histologic criteria) and positive direct immunefluorescence (DIF) with linear deposits of IgG and/or C3 along the BMZ (DIF criteria). 7 DIF and IIF are recognized as gold standards in making diagnosis and excluding other causes of autoimmune blistering disorders as reported by Kitajima et al 11 DIF and IIF availability is currently limited in the setting of this case report hence skin punch biopsy is recommended in addition to clinical history of recurrent ulcers with or without blistering with intense pruritus to make diagnosis.…”