O01 Infantile bullous pemphigoid: when autoimmunity hides an immunodeficiency

Infantile bullous pemphigoid (BP) can be an early manifestation of ZAP-70 deficiency, a rare combined immunodeficiency (CID) characterised by defective T-cell signalling and a propensity to multiple autoimmune manifestations.1 We describe two patients with BP subsequently diagnosed with ZAP-70 deficiency. Case 1: A female neonate presented at 14 days with severe seborrhoeic dermatitis. From 3 months she was repeatedly admitted with severe respiratory infections. Investigations revealed normal full blood count (FBC), but profoundly reduced CD8+ lymphocytes. At 7 months she developed an extensive bullous eruption. Skin biopsy with direct and indirect immunofluorescence confirmed the diagnosis of BP, which was difficult to control and required multiple systemic treatments, including methylprednisolone, dapsone, dupilumab, intravenous immunoglobulin and rituximab. She developed immune-mediated thrombocytopenia and is currently being prepared for bone marrow transplantation (BMT) due to ZAP-70 deficiency. Case 2: A female infant presented at 3 months with bullae of the face and extremities. Skin biopsy with direct and indirect immunofluorescence confirmed BP, which responded to topical corticosteroids and erythromycin. At 9 months she developed recurrent severe respiratory infections requiring ventilation. Laboratory studies showed near-absent CD8+ lymphocytes and confirmed ZAP-70 deficiency. She underwent BMT in June 2024, with no recurrence of blistering. Conclusion: Infantile BP should prompt suspicion of an underlying CID. Assessment of lymphocyte subsets is essential, as ZAP-70 deficiency is characterised by profoundly reduced CD8+ lymphocytes, which may not be apparent on a standard FBC where total lymphocyte numbers can be normal. Early -diagnosis is essential, as BMT offers the only curative -treatment.