We report the case of a 68-year-old female with longstanding
insulin-treated
diabetes mellitus, observed for the first time in our department in August 1999 with multiple painful erosive lesions of the oral cavity and many bullous or erosive lesions on the abdominal wall, back, and thigh. She also had vegetating and verrucous lesions, similar to common
warts, involving the hands and feet, mainly on the palms, palmar surface of the fingers, and nail folds. Her lesions were present for 1 year. Skin and mucous biopsies showed the characteristic histopathologic findings of
pemphigus vulgaris, with an epidermal intercellular
IgG deposition on direct immunofluorescence. Histology of a warty lesion of the finger also showed suprabasal
acantholysis. After partial improvement with low doses of oral
steroids and
azathioprine,
her disease progressed to involve the oral cavity, trunk, hands, feet, and scalp. Control of
her disease required successive treatments of
mycophenolate mofetil and
cyclophosphamide, as well as
corticosteroids. A partial response was obtained with all these treatments. After being controlled by
cyclophosphamide that was slowly tapered, she is now well controlled with
azathioprine and oral
steroids, showing only discrete lesions of the oral mucosa after 1 year of followup. We report this case of
pemphigus vulgaris with unusual clinical aspects, namely vegetating and verrucous lesions as well as nail involvement, rarely described in this disease.