Background: Pemphigus foliaceus is an autoimmune skin disease mediated by a
utoantibodies against desmoglein 1. The endemic form is thought to have an
environmental cause. The Terena reservation of Limao Verde in Mato Grosso d
o Sul, Brazil, is a recently identified focus of the disease, with a preval
ence of 3.4 percent in the population. We tested the hypothesis that normal
subjects living in an endemic area have antibodies against desmoglein 1.
Methods: We used an enzyme-linked immunosorbent assay to detect antibodies
against desmoglein 1 in serum samples from 60 patients with endemic pemphig
us foliaceus (fogo selvagem) who lived in Limao Verde or elsewhere in Brazi
l, 372 normal subjects (without pemphigus foliaceus) from Limao Verde and s
urrounding locations, and 126 normal subjects from the United States and Ja
pan.
Results: Antibodies against desmoglein 1 were detected in 59 of the 60 pati
ents with fogo selvagem (98 percent) but in only 3 of the 126 normal subjec
ts from the United States and Japan (2 percent). Antibodies were also detec
ted in 51 of the 93 normal subjects from Limao Verde (55 percent) and in 54
of the 279 normal subjects from surrounding areas (19 percent). Serum samp
les obtained one to four years before the onset of disease were available f
or five patients; all five had antibodies in the initial serum samples, and
the onset of disease was associated with a marked increase in antibody val
ues.
Conclusions: The prevalence of antibodies against desmoglein 1 is high amon
g normal subjects living in an area where fogo selvagem is endemic, and the
onset of the disease is preceded by a sustained antibody response. These f
indings support the concept that the production of antibodies against desmo
glein 1 is initiated by exposure to an unknown environmental agent. (N Engl
J Med 2000;343:23-30.) (C) 2000, Massachusetts Medical Society.