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Year : 2022  |  Volume : 67  |  Issue : 6  |  Page : 794-795
Synergistic effect of teneligliptin in a case of new-onset bullous pemphigoid post Covid-19 infection

From the Department of Dermatology, Venereology and Leprology, Sardar Patel Medical College, Bikaner, Rajasthan, India

Date of Web Publication23-Feb-2023

Correspondence Address:
Alpana Mohta
From the Department of Dermatology, Venereology and Leprology, Sardar Patel Medical College, Bikaner, Rajasthan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijd.ijd_659_22

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How to cite this article:
Pareek S, Mohta A, Barsiwal S, Meena S. Synergistic effect of teneligliptin in a case of new-onset bullous pemphigoid post Covid-19 infection. Indian J Dermatol 2022;67:794-5

How to cite this URL:
Pareek S, Mohta A, Barsiwal S, Meena S. Synergistic effect of teneligliptin in a case of new-onset bullous pemphigoid post Covid-19 infection. Indian J Dermatol [serial online] 2022 [cited 2023 Mar 23];67:794-5. Available from:


Bullous pemphigoid (BP) is a rare autoimmune bullous disorder mainly affecting the elderly population with <5 cases in every 100,000 people.[1] Dementia, Parkinson's disease, unipolar or bipolar disorder, bedridden condition and drugs such as psycholeptics, spironolactone, chloroquine and furosemide are some common risk factors for it.[2],[3] Vaccines and viral infections have also been implicated. Herein, we report a case of a 73-year-old patient in whom the BP triggered after Covid-19 infection was further aggravated by intake of teneligliptin.

A 73-year-old male presented with multiple tense fluid-filled blisters over his body in February, 2021. The patient gave history of red, raised and itchy lesions which first appeared around his umbilicus 3 weeks back and then slowly spread to involve the rest of his body. These lesions evolved into intensely pruritic fluid-filled blisters over the last 5 days.

Cutaneous examination revealed symmetrically distributed tense vesicles and bullae overlying annular urticated, erythematous plaques over the patient's trunk, upper and lower limbs with sparing of his face, palms and soles [Figure 1]a, [Figure 1]b, [Figure 1]c, [Figure 1]d. Nikolsky sign was negative, and there was no mucosal involvement.
Figure 1: (a-d) Tense fluid-filled blisters overlying erythematous, urticated background with crusted lesions distributed symmetrically over the patient's trunk and extremities

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The patient was a known case of type II diabetes since last 8 years and had been on tab metformin 500 mg BD and tab glimepiride 2 mg OD for the same. He gave history of Covid-19 infection in December 2020 which was diagnosed after a positive RT-PCR.

In histopathological examination, a subepidermal split was seen with a predominantly eosinophilic infiltrate intermixed with a few polymorphs in the blister cavity [Figure 2]a and [Figure 2]b. The dermis showed perivascular and interstitial eosinophils, polymorphs and lymphocytes. Thus, a diagnosis of BP was made. The patient was prescribed oral deflazacort, dapsone and topical corticosteroids which were tapered over the next 6 weeks, thereafter maintaining him on lower doses. He sustained the state of remission for the next few months and was eventually weaned off all treatment in September 2021.
Figure 2: (a): A subepidermal split with a mixed inflammatory infiltrate in the blister cavity as well as in the perivascular and interstitial region of the dermis (H&E, 100X). (b): A magnified view showing the infiltrate in the blister cavity to be comprised mainly of eosinophils and neutrophils (H&E, 400X)

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He again presented in April 2022 with recurrence of BP which was confirmed after histopathological examination. This episode was found to be more severe than the previous one with respect to the number and size of lesions. A detailed history revealed that tab teneligliptin 20 mg OD was added by physician to his anti-diabetic treatment in August 2021. After he failed to show any response to oral immunosuppressants, methylprednisolone pulse therapy was administered (intravenous methylprednisolone 500 mg in 100 ml normal saline/day for 5 days). The patient was discharged on oral deflazacort, dapsone, azathioprine and nicotinamide, along with an advice to the physician to replace teneligliptin with a suitable alternative. Over the next 3 months, he was eventually able to achieve remission with a few intermittent episodes of exacerbation which could be successfully managed with a short course of high-dose oral corticosteroids.

Though it is known that SARS-CoV-2 can induce autoimmunity through complex mechanisms such as molecular mimicry, bystander activation and epitope spreading, there have only been a handful of reports of BP precipitated after Covid-19 infection.[4]

Benzaquen et al.[5] reported that dipeptidyl peptidase-4 inhibitor (DPP4i) intake was associated with an increased risk for triggering BP (adjusted OR, 2.64), with vildagliptin being implicated with the highest risk (adjusted OR, 3.57). Other gliptins such as linagliptin, sitagliptin and anagliptin may also act as culprits.

BP is a prominent dermatological cause of morbidity among the elderly. To the best of our knowledge, this is the first report to explore the synergistic effect of teneligliptin and Covid-19 in BP. Through this patient whose new-onset BP triggered by Covid-19 infection was made rather recalcitrant by chronic intake of teneligliptin, we aim to not only implicate Covid-19 as an emerging trigger of BP in the modern era but also suggest therapeutic prudence while managing co-existing diabetes in such patients.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Kridin K, Ludwig RJ. The growing incidence of bullous pemphigoid: Overview and potential explanations. Front Med 2018;5:220.  Back to cited text no. 1
Bastuji-Garin S, Joly P, Lemordant P, Sparsa A, Bedane C, Delaporte E, et al. Risk factors for bullous pemphigoid in the elderly: A prospective case-control study. J Invest Dermatol 2011;131:637-43.  Back to cited text no. 2
Bastuji-Garin S, Joly P, Picard-Dahan C, Bernard P, Vaillant L, Pauwels C, et al. Drugs associated with bullous pemphigoid. A case-control study. Arch Dermatol 1996;132:272-6.  Back to cited text no. 3
Galván Casas C, Català A, Carretero Hernández G, Rodríguez-Jiménez P, Fernández-Nieto D, Rodríguez-Villa Lario A, et al. Classification of the cutaneous manifestations of COVID-19: A rapid prospective nationwide consensus study in Spain with 375 cases. Br J Dermatol 2020;183:71-7.  Back to cited text no. 4
Benzaquen M, Borradori L, Berbis P, Cazzaniga S, Valero R, Richard MA, et al. Dipeptidyl peptidase IV inhibitors, a risk factor for bullous pemphigoid: Retrospective multicenter case-control study from France and Switzerland. J Am Acad Dermatol 2017;78:1090-610.  Back to cited text no. 5


  [Figure 1], [Figure 2]


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