Neonatal Pemphigus in Homozygous Twins: A Rare Case report
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Pemphigus Vulgaris (PV) is a chronic immunobullous disorder which affects the skin and mucous membranes. Though Pemphigus Vulgaris is the most common form among the pemphigus group of case reports in the literature regarding neonatal pemphigus. .

A 30-year-old lady, a proven case of oral pemphigus which was well controlled with corticosteroids gave birth to monozygotic twins at 28 weeks of gestation, delivered through Lower Segment Caesarean Section (LSCS). Dermatologists were called immediately after delivery in view of skin lesions in the neonates.

• Twin I, weighing 1.4 kg had areas of raw moist erosions with crusting over anterior aspect of neck, right post auricular area, abdomen above the umbilicus and posterior aspect of left leg and twin II weighing 1.3 kg had areas of raw moist erosions over left temporal area of the scalp. Perilesional Nikolsky sign was positive in both. Hair, nail and mucosa were normal. No other abnormalities were noted on physical and systemic examination.
• Tzanck smear from the erosions showed a few acantholytic cells. Histopathological examination from one of the representative skin specimens showed eosinophilic spongiosis with intraepidermal vesicle containing a few acantholytic cells. Direct immunofluorescence showed intercellular deposits of IgG in the lower epidermis in a lace like pattern. Indirect immunofluorescence showed circulating IgG antibodies with a titre of 1:10.

Both of them were treated symptomatically with a course of antibiotics, saline compress and combination of topical antibiotic with corticosteroid cream. The lesions regressed in a span of 2 weeks and healed with milia formation. Babies are on regular follow up with no evidence of new skin lesions.

Neonatal pemphigus is caused by transplacental transfer of IgG antibodies from mother suffering from PV to her foetus. These antibodies bind to neonatal skin after crossing the placenta, and may cause blisters. Neonatal PV has a varied clinical manifestation ranging from mild to widespread cutaneous involvement.