The sequential occurrence of Bullous pemphigoid, membranous nephropathy and rheumatoid arthritis: all in one patient, a case report

Abstract

Bullous pemphigoid (BP) is an autoimmune disease of the skin and mucous membranes. The presentation of BP as a multiple autoimmune syndrome has rarely been reported. We report a 49-year-old man with multiple blistering skin lesions and nephrotic syndrome. Skin-punch and kidney biopsy revealed BP and membranous nephropathy (MN), respectively. Subsequent workup did not reveal a secondary cause for MN. The patient was treated with rituximab and methylprednisolone and his skin lesions and renal disease resolved. Arthritis occurred after discontinuation of the steroid therapy and he was diagnosed with rheumatoid arthritis (RA). The patient started methotrexate treatment, and during the 12-month treatment period, he was free of skin lesions and arthritis with normal kidney function. This case describes the rare temporal coexistence of BP, MN, and subsequently diagnosed RA. Physicians should be aware of developing an additional autoimmune disease in patients who already have co-existing autoimmune diseases.