An acquired form of epidermolysis bullosa without immunoreactants. Report of a case

Bullous tinea pedis with direct immunofluorescence positivity: when is a positive result not autoimmune bullous disease?

Skin biopsy for direct immunofluorescence (DIF) testing is an essential tool in the diagnosis of blistering diseases. In the majority of cases, positive epidermal immunofluorescent staining is indicative of an autoimmune bullous disease (AIBD). We identified 2 patients with bullous dermatophyte infection diagnosed on hematoxylin- and eosin-stained sections who had positive DIF findings on biopsy of perilesional skin. We subsequently reviewed the literature regarding positive DIF findings in conditions other than AIBD. Other infections, including herpesviridae, scabies, and orf, have rarely been reported to yield positive DIF findings, with positive staining at the dermoepidermal junction. Some genodermatoses and many inflammatory skin diseases, including lichen planus, psoriasis, graft-versus-host disease, among others, may also have DIF findings mimicking those of both intra- and subepidermal AIBD. Although rare, positive DIF results occur in conditions other than AIBD. In many instances, the pathophysiological mechanisms behind immunoreactant deposition in these conditions are poorly understood. Misleading DIF results may lead to delay in correct diagnosis and treatment. Clinicians should be aware of potential alternate sources of positivity when there is lack of clinical correlation with immunofluorescence findings.

Penicillamine-induced bullous dermatoses

The successful therapeutic use of D-penicillamine (DPA) has been hindered by its many adverse effects. Autoimmune bullous syndromes are among the less common adverse DPA reactions; they are not dose dependent and appear late in the treatment of diseases of altered immunity, most often rheumatoid arthritis. The majority of the DPA-induced bullous syndromes belong to the pemphigus spectrum, usually pemphigus foliaceus or erythematosus, have a lower prevalence of demonstrable tissue-fixed or circulating antibodies than spontaneously occurring pemphigus, display abnormal direct immunofluorescent patterns, and have a generally favorable prognosis. However, many cases do exhibit a full-blown chronic disease, unaffected by DPA withdrawal. DPA-induced cicatricial pemphigoid is a severe disease of both mucous and cutaneous involvement with a prognosis similar to the spontaneous disease. Cases of DPA-induced epidermolysis bullosa acquisita and DPA-induced bullous pemphigoid were not sufficiently substantiated by immunofluorescence or immunoprecipitation criteria.

Localization of bullous pemphigoid antibody--an indirect immunofluorescence study of 228 cases using a split-skin technique

We have re-examined the site of deposition of IgG anti-basement membrane zone antibodies in 228 sera from suspected cases of bullous pemphigoid (BP), using 1.0 M sodium chloride split-skin as substrate for indirect immunofluorescence. Nine sera (4%) produced fluorescence on the floor of the split suggesting sub-basal lamina antibody deposition compatible with a diagnosis of epidermolysis bullosa acquisita (EBA). This ultrastructural localization was confirmed in only three of these nine by immuno-electron microscopy. Clinical details were available on six of these nine cases, and none had clinical features suggesting EBA. We have found the split-skin immunofluorescence technique unhelpful in identifying 'missed' cases of EBA. The prevalence of EBA presenting as BP would appear to be very low indeed in the U.K.

Disseminated cicatricial pemphigoid in a child and in an adult. Ultrastructural diagnostic criteria and differential diagnosis with special reference to acquired epidermolysis bullosa

The first case of an infant affected with a rare, disseminated variant of benign cicatricial pemphigoid is described, showing the same ultrastructural features of initial blister formation as an adult patient. These consist in edematous changes within the superficial dermis caused by vesiculation or dissolution of cellular and noncellular connective tissue elements, coalescing into subepidermal blisters. Differential diagnosis excludes other nonhereditary bullous disorders because of the ultrastructure of the dermo-epidermal junction in nascent blisters and in perilesional skin. In spite of evident clinical, histological, and immunohistological similarities as well as controversial and confusing immunological studies, acquired epidermolysis bullosa can be clearly separated from our case by a diagnostic hallmark on the electron-microscopical level, i.e., band-like IgG depositions beneath the basal lamina. This is demonstrated in comparing the two cases of disseminated cicatricial pemphigoid with three patients suffering from acquired epidermolysis bullosa, thus providing evidence that disseminated cicatricial pemphigoid and acquired epidermolysis bullosa are two distinct nosologic entities.