Bullous Pemphigoid Associated With Renal Cell Carcinoma and Invasive Squamous Cell Carcinoma

February 2012 | Volume 11 | Issue 2 | Case Reports | 234 | Copyright © February 2012


Mital Patel MD,a Animesh A. Sinha MD PhD,b Erin Gilbert MD PhDa,c

aSUNY Downstate Medical Center, Brooklyn, NY bUniversity at Buffalo and Roswell Park Cancer Institute, Buffalo, NY cWoodhull Medical Center, Brooklyn, NY

Abstract
Background: Bullous pemphigoid (BP) is an acquired, autoimmune, sub-epidermal blistering disease. The incidence of both BP and internal malignancy increases with age, yet the relationship between BP and malignancy has been a matter of debate for many years. Numerous cases have been published that link BP with various internal malignancies. While some analyses of large sets of clinical data fail to show a statistically significant correlation between BP and internal malignancy, others imply that there is a measurable correlation.
Observation: We report a case of a 71-year-old male with invasive squamous cell carcinoma of the left heel and renal cell carcinoma who presented with urticarial bullous pemphigoid.
Conclusions: There are few case reports in the literature associating bullous pemphigoid and renal cell carcinoma or squamous cell carcinoma. To our knowledge, this is the first reported case of coincident renal cell carcinoma, squamous cell carcinoma and urticarial BP. This case further supports investigation for underlying malignancy in patients with BP, particularly in the elderly.

J Drugs Dermatol. 2012;11(2):234-238.

INTRODUCTION

Bullous pemphigoid (BP) is classically an acquired, autoimmune, subepidermal blistering disease. However, it is a polymorphic disease with several ”non-bullous” clinical variants, including: urticarial, vesicular, vegetating, prurigo- nodularis-like BP, and annular or figurate erythema variants. BP often presents with a prodrome, which includes pruritic urticated erythema, occasionally figurate in appearance.
The relationship between BP and malignancy has been the matter of debate for many years, and a number of cases have been published linking bullous pemphigoid with various internal malignancies. 1-14 Several studies in the USA, Sweden, and Europe performed statistical analyses of large sets of clinical data, all of which failed to show a correlation between BP and internal malignancy.15-24 However, there are studies that have shown an increased incidence of malignancy in patients with BP, and these authors recommend work-up for malignancy in patients with BP.25,26 In addition, in several reported cases, treatment of the underlying malignancy lead to clearance of the BP, further supporting that BP may indeed be a paraneoplastic syndrome.1-4

CASE REPORT

We report a case of a 71-year-old cachetic male admitted to the surgical service for a left heel ulcer and a diffuse body rash. The rash was noted on admission; however, the patient could not provide information on duration of the rash or the foot ulcer. On exam he had multiple figurate, annular erythematous plaques with minimal scale spread diffusely on the trunk and extremities (Figure 1). Bullae and vesicles were not present, nor was there mucosal involvement. Several days into his hospitalization he developed multiple, highly pruritic 2–3 mm vesicles on top of the erythematous annular plaques (Figure 2). A tender 3.5 cm fungating hemorrhagic plaque with a surrounding verruciform hyperplasia was noted on the left heel associated with left-sided inguinal lymphadenopathy (Figure 3). Laboratory analysis revealed a leukocytosis with eosinophilia, which peaked at 18%. All other routine laboratory tests were within normal range.
Histopathology of the left heel ulcer showed invasive squamous cell carcinoma. MRI of the left ankle revealed a large soft tissue mass involving the calcaneal plantar fat pad with extension into the calcaneal tuberosity. Inguinal lymph node biopsy showed
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