![(A, B) Subepidermal bulla with mixed inflammatory infiltration in the upper dermis (H&E, virtual slide view). (C) Linear deposition of immunoglobulin (Ig) A along the dermoepidermal junction (direct immunofluorescence [DIF], ×200). (D) Mild widening of the mesangial matrix with focal and segmental mesangial hypercellularity on renal biopsy (periodic acid-Schiff stain, virtual slide view). The renal DIF study result showed mild IgA, C3, and minimal IgM deposits at the mesangium (not shown).](https://www.researchgate.net/publication/315880921/figure/fig1/AS:495783695667200@1495215452673/A-B-Subepidermal-bulla-with-mixed-inflammatory-infiltration-in-the-upper-dermis-H-E_Q320.jpg)
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Brief Report
226 Ann Dermatol
Received November 19, 2015, Revised February 3, 2016, Accepted for publication April 4, 2016
*Current affiliation: Sue Kyung Kim, Department of Dermatology, Seoul Medical Center, 156 Sinnae-ro, Jungnang-gu, Seoul 02053, Korea. Tel:
82-2-2276-7891, Fax: 82-2-2276-7438, E-mail: skkim@seoulmc.or.kr
Corresponding author: Sue Kyung Kim, Department of Dermatology, Ajou University School of Medicine, 164 WorldCup-ro, Yeongtong-gu, Suwon 16499,
Korea. Tel: 82-31-219-5190, Fax: 82-31-219-5189, E-mail: ksk9167@ajou.ac.kr
T
his is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org
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Copyright © The Korean Dermatological Association and The Korean Society for Investigative Dermatology
pISSN 1013-9087ㆍeISSN 2005-3894
Ann Dermatol Vol. 29, No. 2, 2017 https://doi.org/10.5021/ad.2017.29.2.226
BRIEF REPORT
Fig. 1. (A) A 45-year-old woman
presented with multiple erythema-
tous collarettes of blisters on her
whole body, mainly on the trunk.
Note the clustered bullae on the
back. (B) New bullae are found
adjacent to old bullae, forming a
string of beads sign.
Concurrent Linear Immunoglobulin A Dermatosis,
Hashimoto Thyroiditis, and Immunoglobulin A
Nephropathy in an Adult
Ji Young Yang, Inwhee Park1, Sue Kyung Kim*
Departments of Dermatology and 1Nephrology, Ajou University School of Medicine, Suwon, Korea
Dear Editor:
A 45-year-old woman presented with a 5-week history of
vesicular eruption over her body. Four years prior, she
was diagnosed with Hashimoto thyroiditis with anti-thyro-
globulin antibody level, 339 U/ml (reference range, 0∼
100 U/ml) and anti-microsomal antibody level, 1,296
U/ml (reference range, 0∼100 U/ml). She had been taking
medication for 3 years, discontinuing it on her own. In ad-
dition, she had been taking telmisartan 80 mg/day, amlo-
dipine 5 mg/day, and hydrochlorothiazide 12.5 mg/day
Brief Report
Vol. 29, No. 2, 2017 227
Fig. 2. (A, B) Subepidermal bulla with mixed inflammatory infiltration in the upper dermis (H&E, virtual slide view). (C) Linear deposition
of immunoglobulin (Ig) A along the dermoepidermal junction (direct immunofluorescence [DIF], ×200). (D) Mild widening of the
mesangial matrix with focal and segmental mesangial hypercellularity on renal biopsy (periodic acid-Schiff stain, virtual slide view).
The renal DIF study result showed mild IgA, C3, and minimal IgM deposits at the mesangium (not shown).
for 4 months to control hypertension. Physical examina-
tion revealed multiple erythematous collarettes of blisters
with intense pruritus on her whole body (Fig. 1). Skin bi-
opsy with direct immunofluorescence (DIF) study was per-
formed on her back. Hematoxylin-eosin staining revealed
a subepidermal bulla with mixed inflammatory infiltration
in the upper dermis (Fig. 2A, B). The DIF study revealed
linear deposition of immunoglobulin (Ig) A along the der-
moepidermal junction (Fig. 2C), resulting in the diagnosis
of linear IgA dermatosis (LAD). Laboratory test results
were otherwise normal except for the following: white
blood cell count, 15,000/μl with 85.6% neutrophil con-
centration; hemoglobin level, 10.8 g/dl; blood urea nitro-
gen level, 30.6 mg/dl; creatinine level, 1.44 mg/dl; urinary
protein level, 55.9 mg/dl; urinary creatinine level, 96.9
mg/dl; urinary protein-to-creatinine ratio, 0.58; and uri-
nary red blood cell count, many per high power field. On
referral to the department of nephrology for evaluation,
she was diagnosed with IgA nephropathy by kidney biop-
sy (Fig. 2D). Moreover, further evalution revealed normo-
cytic normochromic anemia with elevated serum ferritin
level, implying anemia of chronic inflammation. During
12-month follow-up, the cutaneous lesions had been fairly
well controlled with dapsone 50∼100 mg/day, with or
without colchicine 1.2 mg/day.
LAD is an acquired, autoimmune vesiculobullous derma-
tosis characterized by subepidermal blisters with deposi-
tion of linear homogeneous IgA at the basement membrane.
Its pathogenesis is unclear, but associations with malig-
nancies, drugs, and inflammatory diseases, notably ulcer-
Brief Report
228 Ann Dermatol
ative colitis, have been reported in adults1. Several cases
of LAD with IgA nephropathy have been reported in chil-
dren1, but a few in adults2.
Hashimoto thyroiditis is an autoimmune thyroiditis dem-
onstrating high titers of thyroid antibodies. It is associated
with other autoimmune diseases such as Addison disease,
type 1 diabetes mellitus, vitiligo, rheumatoid arthritis, or
systemic lupus erythematosus. To the best of our knowl-
edge, only one case associated with LAD has been re-
ported3. As they share the autoimmune pathogenesis, reg-
ulatory T cells might play a role in LAD and Hashimoto
thyroiditis4.
IgA nephropathy is an immune complex-mediated glomer-
ulonephritis characterized by diffuse mesangial IgA depos-
it, sometimes with IgM, IgG, complement 3, or Ig light
chains. IgA in the mesangium is typically of the polymeric
IgA1 subclass. Pena-Penabad et al.2 suggested a possible
role of the IgA1 subclass in the shared pathogenesis be-
tween LAD and IgA nephropathy. Furthermore, in a ge-
nome-wide association study of IgA nephropathy, six new
genome-wide significant associations were found, most of
which were associated with the risk of inflammatory bow-
el disease5. These loci could be related to LAD, as the as-
sociation between LAD and ulcerative colitis is well
documented.
In conclusion, we report a rare case of concurrent LAD,
Hashimoto thyroiditis, and IgA nephropathy.
CONFLICTS OF INTEREST
The authors have nothing to disclose.
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