Multiimmunity Ratio in a Patient with Bullous Pemphigoid and Rheumatoid Arthritis

Abstract

Rheumatoid arthritis (RA) and bullous pemphigoid (BP) are autoimmune diseases influenced by genetic and environmental factors, with the concept of "shared autoimmune diathesis" suggesting that individuals with one autoimmune condition may be predisposed to developing another. This report describes a 62-year-old female with a 30-year history of untreated RA who presented with a progressive skin eruption initially misdiagnosed as herpes zoster. Over a four-month period, the patient developed pruritic bullous lesions predominantly in flexural areas. Histopathology and direct immunofluorescence confirmed BP by revealing subepidermal blisters with prominent eosinophilic infiltrate and linear IgG deposits along the dermoepidermal junction. Initial management with high-dose prednisone and azathioprine resulted in partial improvement; however, due to persistent lesions, rituximab was introduced, leading to significant clinical improvement. This case highlights the diagnostic challenges and therapeutic complexities encountered when RA and BP coexist, underscoring the potential shared pathophysiological mechanisms underlying autoimmune diathesis. The successful use of rituximab in this patient aligns with current literature advocating for biologic therapy in refractory BP cases, particularly in the context of other autoimmune disorders. These findings emphasize the importance of a multidisciplinary approach—integrating dermatology, rheumatology, and immunology—to ensure timely diagnosis and optimal management, ultimately improving patient outcomes in complex autoimmune presentations.