Pruritic Vesicular Rash In A Pregnant Woman… Spot diagnosis?

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Image Source: The New England Journal of Medicine

The images above show vesicular, papular, and pruritic rashes across the abdomen, thorax, arms, and legs of a 30-year-old pregnant patient in her 34th week of gestation. She complains of the eruption of rash 5 days before presenting to the emergency department.

On physical examination, confluent papules with blisters on
the arms (Panel A), thorax, and abdomen (Panel B) were noted. The rest of the
examination was normal. Head, neck, and mucus membranes were spared. No lymph
nodes were palpable.

Serological tests were conducted to check the antibody levels.
The anti-bullous pemphigoid 180 antibody level was greater than 200 U/mL
(normal range: 0-20). The rest of the antibody titers were normal, including
antinuclear antibodies, anti-bullous pemphigoid 230 antibodies, anti-desmoglein
1 antibodies, and anti-desmoglein 3 antibodies.

A specimen
was obtained from the affected skin for histopathological analysis, which
showed modest interpapillary spongiosis extending into the skin adnexa. A mild
leucocytic infiltrate was seen around the superficial vessels along with a few
eosinophils. Immunofluorescence tests revealed IgM, IgG, and C3 on the subdermal
basal membrane.

What is the diagnosis?

This pregnant woman was diagnosed with pemphigoid
gestationis.

Systemic glucocorticoids were started, which resolved the
rash in 3 months. At 38-week-gestation, she gave birth to a healthy baby via
spontaneous vaginal delivery without any rash or associated complaints.

Pemphigoid gestationis

Image Source: DermNet

Pemphigoid gestationis was previously known as herpes
gestationis
as the lesions resemble the herpetic lesions, so initially, herpes
was considered to be the culprit pathogen, which was later proven to be false.
This skin condition showed resemblance to the pemphigoid group of autoimmune
blistering skin disorders, hence the name.

Pemphigoid gestationis is when the body’s immune system malfunctions
and attacks its own cells; in medical jargon, it is classified as an autoimmune
disease. Patients with this rare skin condition usually present late in
the pregnancy, in the second or third trimester, with complaints
of severe itching and blisters. Sometimes, the only complaint may be itching as
it occurs even before the lesions erupt.

Are there any risks to the fetus?
The fetus is at risk of pre-term birth, and there is also a risk of small for gestational age (SGA). Low-birth-weight is another risk, especially if the disease onset is in the first and the second trimester of pregnancy.

Does the treatment with glucocorticoids adversely affect the developing fetus?
The use of glucocorticoids has not been seen to affect the obstetrical outcomes adversely. The fetus doesn’t show any side effects, either.

What is the risk of pemphigoid gestationis in subsequent pregnancies? لعبة اون لاين
Studies have shown that pregnant patients suffering from pemphigoid gestationis are at greater risk in the subsequent pregnancies with an earlier and more severe course. لعبة بوكر حقيقية

References

Paolo Agostinis, M. a. (2020, August 27). Pemphigoid Gestationis. Retrieved from The New England Journal of Medicine: https://www. العاب لربح المال الحقيقي nejm.org/doi/full/10.1056/NEJMicm2000922

Chi CC, Wang SH, Charles-Holmes R, et al. Pemphigoid gestationis: early-onset and blister formation are associated with adverse pregnancy outcomes. Br J Dermatol. 2009;160(6):1222-1228. doi:10.1111/j.1365-2133.2009.09086.x

Sävervall C, Sand FL, Thomsen SF. Pemphigoid gestationis: current perspectives. Clin Cosmet Investig Dermatol. 2017;10:441-449. Published 2017 Nov 8. doi:10.2147/CCID.S128144

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Dr. Arsia Hanif has been a meritorious Healthcare professional with a proven track record throughout her academic life securing first position in her MCAT examination and then, in 2017, she successfully completed her Bachelors of Medicine and Surgery from Dow University of Health Sciences. She has had the opportunity to apply her theoretical knowledge to the real-life scenarios, as a House Officer (HO) serving at Civil Hospital. Whilst working at the Civil Hospital, she discovered that nothing satisfies her more than helping other humans in need and since then has made a commitment to implement her expertise in the field of medicine to cure the sick and regain the state of health and well-being. Being a Doctor is exactly what you’d think it’s like. She is the colleague at work that everyone wants to know but nobody wants to be. If you want to get something done, you approach her – everyone knows that! She is currently studying with Medical Council of Canada and aspires to be a leading Neurologist someday. Alongside, she has taken up medical writing to exercise her skills of delivering comprehensible version of the otherwise difficult medical literature. Her breaks comprise either of swimming, volunteering services at a Medical Camp or spending time with family.

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