Development of an IgG4-based Classifier/Predictor of Endemic Pemphigus Foliaceus (Fogo Selvagem)

Fogo Selvagem (FS) is mediated by pathogenic, predominantly IgG4, anti-Dsg1 autoantibodies and is endemic in Limao Verde (LV), Brazil. IgG and IgG-subclass autoantibodies were tested in a sample of 214 FS patients and 261 healthy controls by Dsg1-ELISA. For model selection, the sample was randomly divided into training (50%), validation (25%) and test (25%) sets. Using the training and validation sets, IgG4 was chosen as the best predictor of FS, with index values above 6.43 classified as FS. Using the test set, IgG4 has sensitivity 92% (95% CI: 82−95%), specificity 97% (95% CI: 89−100%) and area under the curve 0.97 (95% CI: 0.94−1.00). The IgG4 positive predictive value (PPV) in LV (3% FS prevalence) was 49%. The sensitivity, specificity and PPV of IgG anti-Dsg1 were 87%, 91% and 23%, respectively. The IgG4-based classifier was validated by testing 11 FS patients before and after clinical disease and 60 Japanese pemphigus patients. It classified 21/96 normal individuals from a LV cohort as having FS serology. Based on its PPV, half of the 21 individuals may currently have preclinical FS and could develop clinical disease in the future. Identifying individuals during preclinical FS will enhance our ability to identify etiological agent(s) triggering FS