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Epidural abscess as a side effect of an immunosuppressive therapy treatment for bullous pemphigoid

Dear Editor: Although immunosuppressive therapy has been effectively used for various autoimmune diseases, complications have also been observed in many cases. The following is our experience of a patient with bullous pemphigoid (BP) who developed an epidural abscess after high-dose corticosteroid therapy. The 52-year-old Japanese male was diagnosed with BP (Fig. 1). We initially treated him with oral prednisone (35 mg/day) but later treated him with several immunosuppressive agents including cyclosporine. His bullous lesions recurred even after steroid pulse therapy with methylprednisone (1000 mg/ day) for 3 days. His serum antibody titer against 180-kDa BP-specific antigen reached over 150 (index value; cut-off value: 9) on enzyme-linked immunosorbent assay (ELISA) (Fig. 2). Because of the failure of the steroid pulse therapy, we performed plasmapheresis (manual bag centrifugation procedure) on 4 December 2002. After this treatment, there was no more development of the bullous eruptions, accompanied by a decrease of the serum titer against 180-kDa BP antigen antibodies to 54 (ELISA), and he was discharged from the hospital. In May 2003, 6 months after his discharge, there was a recurrence of the bullous eruption, and he was readmitted for treatment with double filtration plasmapheresis. However, this time the eruption did not respond to this treatment. Therefore, we started plasmapheresis with a manual bag centrifugation procedure on 22 June. It had to be discontinued 8 days later when he developed a high fever (39.4°C). Bacteriological cultures of the arterial blood and skin exudates both revealed numerous colonies of methicillin-resistant Staphylococcus aureus (MRSA). On 5 July, after another bacteriological examination, we started to treat him with intravenous vancomycin hydrochoride (2 g/day), which proved effective in suppressing the high fever, and was stopped the formation of the bullous eruptions. Soon after, however, he began to develop a backache during the second course of plasmapheresis. Although his high fever and backache improved with several courses of intravenous antibiotic treatment, we