Diagnosis
Because it is a rare disease, diagnosis is often complicated and takes a long time. Early in the disease patients may have erosions in the mouth or blisters on the skin. These blisters can be itchy or painful. Theoretically, the blisters should demonstrate a positive Nikolskys sign, in which the skin sloughs off from slight rubbing, but this is not always reliable. The gold standard for diagnosis is a punch biopsy from the area around the lesion that is examined by direct immunofluorescent staining, in which cells are acantholytic, that is, lacking the normal intercellular connections that hold them together. These can also be seen on a Tzanck smear. These cells are basically rounded, nucleated keratinocytes formed due to antibody mediated damage to cell adhesion protein desmoglein. Pemphigus vulgaris is easily confused with impetigo and candidiasis. IgG4 is considered pathogenic. The diagnosis can be confirmed by testing for the infections that cause these other conditions, and by a lack of response to antibiotic treatment. Treatment
Corticosteroids and other immunosuppressive medications have historically been employed to reduce pemphigus symptoms, yet steroids are associated with serious and long-lasting side effects and their use should be limited as much as possible. Intravenous immunoglobulin, mycophenolate mofetil, methotrexate, azathioprine, and cyclophosphamide have also been used with varying degrees of success. An established alternative to steroids are monoclonal antibodies such as rituximab, which are increasingly being used as first-line treatment. In summer 2018, the FDA granted full approval to rituximab for this application, following successful fast track evaluation.
Use and dosage
The maximum upper tolerance limit (UTL) for magnesium in supplement form for adults is 350 mg of elemental magnesium per day, according to the National Institutes of Health (NIH). In addition, according to the NIH, total dietary requirements for magnesium from all sources (in other words, food and supplements) is 320–420 mg of elemental magnesium per day, though there is no UT for dietary magnesium. Laxative
Magnesium citrate is used as a laxative agent.As a laxative syrup with a concentration of 1.745 g of magnesium citrate per fluid ounce, a typical dose for adults and children twelve years or older is between 7 and 10 US fluid ounces (210 and 300 ml; 7.3 and 10.4 imp fl oz), followed immediately with a full 8 US fluid ounces (240 ml; 8.3 imp fl oz) glass of water. Consuming an adult dose of 10 oz of laxative syrup (@ 1.745 g/oz) implies a consumption of 17.45 g of magnesium citrate in a single 10 US fl oz (300 ml; 10 imp fl oz) dose resulting in a consumption of approximately 2.0 g of elemental magnesium per single dose. This laxative dose contains five times the recommended nutritional dose for children. Magnesium citrate is not recommended for use in children and infants two years of age or less. Magnesium deficiency treatment
Although less common, as a magnesium supplement the citrate form is sometimes used because it is believed to be more bioavailable than other common pill forms, such as magnesium oxide.