无相关性的两只犬的多发性自体免疫性皮肤病：落叶型天...

王帆

Cutaneous polyautoimmunity in two unrelated dogs: pemphigus foliaceus and generalized discoid lupus

Erythematosus

无相关性的两只犬的多发性自体免疫性皮肤病：落叶型天疱疮和全身型盘状红斑狼疮

作者：Britt J. Levy, Keith E. Linder，Lisa B. Mamo, Ina Herrmann and Petra Bizikova

翻译：唐翔

Background – Polyautoimmunity, the concurrent expression of two or more distinct autoimmune diseases (ADs) in a single individual, is a known phenomenon in humans and has been rarely reported in dogs. To the best of the authors’ knowledge, comorbid pemphigus foliaceus (PF) and generalized discoid lupus erythematosus (GDLE) has not been reported in dogs.

Hypothesis/Objectives – To describe the clinical, histological and immunological features and treatment outcome of two unrelated dogs with comorbid PF and GDLE.

Animals – One 10-year-old, spayed German shepherd dog and one 8-year-old, castrated American Staffordshire terrier presented for evaluation of a symmetrical, facial- and/or pedal-dominant pustular dermatitis with concurrent, truncal scaly plaques.

Methods – For each dog, clinicopathological characterization included physical examination, lesion cytological evaluation, bacterial culture and sensitivity testing, skin histopathological investigation and direct and indirect immunofluorescence testing. Additional diagnostic imaging and haematological testing was performed to exclude extracutaneous disease.

Results – Both dogs exhibited lesions clinically and histologically compatible with PF and GDLE. Moreover, one dog exhibited generalized leucotrichia and chronic superficial keratitis. Remission was achieved with immunosuppressive dosages of prednisolone [high-dose pulse (Case 1) or standard immunosuppressive dosage (Case 2)] and ciclosporin (5–6 mg/kg/day). Tissue-bound antikeratinocyte immunoglobulin (Ig)G and IgM were detected in both dogs. A weak basement membrane zone deposit of C3 was seen in one dog. Circulating antikeratinocyte and anti-desmocollin-1 IgG were detected in one dog.

Conclusions and clinical importance – Cutaneous polyautoimmunity can occur in the dog. Depending on the specific disease combinations, overlapping clinical features may present diagnostic and/or therapeutic challenges. Moreover, these cases should be monitored for development of additional cutaneous or extra-cutaneous AD(s).

摘要

背景-多发性自体免疫是指在一个病患中出现两种或两种以上的不同的自体免疫性疾病（ADs），在人医中已明确而在犬中鲜有报道。据作者所知，尚未有过关于犬共患落叶型天疱疮（PF）和全身型盘状红斑狼疮（GDLE）的报告。

假设/目的-旨在描述无相关性的共患PF和GDLE的两只犬的临床表现、组织学特征和免疫学特征及治疗效果。

动物-一只10岁已绝育的德国牧羊犬和一只8岁已去势的美国斯塔福㹴犬，评估其对称性面部和/或爪部脓疱性皮炎，同时并发躯干部位皮屑性斑块。

方法-对于每只犬，临床病理学特征包括体格检查、病变细胞学检查、细菌培养和药敏试验、皮肤组织病理学研究及直接和间接免疫荧光试验。另外还要进行影像学诊断和血液学检查，以排除皮肤系统外疾病。

结果-两只犬均表现出与PF和GDLE临床和组织学相符的病变。此外，一只犬表现出全身型白毛症和慢性浅表性角膜炎。使用免疫抑制剂量的泼尼松龙 [高剂量脉冲（病例1），或标准免疫抑制剂量（病例2）] 和环孢素（5-6 mg/kg/d）达到缓解。在两只犬身上均检测到组织结合型抗角质细胞免疫球蛋白(Ig) G 和 IgM。在一只犬身上观察到C3的弱基底膜带沉积。在一只犬身上检测到循环抗角质细胞和抗桥粒胶蛋白-1 IgG。

结论和临床价值-犬可发生多发性自体免疫性皮肤病。根据特定的疾病组合、重叠的临床特征可能带来诊断和/或治疗上的困难。此外，应监测这些病例是否发生其他皮肤或皮肤系统外ADs。

Case 1

病例1

A 10-year-old, spayed, sable German shepherd dog was presented for evaluation of a pruritic, erosive and crusting dermatitis, initially noted three years previously. Historically, treatment with anti-inflammatory dosages of prednisone and oral antibiotics yielded incomplete control and signs would flare upon treatment cessation. Without treatment, lesions remained mild and limited to the trunk in the winter, and became more generalized and severe from spring to autumn. Following the most recent flare, the owner reported prominent shedding and temporary hypotrichosis, which was followed by generalized leucotrichia. The dog was then referred to the authors (Figure 1a–c; Figure S1). Examination revealed diffuse, mild hypotrichosis with multifocal, 2–4 mm crusts over the dorsal muzzle, eyelids, pinnae and distal limbs, and less so on the footpad margins. Beneath the crusting, superficial erosions with mild purulent exudate were noted. Dorsal truncal lesions consisted of depigmented centres with scarring, thick adherent scales and crusts, and were painful upon palpation. Removal of crusts revealed deep erosions. Severe reticulated hyperpigmentation was diffusely present in the groin region. Mucocutaneous junctions and mucosae were unaffected. No other abnormalities were found on the rest of the physical examination.

一只10岁已绝育的深色毛德国牧羊犬，因瘙痒、糜烂和结痂性皮炎就诊，最初注意到这种症状是在3年前。曾经使用过抗炎剂量的泼尼松和口服抗生素治疗，不能完全控制病情，治疗停止后症状复发。不治疗时，在冬季病变较轻且局限于躯干部位，而在春季到秋季病变发展到全身且严重。在最近的一次突然发病后，主人记录到有明显的脱毛和暂时性少毛症，继而出现全身型白毛症。然后将犬转诊给作者（图1a–c；图S1）。检查发现弥散性的轻度少毛症伴多灶性，2-4mm的结痂，位于口鼻背侧、眼睑、耳廓及四肢远端 ，而爪垫边缘较少。在结痂下可观察到浅表糜烂伴轻度脓性渗出物。躯干背侧病变包括中央色素减退伴有瘢痕、厚的皮屑和结痂粘附，触诊时疼痛。去除结痂显示深度糜烂。腹股沟区弥散性存在重度网状色素沉着。皮肤粘膜交界处和粘膜未受影响。其余体格检查未发现其他异常。

Figure 1. Clinical presentation of cutaneous polyautoimmunity (Case 1).

(a) Generalized leucotrichia with sporadic patches of original hair colour (sable).

(b) Focal patches of truncal alopecia with fine plaques characterized by a peripheral hyperpigmentation with central depigmentation, scarring, deep erosions and crusting.

(c) Diffuse hair thinning to alopecia and multifocal, 2–4 mm crusts on the dorsal muzzle and eyelids.

图1.多发性自体免疫性皮肤病的临床表现（病例1）

（a）全身型白毛症，偶见原有毛发颜色（深色）的斑块。

（b）躯干处存在局灶性的脱毛斑片伴有细小斑块，其特征为外周色素沉着伴有中央色素减退、瘢痕、深部糜烂和结痂。

（c）弥散性的毛发稀少至脱毛，且在口鼻背侧和眼睑处存在多个2-4mm的结痂。

Cytological findings from facial crusts revealed numerous acantholytic keratinocytes mixed with nondegenerate neutrophils, whereas findings from truncal plaques showed fewer neutrophils intermixed with lymphocytes and plasma cells. Micro-organisms were not noted. Skin biopsy samples submitted for histological examination from facial and truncal lesions showed a subcorneal pustular dermatitis with acantholysis and a cell-rich lymphocytic interface dermatitis with mural folliculitis, respectively (Figure 2a–c). Nonpigmented hair bulbs had mild peribulbar pigment dispersal (Figure 2d). Gram and periodic acid Schiff (PAS) staining and aerobic culture were negative. These findings, taken together with the clinical features, were compatible with comorbid pemphigus foliaceus (PF) and generalized discoid lupus erythematosus (GDLE). Results of performed immunotesting are listed in Table 1 and Figure S2 depicts positive staining results. Thoracic radiographs, complete blood count, biochemical testing and thyroid panel were within normal limits.

面部结痂细胞学结果显示有大量棘层松解细胞混合非退行性中性粒细胞，而躯干斑块细胞学结果显示少量的中性粒细胞混合淋巴细胞和浆细胞。且未见微生物。面部和躯干病变的皮肤活检样本的组织病理学结果分别显示角质层下脓疱性皮炎伴有棘层松解和富含细胞的淋巴细胞界面性皮炎伴有毛囊壁炎（图2a—c）。无色素毛球部有轻度毛球周色素扩散（图 2d）。革兰氏和过碘酸希夫 (PAS) 染色及需氧培养均为阴性。这些结果结合临床特征，与落叶型天疱疮 (PF) 和全身型盘状红斑狼疮 (GDLE) 相符。表1列出了免疫检测结果，图S2描述了阳性染色结果。胸部X线片、全血细胞计数、生化检查和甲状腺检测均在正常范围内。

Figure 2. Histopathological findings for Case 1.

(a) Pemphigus foliaceus associated subcorneal pustular dermatitis occurs with acantholytic keratinocytes, eosinophils, and neutrophils in pustules; x200.

(b) Cutaneous lupus type cell-rich interface dermatitis with basal cell vacuolation, apoptosis, and loss is present in association with lymphocyte infiltration (arrows) and prominent melanin pigment dispersal to the dermis; x200.

(c) In areas of interface dermatitis, lymphocytic interface and mural folliculitis are characterized by basal cell loss and lymphocyte infiltration of the basal layer and inner layers of hair follicle wall, involving the infundibulum, isthmus and inferior follicle; x400.

(d) Pigment dispersal around hair bulbs (arrows) supported previous bulbitis, which was not captured; x400. Haematoxylin and eosin

图2.病例1的组织病理学结果。

（a）落叶型天疱疮相关的角质层下脓疱性皮炎，脓疱内有棘层松解细胞、嗜酸性粒细胞和中性粒细胞浸润；x200.

（b）皮肤狼疮类型呈现细胞丰富的界面性皮炎，伴有基底细胞空泡化、细胞凋亡和缺失，可见淋巴细胞浸润（箭头）和明显的黑色素扩散至真皮层；x200.

（c）在界面性皮炎区域，淋巴细胞界面和毛囊壁毛囊炎表现为基底细胞缺失以及淋巴细胞浸润到毛囊壁基底层和毛囊壁内层，涉及到漏斗部、峡部和毛囊下部；x400.

（d）色素扩散至毛球周围（箭头），提示早期有毛球炎，但未被捕获到；x400.苏木精-伊红染色

Except for the leucotrichia, remission of all skin lesions occurred within a month of starting treatment with oral ciclosporin (5 mg/kg/day; Atopica, Elanco; Greenfield, IN, USA) combined with a single high-dose prednisolone pulse (10 mg/kg/day p.o. for three days, followed by 1 mg/kg/day for a month; PrednisTab, Lloyd Inc.; Shenandoah, IA, USA). Prednisolone was then slowly tapered and stopped four months later. Remission was maintained with ciclosporin (5 mg/kg/day) and intermittent bathing (Biohex,VetBioTek；Largo,FL,USA) apart from a mild flare (several truncal plaques clinically compatible with GDLE) five months later. Potential confounding factors included a temporary switch to generic ciclosporin (5 mg/kg /day; CycloSPORINE, TEVA; Parsippany, NJ, USA) one month before the flare and a seasonal change leading to increased UV-light exposure. Additionally, the dog also developed a chronic superficial keratitis (CSK) during the flare. Complete remission of CSK was achieved within a month of starting 0.2% ciclosporin ophthalmic ointment (1/4 inch strip, both eyes, twice daily ongoing; Optimmune, Merck; Madison, NJ, USA) and neomycin-polymyxin-dexamethasone ointment (1/4 inch strip, both eyes, once daily for 30 days; Falcon Pharmaceutical Ltd; Fort Worth, TX, USA). Skin lesions resolved with the increase of oral ciclosporin (Atopica) dosage to 6 mg/kg/day and a short tapering course of prednisolone (2 mg/kg /day p.o. for seven days, reduced by 50% every two weeks until cessation). At the time of writing, six months later, all signs remain fully controlled with oral ciclosporin (6 mg/kg/day) and twice daily 0.2% ciclosporin ophthalmic ointment; however, generalized leucotrichia persists.

在开始口服环孢素 (5 mg/kg/d) 联合单次高剂量泼尼松龙脉冲（10 mg/kg/d p.o，连续用3天，随后改为1mg/kg/d，持续用1个月）治疗的1个月内，除白毛症外，所有病变都有缓解。然后泼尼松龙缓慢减量，4个月后停药。除了5个月后有轻度的复发（几处躯干斑块在临床上与GDLE相符）外，使用环孢素（5 mg/kg/d）和间歇性药浴，病变可维持缓解。潜在混杂因素包括复发前1个月暂时转换为通用环孢素（5 mg/kg/d），以及季节改变导致紫外线暴露增加。此外，该犬在复发期间还发生了慢性浅表性角膜炎 (CSK)。使用0.2%环孢素眼膏（1/4 英寸长条状，双眼使用，每日两次，持续使用）和新霉素-多粘菌素-地塞米松软膏（1/4 英寸长条状，双眼使用，每日一次，持续30天）一个月，CSK完全缓解。皮肤病变随着口服环孢素(Atopica)剂量增加至6 mg/kg/d和泼尼松龙短期逐渐减量（2 mg/kg/d p.o.，持续7天，每2周减少 50%，直至停药）而缓解。撰写时，6个月后，口服环孢素（6 mg/kg/d）和每日两次 0.2% 环孢素眼膏，所有症状均得到完全控制；然而，全身型白毛症持续存在。

Case 2

病例2

An 8-year-old, castrated American Staffordshire terrier was referred with a one month history of severe pruritus and skin lesions unresponsive to lokivetmab (Cytopoint, Zoetis; Kalamazoo, MI, USA), oclacitinib (0.5 mg/kg/day; Apoquel, Zoetis) and oral antibiotics. Patchy alopecia with erythroderma and thick, silver-grey, scaly plaques affected c. 70% of the body (Figures 2a,b, Figure S3). On the abdomen and concave pinnae, small pustules often coalesced into annular to polycyclic arrangements, and merged with shallow erosions and scale-crusts. Marked hyperkeratosis and crusting affected all footpads, which upon compression elicited purulent exudate and pain. No other abnormalities were found on the rest of the physical examination. Cytological findings of intact pustules revealed neutrophilic and eosinophilic inflammation with numerous acantholytic keratinocytes, devoid of bacteria. Cytological findings of abdominal erosions contained coccoid bacteria, which were confirmed by culture to be meticillin- resistant Staphylococcus pseudintermedius sensitive to doxycycline. Skin biopsy samples of truncal plaques and pinnal and footpad pustules and crusts submitted for histological examination revealed a cell-rich interface dermatitis and subcorneal pustular dermatitis with acantholysis, respectively (Figure S4). Gomorri methenamine stain (GMS) and PAS stains were negative. Immunotesting results are listed in Table 1. The combined clinical, histological and immunological findings supported a diagnosis of comorbid PF and GDLE with secondary superficial pyoderma. Thoracic computed tomography, complete blood count, biochemical testing and thyroid panel were normal.

转诊病例1只8岁已去势的美国斯塔福㹴犬，该犬有1个月的重度瘙痒和皮肤病变病史，赛妥敏、奥拉替尼（0.5 mg/kg/d）和口服抗生素无效。脱毛斑，伴有皮肤发红和厚的银灰色鳞皮屑性斑块，占机体70%面积（图2a，b,图S3）。在腹部和耳廓凹面上，小脓疱常合并成环状至多环状排列，并与浅表糜烂和皮屑性结痂融合。所有爪垫上明显存在角化过度和结痂，经压迫后有脓性渗出和疼痛。其余体格检查未发现其他异常。完整脓疱的细胞学检查显示中性粒细胞和嗜酸性粒细胞炎症伴大量棘层松解细胞且未见细菌感染。腹部糜烂病变的细胞学检查结果发现有球菌，经培养证实为对多西环素敏感的耐甲氧西林假中间型葡萄球菌。对于躯干斑块及耳廓、爪垫脓疱、结痂的皮肤活检样本的组织学检查分别发现富含细胞的界面性皮炎和角层下脓疱性皮炎伴棘层松解（图S4）。Gomorri六亚甲基四胺染色（GMS）和PAS染色均为阴性。免疫检测结果列于表1。结合临床表现、组织学检查和免疫学结果支持同时患有PF和GDLE且伴继发浅表性脓皮病的诊断。胸部计算机断层扫描、全血细胞计数、生化检查和甲状腺检查均正常。

Within one week of treatment with prednisolone (1 mg/kg/day p.o.) and doxycycline (5 mg/kg p.o. twice daily for 30 days; Heritage Pharmaceuticals; Edison, NJ, USA) the dog’s pruritus, erythema and pedal pain improved and pustules on the abdomen were resolving. By Week 3, pinnal pustules had resolved and scales and crusts decreased by 80%; ciclosporin (4.8 mg/kg/day; Atopica, Elanco) was added and complete remission of all remaining lesions was achieved two weeks later. Relapses of subcorneal pustules (pinnae, footpads) occurred with each attempt to reduce prednisolone < 1 mg/kg/day. Due to development of iatrogenic Cushing’s syndrome, ciclosporin was increased to 6 mg/kg/day and prednisolone tapered and stopped within seven days. Three months later, ciclosporin was reduced to 4.5 mg/kg/day. Attempts to further reduce this dosage resulted in minor flares of pustules on footpads and pinnae. At the time of writing, six months later, both PF and GDLE remain fully controlled with ciclosporin at 4.5 mg/kg/day.

使用泼尼松龙（1 mg/kg/d p.o.）和多西环素（5 mg/kg p.o.，每日两次，持续30天）治疗一周，犬的瘙痒、红斑和爪部疼痛得到改善，腹部脓疱消退。到第3周，耳廓脓疱消退，皮屑和结痂减少 80%；加用环孢素（4.8 mg/kg/d），2周后所有其余病变均完全缓解。每次尝试把泼尼松龙减至 < 1 mg/kg/d 时，角质层下脓疱（耳廓、爪垫）就复发。由于发生医源性库兴综合征，环孢素增加至6 mg/kg/d，泼尼松龙逐渐减量，并在7天内停药。3个月后环孢素减量至4.5 mg/kg/d。尝试进一步降低该剂量时就会出现爪垫和耳廓上的脓疱轻微发作。撰写本文时，6个月后，使用4.5 mg/kg/d的环孢素可完全控制PF和GDLE。

Discussion

讨论

Polyautoimmunity, the cooccurrence of two or more distinct autoimmune diseases (ADs) in a single individual, is a known phenomenon in humans. Susceptibility to polyautoimmunity can be the result of genetics or a cancer such as thymoma; both predisposing an individual towards autoreactivity and loss of immune tolerance.Reports in dogs remain limited to isolated case reports and a single preliminary genome-wide association study in Italian greyhounds, in which the cooccurrence of two or more, mostly extracutaneous ADs [e.g. systemic lupus erythematosus (SLE), immune-mediated haemolytic anaemia (IMHA), immune-mediated thrombocytopenia (ITP), Addison’s disease and/or thyroiditis] resembles the autoimmune polyendocrine syndrome type 2.(and File S1) Tests to rule out thymoma and hypothyroidism were, therefore, performed in both cases.

多发性自体免疫是指在一个病患中出现两种或两种以上的不同的自体免疫疾病（ADs），在人医已知有该病存在。多发性自体免疫的易感性可能是遗传性或肿瘤疾病（如胸腺瘤）；两种易感诱因均可使个体出现自体反应性和免疫耐受丧失。在犬中的报告仍然局限于单独的病例报告和在意大利灵缇犬中进行的一项初步全基因组关联研究，在该研究中同时发生两种或两种以上发病，主要是皮肤系统外的自体免疫病 [例如系统性红斑狼疮 (SLE)、免疫介导性溶血性贫血 (IMHA)、免疫介导性血小板减少症 (ITP)、艾迪森病（原发性肾上腺皮质功能减退症）和/或甲状腺炎] ，类似于2型自体免疫性多内分泌腺体综合征（和文件 S1），两个病例均排除了胸腺瘤和甲状腺功能减退。

Comorbid PF and DLE is rarely described in people; the presentation differs from pemphigus erythematosus (PE), which is classified as a mild, facial form of PF with lesions clinically, but not histologically, resembling a DLE-associated malar rash.In veterinary medicine, PE is defined as a pustular, erosive and crusting disease of the face with clinical features of DLE and histological findings characteristic of both PF and DLE. Both dogs in this report had trunk dominant plaques corresponding clinically and histologically with GDLE, which did not overlap with the PF-associated skin lesions on the pinnae, paws and face. As this presentation does not correspond to the human or veterinary classification of PE, a diagnosis of comorbid PF and GDLE was made.

PF和DLE共患病在人类中鲜有描述；其表现不同于红斑性天疱疮 (PE)，PE被归类为轻度的、面部型PF，病变在临床上但非组织学上类似于DLE相关的颊部红斑。在兽医学中，PE是指面部的脓疱性、糜烂性和结痂性疾病，临床特征表现为DLE，组织学表现同时具有PF和DLE的特征。本报告中的两只犬在临床表现和组织学检查上均存在与GDLE相符的躯干处明显斑块，其与PF相关的耳廓、爪部和面部皮肤病变不重叠。由于该表现不符合人医或兽医对PE的分类，因此诊断为PF 和GDLE共患病。

Case 1 also developed acquired leucotrichia without epidermal or mucosal depigmentation. An underlying pathogenesis could not be elucidated, as peribulbar pigment dispersal was the only finding on multiple examined skin biopsy recuts. In humans, paroxysmal leucotrichia without leucoderma is a feature of canities subita (aka Marie Antoinette syndrome).The prevailing hypothesis considers canities subita to be form of alopecia areata (AA), although alopecia may not always be appreciated.Hair, but not epidermal, depigmentation without apparent alopecia also was reported in follicular vitiligo, which, as stated by the authors, could be a bridge between AA and vitiligo. Interestingly, about one year after the first skin lesions appeared, the owners of Case 1 reported excessive hair shedding and transient generalized coat thinning shortly before the onset of generalized leucotrichia. Disappointingly, the dog’s leucotrichia remained unchanged despite successful management of both PF and GDLE.

病例1还出现获得性白毛症，无表皮层或黏膜层色素减退。因为多次的皮肤活检结果只发现了毛球周色素扩散，所以潜在的发病机制尚不清楚。在人医中，突发性白发症不伴有白斑病是“一夜白头”的特征为（又名 Marie Antoinette 综合征）。目前流行的假说认为“一夜白头”是斑秃(AA)的一种形式，但并不总是出现脱发。毛发（而非表皮层）色素减退也在毛囊性白癜风中有报告，如作者所述，这可能是AA和白癜风之间的过度。有趣的是，在首次皮肤病变出现后约一年，病例1的主人报告在全身性白毛症发作前不久出现了毛发过度脱落和一过性全身被毛稀疏。令人失望的是，尽管成功缓解了PF和GDLE，但犬的白毛症仍未改善。

Human AA and vitiligo are mediated by a Th1 dominant, IFN-gamma directed cytotoxic lymphocyte response,and a published case of canine exfoliative cutaneous lupus erythematosus also revealed a predominantly Th1/ IFN-associated inflammation. Intriguingly, CSK, the most recently diagnosed AD in Case 1, also is a lymphocyte-and IFN-gamma-driven condition. Although PF is an antibody-mediated AD, evidence suggests that autoreactive T cells play a central role in the initiation and propagation of the disease, thus remaining an important therapeutic target. Considering the suspected immunopathogeneses of ADs in cases herein, treatment with prednisolone and ciclosporin was elected. Both drugs have been shown to be effective historically in canine PF and cutaneous lupus erythematosus (File S1); prednisolone is a fast-acting immunosuppressant with effects on both cell-mediated and humoral immunity, whereas ciclosporin preferentially targets T cells and reduces IFN-gamma production.

人类的AA和白癜风是由Th1主导的、γ干扰素直接介导的细胞毒性淋巴细胞反应，已发表的一例犬表皮剥脱型皮肤红斑狼疮病例也显示主要是Th1/IFN相关的炎症反应。有趣的是，CSK（慢性浅表性角膜炎），最近在病例1中诊断为AD，也是一种淋巴细胞和γ干扰素介导的疾病。尽管PF是一种抗体介导的AD，但证据表明，自体反应性T细胞在疾病的发生和传播中发挥核心作用，因此仍然是一个重要的治疗靶点。 考虑到本文病例中AD的发病机制怀疑是免疫性，所以选择泼尼松龙和环孢素治疗。这两种药物一直以来均可有效治疗犬PF和皮肤红斑狼疮（文件S1）；泼尼松龙是一种速效免疫抑制剂，对细胞介导和体液免疫均有作用，而环孢素优先靶向T细胞并减少γ干扰素的生成。

The above cases document the existence of cutaneous polyautoimmunity in the dog. Depending on the specific disease combinations, overlapping clinical features may present diagnostic and/or therapeutic challenges. Moreover, these cases should be monitored for development of additional cutaneous and/or extracutaneous ADs.

上述病例记录了犬多发性自体免疫性皮肤病的存在。根据特定的疾病组合，重叠的临床特征可能带来诊断和/或治疗上的困难。此外，应监测这些病例是否发生其他皮肤和/或皮肤系统外AD。

Table 1. Immunofluorescence testing results

表1.免疫荧光检测结果

Direct immunofluorescence (IF) was performed on formalin-fixed, paraffin-embedded biopsies collected from the affected dogs. The indirect IF was performed on frozen footpad and buccal mucosa tissues collected from healthy dogs (limit of detection 1:50) and on 293T cells transfected with canine DSC1 or DSG1 (limit of detection 1:10).

Secondary antibodies: rabbit anti-canine IgG (Fc fragment) – Alexa 488 (304-485-008, Jackson ImmunoResearch Lab Inc.; West Grove, PA, USA) and goat anti-canine IgM-fluorescein isothiocyanate (A40-116F, Bethyl; Montgomery, TX, USA), goat anti-canine IgA-fluorescein isothiocyanate (A40-104F, Bethyl), goat anti-canine IgE-fluorescein isothiocyanate (AHP946F, Bio-Rad; Hercules, CA, USA) and goat anti-canine C3-fluorescein isothiocyanate (DPATB-H81281, Creative Diagnostics; Shirley, NY, USA). Abbreviations:

C3, complement C3;

DSC1, desmocollin-1;

DSG1, desmoglein-1;

IL, intralesional skin;

PL, perilesional skin.

对福尔马林固定、石蜡包埋的患犬活检组织进行直接免疫荧光 (IF) 检测。对采集自健康犬的冷冻爪垫和口腔粘膜组织（检测限 1:50）以及转染犬DSC1或DSG1的 293T细胞（检测限 1:10）进行间接IF。

二抗：兔抗犬 IgG（Fc片段）–Alexa 48（304-485-008,杰克逊免疫研究实验室公司；美国宾夕法尼亚州西格里夫）和山羊抗犬 IgM-异硫氰酸荧光素 (A40-116F,酶标二抗；美国得克萨斯州蒙哥马利)、山羊抗犬 IgA-异硫氰酸荧光素 (A40-104F,酶标二抗)、山羊抗犬IgE-异硫氰酸荧光素 (AHP946F,美国伯乐；美国加利福尼亚州赫拉克勒斯市) 和山羊抗犬C3-异硫氰酸荧光素 (DPATB-H81281,创新诊断公司；美国纽约州雪莉市)。

缩略语

C3，补体 C3；

DSC1，桥粒胶蛋白-1；

DSG1，桥粒芯胶蛋白-1；

IL，病变内皮肤；

PL，病变周围皮肤。

Figure 3. Clinical presentation of cutaneous polyautoimmunity (Case 2).

(a) Alopecia, erythema and thick, silver-grey, scaly plaques.

(b) Marked footpad hyperkeratosis and crusting

图 3. 多发性自体免疫性皮肤病的临床表现（病例 2）。
(a) 脱毛、红斑和厚的银灰色皮屑性斑块。

(b) 明显的爪垫角化过度和结痂

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