Diagnostic importance of immunofluorescence in oral bullous diseases and lupus erythematosus

Pain management of pemphigus vulgaris

Pemphigus is a rare autoimmune bullous disease which affects the mucous membranes and skin. Pemphigus vulgaris (PV) is the most prevalent type of pemphigus. PV presents with extremely painful, non-healing oral erosions. However, there are only a handful of reports addressing the pain management of PV. We would like to present a case of a painful PV, which was successfully managed.

Bullous Pemphigoid: A 10-Year Study of Discordant Results on Direct Immunofluorescence

Background:

Bullous pemphigoid (BP) is the most common subepidermal autoimmune disorder characterized by tense bullae. It is associated with circulating autoantibodies against BP antigen-1 and BP antigen-2. Diagnosis is based upon clinical, histopathologic, and immunopathologic examination. Direct immunofluorescence (DIF) of perilesional skin highlights C3 with or without IgG in a linear pattern along the basement membrane.

Objectives:

We hypothesized that repeat biopsies may be required for a definitive DIF diagnosis of BP, as initial DIF evaluation may result in a false-negative result.

Methods:

A retrospective chart review was conducted on 1143 specimens collected for evaluation for BP. Cases from 2 Vancouver Coastal Health Authority laboratories from 2006 to 2016 were reviewed. Results were interpreted as positive, negative, or indeterminate based on pathologic description and specimen quality.

Results:

After meeting the inclusion criteria, 739 specimens were further evaluated. There were 289 cases of BP in the 10-year period. Five patients (1.73%; 95% confidence interval [CI], 1.50-1.96) required a second biopsy to support a BP diagnosis, and within this group, 1.04% of the 289 (95% CI, 0.811-1.27) were true successive negative-to-positive DIF results.

Conclusions:

DIF is the most reliable test used to diagnose BP; however, a small percentage of patients will initially have a negative result. False-negative or indeterminate results may be due to specimen sampling from lesional skin or due to a subthreshold quantity of immune complexes in the skin. Repeat biopsy is warranted despite an initial negative DIF if BP is clinically suspected.

Identification of a 168-kDa mucosal antigen in a subset of patients with cicatricial pemphigoid

This study describes the presence of antibodies in sera from patients with cicatricial pemphigoid specific for a 168-kDa antigen expressed by buccal mucosa. Six cicatricial pemphigoid sera unreactive, with epidermal or dermal proteins in immunoblot assay were tested on mucosal protein extracts. Four of these sera labeled a mucosal 168-kDa antigen (M168) under reducing conditions. An additional cicatricial pemphigoid serum with circulating antibodies to 180-kDa bullous pemphigoid antigen (BPAg2) also labeled M168. None of these cicatricial pemphigoid sera reacted with the alpha, beta, or gamma subunits of laminin-5. Nitrocellulose elution studies showed that the M168 antigen is a basement membrane antigen and labeled the epidermal side of salt-split skin. Immunoaffinity-purified anti-M168 antibodies did not bind to the 230-kDa bullous pemphigoid antigen (BPAg1) or to the 180-kDa BPAg2. None of the control sera from healthy individuals or from bullous pemphigoid, pemphigus vulgaris, or pemphigus foliaceus patients reacted with Ml68. This study demonstrates the specificity of some cicatricial pemphigoid sera against a 168-kDa antigen that is different from the laminin-5 subunits and shares no epitopes with the antigens of bullous pemphigoid (BPAg1, BPAg2) or the epidermolysis bullosa acquisita.

Treatment of oral pemphigus vulgaris

BACKGROUND

Oral pemphigus is considered to represent either an initial stage of pemphigus vulgaris that should be treated with high doses of immunosuppressive drugs to prevent its spread to the skin or a variety of the disease that does not need aggressive treatment. The absence of a widely accepted therapeutic method and the obscure nature of this disease prompted this study.

METHODS

Twenty-eight patients with oral pemphigus were randomly divided into three groups. The first group received only steroids at a dose of 40 mg of prednisone equivalent. In the other two groups the same dose of steroids was administered, but combined with either 100 mg of cyclophosphamide or 5 mg/kg of cyclosporine as an adjuvant. Direct immunofluorescence studies were performed on specimens obtained from both buccal mucosa and oral skin.

RESULTS

There was no significant difference in the duration of treatment required to achieve remission and in the relapse rate among the three groups. The incidence of complications was higher with combination treatment. Deposited immunoreactants were detected with equal frequency in specimens obtained from the buccal mucosa and normal skin.

CONCLUSIONS

Oral pemphigus most likely represents an initial stage of a disease that can become generalized. Administration of moderate doses of steroids alone is effective in controlling the disease.

Oral pemphigus vulgaris in young adults

Three patients, aged 31, 26, and 22 years, had pemphigus vulgaris. A delay in diagnosis and appropriate treatment occurred because the initial presentation was confined to the oral mucosa.

Desquamative gingivitis: preliminary observations with tetracycline treatment

Fourteen patients admitted to our clinic were found to have desquamative gingivitis. They were treated with doxycycline monohydrate, a semisynthetic tetracycline, for 6 to 8 weeks. The gingival lesions were recorded photographically and were classified according to severity by means of a four-graded mucosal index system. Biopsies for histologic and immunohistochemical examination were taken initially. Symptoms and clinical changes of the mucosa were recorded during the treatment period. Initial and final mucosal index scores were compared. A statistically significant improvement was obtained after tetracycline treatment.

Oral pemphigus vulgaris in a 6-year-old girl

An extremely rare case of pemphigus vulgaris in a 6-year-old girl with prominent oral manifestations is presented. The disease was first noted at the age of 2 years, yet no diagnosis was made. Clinical, histopathologic, and immunologic criteria served to confirm the diagnosis. A review of the literature has revealed 22 well-documented cases of pemphigus vulgaris in children under the age of 17 years. It is concluded that although oral pemphigus vulgaris is rare in young persons, it must be included in the differential diagnosis in those cases that have a prolonged history of erosive or bullous lesions.

Pemphigus vulgaris presenting as a gingival lesion. A case report

A 26-year-old hispanic male presented with a nonspecific gingival lesion initially presumed to be of infectious etiology. During continued follow-up over several weeks, the lesion evolved into one typical of desquamative gingivitis. Direct immunofluorescent testing and routine histopathology resulted in a diagnosis of pemphigus vulgaris, which was confirmed by indirect immunofluorescence. Although it is unusual for pemphigus vulgaris to present with the gingiva as the sole primary site of involvement, this case serves to enhance our awareness of the gingiva as a site at which systemic disease can be manifested.

Cicatricial pemphigoid, bullous pemphigoid, and epidermolysis bullosa acquisita antigens: differences in organ and species specificities and localization in chemically-separated human skin of three basement membrane antigens

Bullous pemphigoid, cicatricial pemphigoid, and epidermolysis bullosa acquisita are three autoimmune diseases characterized by the presence of subepidermal blisters, in vivo-bound immunoreactants along the dermoepidermal junction, and variably detectable circulating anti-basement membrane autoantibodies. In order to better characterize the antigen(s) defined by cicatricial pemphigoid sera, indirect immunofluorescence was performed on a variety of human organs, skins of different animals, and on human skin chemically-split within the lamina lucida, comparing sera from cicatricial pemphigoid patients with sera from these two other blistering diseases. Sera from patients with each disease bound to the dermoepidermal junction of every laboratory animal species examined. In contrast, more mucosal tissues were bound by anti-basement membrane autoantibodies from patients with cicatricial pemphigoid and epidermolysis bullosa acquisita than from patients with bullous pemphigoid, consistent with the marked tendency for mucosal involvement in patients with the former two diseases. In addition, one of the cicatricial pemphigoid sera stained basal cell surfaces as well as dermoepidermal junction. Differences were also apparent in the staining of chemically-split human skin. The combined findings suggest that cicatricial pemphigoid and bullous pemphigoid antigens are distinct despite their common localization within the lamina lucida of the dermoepidermal junction. These data also suggest the presence of at least two different cicatricial pemphigoid antigens.

Epidermolysis bullosa: variability of expression of cicatricial pemphigoid, bullous pemphigoid, and epidermolysis bullosa acquisita antigens in clinically uninvolved skin

Indirect immunofluorescence was performed on skin from 13 patients with epidermolysis bullosa (EB) (simplex, 6; junctional, 2; dystrophic, 5) to compare the expression of 3 basement membrane components, bullous pemphigoid (BP) antigen, cicatricial pemphigoid (CP) antigen, and epidermolysis bullosa acquisita (EBA) antigen, in clinically uninvolved tissue. In addition, expression of laminin, type IV collagen, and KF-1 antigen was also evaluated. Whereas laminin, type IV collagen, and KF-1 antigen were each detectable in EB skin in a manner identical to that previously reported, marked variability was noted in the expression of BP, CP, and EBA antigens. However, no correlation was noted comparing lack of expression of any one of these latter antigens with either of the remaining two. Of these 3 antigens, BP antigen was the least often detectable, particularly in skin from patients with EB simplex. The lack of detectable BP antigen in EB simplex skin appeared to correlate with more extensive disease involvement and/or younger patient age. These findings may, therefore, limit the usefulness of BP serum in immunofluorescence mapping. Additionally, the disparity in expression of basement membrane antigens defined by BP and CP sera suggests that BP antigen and CP antigen are distinct entities.

Desquamative gingivitis and extragingival collapsed bulla

Mucous membrane pemphigoid is a relatively rare, chronic scarring vesiculobullous disease that frequently affects the oral and ocular mucosa. Other mucous membranes and skin are less frequently affected. Characteristic oral lesions include desquamative gingivitis, and extragingival ulcers and collapsed vesicles and bullae. Ocular involvement may lead to blindness. Local and systemic corticoid hormones, dapsone, and periodontal therapy have all been used with variable success to treat the disease.

Immunofluorescence and immunoelectron microscopic studies in cicatricial pemphigoid

We have studied various tissues from 10 patients with cicatricial pemphigoid using direct and indirect immunofluorescence, mechanical suction blister induction, and immunoelectron microscopy. In 8 of the 10 patients, direct immunofluorescence of buccal mucosa showed a linear deposition of immunoreactants, IgG and C3 being those most commonly detected. Direct immunofluorescence of skin was positive in only 4 patients. Only 1 patient had a detectable circulating anti-basement membrane zone antibody. Substitution of normal human oral mucosa for adult skin as the tissue substrate for indirect immunofluorescence did not prove useful in the detection of circulating autoantibodies. Immunoelectron microscopy was performed in the skin or mucosa (buccal or ocular) of 6 patients, revealing lamina lucida localization of in vivo-bound immunoreactants. Indirect immunofluorescence studies on mechanically induced suction blisters in skin of 2 patients with in vivo-bound IgG suggest that the lamina lucida antigen involved in cicatricial pemphigoid may be distinct from the bullous pemphigoid antigen.

The use of monoclonal antibodies in skin basement membrane research

Recent experiments have indicated that it is possible to uncover new antigens within both the basement membrane zone and the epidermis of normal adult human skin by producing murine anti-human monoclonal antibodies following immunization with human skin preparations. Already one such monoclonal antibody has defined a biochemical defect that may be important in the pathogenesis of one of the more severe blistering skin diseases, dystrophic epidermolysis bullosa. It is likely that further attempts at hybridoma production using basement membrane extracts of skin will lead not only to the identification of other as yet unknown components of the human dermo-epidermal junction, but may also shed insight into the biochemical basis of one or more cutaneous diseases involving that region of the skin.

Chronic pemphigus vulgaris of the gingiva. A case report with a 6-year follow-up

Since the initial lesions of pemphigus vulgaris often appear in the oral cavity, dentists have a major role in the recognition and diagnosis of this condition. The patient reported here was seen with a mild gingival form of the disease and has been managed successfully for the past 6 years without systemic steroids and with minimal topical steroid therapy. For most of that period he was managed without medication. Various aspects of the disease, including diagnosis, the significance of pemphigus antibodies and therapy are reviewed to provide a better perspective on this case.

Immunoperoxidase technique in diagnosis of oral pemphigus vulgaris: an alternative method to immunofluorescence

Five cases of oral pemphigus vulgaris, diagnosed on the basis of clinical, histopathologic, and immunopathologic criteria, were selected. Sections were stained with the peroxidase antiperoxidase (PAP) technique of immunocytochemical staining. The findings correlated well with those reported by direct immunofluorescence demonstrating the same intercellular substance (ICS) pattern of staining. Because this staining technique is applied to routinely processed and paraffinized tissue, it may be of particular value to the oral pathologist who often receives formalin-fixed material before the need for immunopathologic studies is recognized. In addition, interpretation does not require specialized microscopy and tissue sections can be stored and retrieved for retrospective study.

Clinical and cytological features of oral pemphigus

Nine patients with pemphigus vulgaris and one with pemphigus vegetans were studied. All ten patients had oral lesions, five of them skin involvement as well. The patients were followed up for variable periods at different intervals. At each visit, their clinical condition was assessed as mild, moderate, severe or remissive. At examinations, oral light microscopical smears and blood samples for indirect immunofluorescence were taken. From one patient with pemphigus vulgaris, smears from skin blister fluid were also studied. The highest intercellular antibody titers were found in severely affected patients, and those at the mild stage of the disease usually gave low or negative titers. A correlation between the number of acantholytic cells in smears and the clinical condition of the patient was usually found: improvement of the clinical state was followed by decreased numbers of acantholytic cells. Acantholytic cells were rounded or ovoid, having an enlarged, hyperchromatic, centrally or eccentrally situated nucleus. The cytoplasm was usually eosinophilic. Neutrophilic polymorphonuclear leucocyte/acantholytic cell rosettes were sometimes seen in the smears, as well as eosinophil/acantholytic cell rosettes. Variable numbers of leucocytes (from 3 to 11) were seen surrounding the acantholytic cell. Both binucleated epithelial and acantholytic cells and multinucleated giant cells were found in the smears. Multinucleated giant cells were sometimes seen engulfing cells resembling acantholytic cells.

Desquamative lesions of the gingiva

Previous reports, as well as the investigations reported here, clearly indicate that desquamative gingivitis is a clinical manifestation of several diseases. Correct identification of the underlying etiology is very important since approximately one-third of the patients with desquamative gingivitis may have cicatricial pemphigoid or pemphigus. These two diseases have broad and sometimes systemic medical implications. In cicatricial pemphigoid, not only the oral mucosa but also the conjunctiva may be involved with subsequent blindness. Because of this, patients with cicatricial pemphigoid should also be examined by an ophthalmologist and may require care of a dermatologist for systemic treatment. In pemphigus, 50% of the cases start with only oral lesions with later development of skin lesions. Because of the life-threatening nature of this disease, patients are usually placed on high systemic doses of corticosteroids. Patients with pemphigus should be referred to a dermatologist immediately.

Oral pemphigus vulgaris: an immunofluorescent study of fifty-eight cases

Oral mucosa biopsy specimens and sera from fifty-eight patients with pemphigus vulgaris limited to the oral cavity were studied by the direct and indirect immunofluorescence technique. Direct immunofluorescence demonstrated intercellular substance (ICS) deposition of IgG, either alone or in combination with C3, IgA, and IgM, in fifty-seven out of fifty-eight (98.3 per cent) oral mucosa biopsy specimens examined. At the time of initial evaluation circulating ICS antibodies were detected in twenty-eight out of fifty-eight patients (48.3 per cent) when a compound animal epithelial tissue was used as substrate. However, when normal human oral mucosa was used as substrate, circulating ICS antibodies were observed in fifty out of fifty-eight patients (86.2 per cent). It is concluded that direct and indirect immunofluorescence is a valuable diagnostic test in the early diagnosis of oral pemphigus vulgaris. In addition, normal human oral mucosa is a more appropriate substrate than animal epithelial tissue.

Immunofluorescent study of cytologic smears in oral pemphigus: A simple diagnostic technique

This study was undertaken in order to explore the diagnostic efficacy of the direct immunofluorescent technique for demonstration in vivo bound immunoglobulins to desquamated epithelial cells from patients with oral pemphigus. Cytologic smears were obtained with a wooden spatula from the oral lesions of thirty patients with known pemphigus vulgaris. Control smears were taken from thirty-five patients twenty suffering from various other mucosal diseases and fifteen devoid of oral lesions. The smears were stored at -30 degrees C. and prepared within 48 hours for examination by the direct immunofluorescent technique. Deposition of IgG was demonstrated in all thirty smears from the oral pemphigus lesions. None of the control smears gave positive results. These findings suggest that the direct immunofluorescent technique using cytologic smears may provide an additional simple and reliable method in the diagnosis or oral pemphigus vulgaris.

Immunology in dentistry

Implications of immunology in dental treatment are explained through discussion of the basic scientific principles of allergy, autoimmunity, immunization, immune dysfunction, tumor immunology, immunosuppression, and transplantation immunobiology.

Prepubertal oral pemphigus vulgaris

Although rare, oral pemphigus vulgaris must be considered in those patients who have a prolonged history of oral lesions. The fact that chronic oral lesions characteristically precede skin changes in pemphigus emphasizes the importance of this disease to the dental profession. Patients with long-term and recurrent vesiculoulcerative oral lesions should undergo biopsy examination to establish the diagnosis. The dentist and the physician must collaborate to establish an appropriate diagnostic and therapeutic plan for the management of these patients.

Assessment of a tissue transport-medium in preservation of tissue-fixed immunoglobulins and complement demonstrated by direct immunofluorescence. A pilot study with skin from SLE patients

The present work was undertaken in order to test the value of a tissue transport-medium (Histocon) for direct immunofluorescence studies. For this purpose one skin biopsy was performed on each forearm of 26 patients with systemic lupus erythematosus. One of the specimens was left in ice-cold Histocon solution for 4, 8, or 20 hours, and the other was immediately quick-frozen. The results of the immunofluorescence tests with the two methods yielded similar results. It is concluded that the solution allows the preservation of tissue-fixed immunoglobulins and complement during short periods of transport.

Benign mucous membrane pemphigoid (cicatricial mucosal pemphigoid): a reconsideration

The name cicatricial mucosal pemphigoid is suggested in an attempt to clarify several synonymous terms and to omit the prefix "benign." The clinical features are reviewed and seven case reports illustrating different aspects are presented. The severe effects of ocular and pharyngeal involvement are highlighted, immunologic findings and treatment are discussed, and the link with neoplasia is emphasized.

Effects of an immunofluorescent transport solution on the ultrastructure of human biopsies

Although immunofluorescent tests have been demonstrated to be of value in the diagnosis of many oral and skin lesions, the use of this technique has until recently been cumbersome because of the requirement for frozen tissue specimens. This has been circumvented by the development of a solution in which tissue can be transported to the testing laboratory at ambient temperatures. To verify that the immunofluorescent findings in gingiva and skin kept in this solution are not artifactual, ultrastructural studies were performed on such tissue. These revealed that over-all tissue architecture, individual cells, and the epidermal-connective tissue interface remain intact. Since the majority of oral lesions submitted for immunofluorescent testing are suspected of being pemiphigus or pemphigoid, the finding that these tissue features remain intact indicates that the distribution of immunofluorescence is related to definite morphologic structures and provides additional evidence for the validity of using the transport solution.

Intraoral pemphigus vulgaris

Twenty-eight cases of intraoral pemphigus vulgaris are presented. All had histologic confirmation, including twenty-six from intraoral biopsies. Detailed descriptions involving many clinical features are reported and discussed. Pertinent histologic findings are also described.

Oral non-dystrophic bullous eruption mainly limited to the gingivae: a mechano bullous response. A variant of cicatricial mucous membrane pemphigoid?

Fourteen patients with recurrent blistering entirely restricted to the mouth have been observed for up to 7 years. Their average age was 52 years, and there was a predilection for females (ratio 2-5:1). Patients presented with thick-roofed blisters and denuded, red, boggy areas of mucosa. The area of maximal involvement with the labial gingiva, and whilst the blisters would arise spontaneously, mechanical trauma was the obvious provocative factor in all patients. Gentle friction on normal looking mucosa would produce a bulla which became blood filled. Re-epithelialization usually occurred within 1-3 weeks, with no scarring. Biopsies showed subepithelial bullae, and direct immunofluorescence was positive in the basement membrane zone of 2 of the 5 cases examined. The most striking feature was the extreme fragility of the epithelial attachment to the underlying corium, as shown by a useful clinical test with a probe. In 10 patients, the condition gradually remitted and the probe test became difficult to perform. The term acquired oral non-dystrophic epidermolysis bullosa was considered for the diagnosis, although a forme fruste of cicatricial mucous membrane pemphigoid remained an alternative.