|Year : 2014 | Volume
| Issue : 2 | Page : 134-138
Immunobullous disorders: Clinical histopathological and immunofluorescence study of thirty-six cases
Srinath M Kambil1, P Madavamurthy2
1 Department of Dermatology, Father Muller Medical College, Mangalore, India
2 Department of Dermatology, Jagadguru Jayadeva Murugarajendra Medical College, Davangere, Karnataka, India
|Date of Web Publication||1-Jul-2014|
Srinath M Kambil
Department of Dermatology, Father Muller Medical College, Kankanady, Mangalore - 575 002, Karnataka
Source of Support: None, Conflict of Interest: None
Background: Immunobullous disorders are characterized by antibody-mediated bullous lesions affecting the skin and mucosa. Accurate diagnosis of these disorders requires clinicopathological correlation along with immunofluorescence study. Aims and Objectives: To study the clinical, histopathological, and immunopathological features of immunobullous disorders and to analyse the utility of immunofluorescence in the diagnosis of these disorders. Materials and Methods: A total of 36 cases of immunobullous disorders observed over a span of 2 years in our institution were studied. Detailed clinical examination, histopathological examination and immunofluorescence study were done in all cases. Results: Out of 36 cases studied, 18 cases (50%) belonged to pemphigus group, 10 cases (27.78%) were bullous pemphigoid (BP), 5 cases (13.89%) were linear IgA disease (LAD), 2 cases (5.56%) were cicatricial pemphigoid (CP) and 1 case (2.77%) was lichen planus pemphigoides (LPP). Twenty-one patients (58.33%) were in the age group of 21-60 years, 9 patients (25%) were above 60 years and 6 patients (16.67%) were below 20 years. Histopathology of all cases of pemphigus vulgaris (PV) showed suprabasal bulla with acantholytic cells. Pemphigus foliaceus (PF) showed subcorneal bulla in all three cases. Immunofluorescence in all 15 cases of PV showed IgG deposition in intercellular substance (ICS) and C3 deposition in ICS in six cases. PF showed IgG deposition in ICS in all three cases. BP and CP showed deposition of IgG and C3 in a linear band at basement membrane zone (BMZ) in all cases. All cases of LAD showed linear IgA band at BMZ. Conclusion: In three cases (two cases of BP and 1 LAD), immunofluorescence was absolutely essential to come to a final diagnosis, while in two cases of CP immunofluorescence helped in confirming the clinical diagnosis as histopathological finding was nonspecific. In the remaining cases it helped in confirming the diagnosis suggested by clinical examination and light microscopy.
Keywords: Immunobullous disorders, immunofluorescence, pemphigus
|How to cite this article:|
Kambil SM, Madavamurthy P. Immunobullous disorders: Clinical histopathological and immunofluorescence study of thirty-six cases. Muller J Med Sci Res 2014;5:134-8
|How to cite this URL:|
Kambil SM, Madavamurthy P. Immunobullous disorders: Clinical histopathological and immunofluorescence study of thirty-six cases. Muller J Med Sci Res [serial online] 2014 [cited 2019 Jul 22];5:134-8. Available from: http://www.mjmsr.net/text.asp?2014/5/2/134/135747
| Introduction|| |
Autoimmune vesiculobullous disorders are a heterogenous group of disorders in which autoantibodies target structures essential for integrity of skin and mucous membrane leading to blister formation.  Depending on the location of the bulla, these disorders can be classified as intraepidermal and subepidermal.  To arrive at a diagnosis, clinical examination should be aided by histopathological examination, but a definitive diagnosis can be achieved only using immunofluorescence study. The aim of this study was to analyse the clinical, histopathological and immunofluorescence features of immunobullous disorders and to evaluate the diagnostic significance of immunofluorescence in these disorders.
| Materials and Methods|| |
A total of 36 patients with immunobullous disorders observed over a period of 2 years from September 2004 to August 2006 in our institution were studied.
A detailed history and thorough clinical examination was carried out in all cases. Cytological examination (Tzanck smear) was done by taking a smear by scraping the base of the deroofed bulla which was stained with Giemsa and observed under light microscope.
Histopathological examination was done by taking skin or mucosal biopsy of a representive lesion which was stained with hematoxylin and eosin and observed under light microscope. For direct immunofluorescence (DIF), skin or mucosal biopsy was taken from perilesional tissue and sent to immunofluorescence center in Michels transport medium where it was stained and seen under immunofluorescence microscope. For indirect immunofluorescence (IIF), 5-10 ml of blood was collected into sterile test tube and allowed to stand for 1 hour. Serum was taken using pipette and mailed to immunofluorescence center.
| Results|| |
A total of 36 patients with immunobullous disorders were studied. Of these, 18 cases (50%) belonged to pemphigus group, 10 cases (27.78%) were bullous pemphigoid (BP), 5 cases (13.89%) were linear IgA disease (LAD), 2 cases (5.56%) were cicatricial pemphigoid (CP) and 1 case (2.77%) was lichen planus pemphigoides (LPP) [Table 1].
Out of the 18 cases of pemphigus group, 15 cases (83.33%) were pemphigus vulgaris (PV) and three cases (16.67%) were pemphigus foliaceus (PF).
Out of 36 patients, 21 patients (58.33%) were in the age group of 21-60 years, nine patients (25%) were above 60 years and six patients (16.67%) were below 20 years. PV was most common in 31-40 years with five cases followed by 21-30 years with four cases. Two patients with PF belonged to age group of 41-50 years and one patient was in the 31-40-years age group. BP was most common above 70 years with five cases followed by 2 cases in 41-50 years group. One case of CP was seen in 41-50 years and 1 case in 61-70 years group. LAD was most common in 0-10 age group with three cases. Single case of LPP was seen in third decade [Table 2].
Out of 36 cases, there was slight male preponderance (58.33%) compared to females (41.67%). Pemphigus group was slightly more in males (55.56%) compared to females (44.44%). BP was slightly more common in males (60%) compared to females (40%). LAD showed male preponderance (80%) [Table 3].
Out of 15 cases of PV, 13 cases had mucocutaneous involvement while two cases had only oral erosions. Out of 13 cases with cutaneous involvement, 11 had lesions on trunk, seven had lesions on extremities, eight had face involvement, five had lesions in flexures and five had scalp involvement. All three cases of PF had skin lesions without mucosal involvement. Face and trunk had lesions in all cases while two cases had scalp involvement also. All the 10 cases of BP presented with tense bulla where as urticarial plaques were seen in one case. Extremities were involved in all 10 cases, trunk had lesions in eight cases, face was involved in three cases and oral involvement was seen in two cases. Both cases of CP had oral and conjuctival erosions and scarring while one case had vesicles and erosions on abdomen and genitalia. All five patients with LAD presented with tense bulla on skin and oral erosions were seen in two cases. Trunk was involved in all cases, face and extremities were involved in four cases, scalp was involved in one case and genitalia in one case. Single case of LPP in the study presented with violaceous papules and plaques, vesicles and flaccid bulla on both normal skin and violaceous plaques.
Histopathology of all cases of PV showed suprabasal bulla with acantholytic cells. Inflammatory infiltrate was seen in bulla cavity in 11 cases. PF on histopathology showed subcorneal bulla in all three cases while eosinophilic infiltrate in epidermis was seen in two cases and spongiosis in one case. Tzanck smear showed acantholytic cells in all cases of pemphigus with skin lesions.
All cases of BP showed subepidermal bulla with eosinophils in bulla cavity. Histopathology was nonspecific in both cases of CP. LAD on biopsy showed subepidermal bulla in all cases. Predominant inflammatory infiltrate in bulla cavity was neutrophils in four cases while one case showed eosinophilic infiltrate. LPP on histopathology showed subepidermal bulla and also hyperkeratosis, hypergranulosis, acanthosis, basal cell degeneration and lymphocyte infiltrate in dermis.
Immunofluorescence in all 15 cases of PV showed IgG deposition in intercellular substance (ICS) where as C3 deposition in ICS was seen in 6 cases [Figure 1]. In PF direct immunofluorescence (DIF) showed IgG deposition in ICS in all 3 cases. DIF in all cases of BP showed deposition of IgG and C3 in a linear band at basement membrane zone (BMZ) [Figure 2]. Both cases of CP showed linear IgG and C3 deposition at BMZ on DIF. All cases of LAD showed linear IgA band at BMZ. LPP on DIF showed IgG and C3 deposition in linear fashion at BMZ.
| Discussion|| |
Autoimmune vesiculobullous disorders are characterized by antibody mediated bullous eruption affecting skin and or mucosa.  It includes intraepidermal disorders like pemphigus vulgaris (PV) and pemphigus foliaceus (PF) and subepidermal disorders like bullous pemphigoid (BP), cicatricial pemhigoid (CP), linear IgA disease (LAD), dermatitis herpetiformis, pemphigoid gestationis, lichen planus pemphigoides (LPP), epidermolysis bullosa acquisita and bullous systemic lupus erythematosus.  Light microscopy is a simple method for diagnosis of immunobullous disorders and should be correlated with clinical findings. But to make a definitive diagnosis immunofluorescence technique is required and it is considered as the gold standard. Direct immunofluorescence (DIF) is done using perilesional skin or mucosa as substrate where as indirect immunofluorescence (IIF) is done using patient's serum. 
Pemphigus vulgaris is characterized by flaccid bullae and erosions with histopathological finding of suprabasal split and acantholysis and DIF showing IgG in ICS in nearly 100% of cases and C3 in 50-100% of cases. , BP usually presents in elderly with tense bullae on trunk and extremities with histopathology showing subepidermal bulla with predominant eosinophilic infiltrate and DIF showing C3 and or IgG at BMZ in almost all cases. , Most patients of LAD are children presenting with tense bullae with some lesions showing 'cluster of jewel appearance'. Histopathology shows subepidermal bulla with predominant neutrophilic infiltrate and DIF shows linear IgA deposition at BMZ in all cases. , CP is subepidermal blistering disorder which leads to scarring and it affects predominantly the mucosa of eyes and mouth with skin being involved in one-third of cases. DIF shows C3 and or IgG at BMZ in 50% of cases. ,
In the present study, pemphigus (50%) was the most common immunobullous disorder with PV being the most common subtype followed by PF. Similar findings were reported in various studies. ,,, Maximum cases (77.78%) of pemphigus were seen in the age group of 21-50 years. Oral erosions were seen in all cases of PV (100%) while none of the patients with PF had oral lesions. Pemphigus group was slightly more common in males (55.56%) as noted in studies by Arya et al.,  BP was the most common subepidermal bullous disorder in our study and similar findings were noted in other studies. , Maximum number of cases of BP (50%) was seen in age above 70 years which was also noted by others. , Extremities (100%) were involved in all cases of BP followed by trunk (80%). LAD showed a definite male preponderance (80%) and most cases were seen in children.
All cases of PV (100%) showed suprabasal bulla and acantholytic cells on histopathology and immunofluorescence showed IgG deposition in ICS in all cases (100%) while C3 deposition in ICS was seen in 40% of cases. All cases of PF (100%) showed subcorneal bulla and IgG deposition in ICS. All the 18 cases of pemphigus were found on histopathology and immunofluorescence to be consistent with clinical diagnosis.
Cases in which immunofluorescence showed linear band of IgG and C3 at BMZ were given a final diagnosis of BP. All nine cases clinically suspected as BP were found to be histopathologically consistent with the diagnosis. On DIF eight out of nine cases were proven to be consistent while one case turned out to be linear IgA disease. In addition two cases clinically diagnosed as LAD showed features of BP on histopathology and immunofluorescence.
Cases which had linear IgA deposition at BMZ were given final diagnosis of LAD. Out of 6 cases clinically suspected as LAD, 4 cases were consistent with the diagnosis on histopathology and DIF. 1 case clinically diagnosed as BP, showed histopathological features of BP, but on DIF showed features of LAD.
The 2 cases clinically diagnosed as CP showed nonspecific features on histopathology, but DIF helped to confirm the diagnosis. A single case of LPP in the study showed good clinicopathological correlation which was confirmed by DIF.
In 91.67% of clinically suspected cases immunofluorescence finding was consistent with clinical diagnosis (clinico-immunological correlation). 88.89% of clinically suspected cases were found to have same condition on histopatholgy (clinico-histopathological correlation) [Table 4].
|Table 4: Clinical, immunological and histopatholgical correlation in 36 cases|
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Clinical examination and histopatholgy helped in diagnosing majority of cases, but 2 additional cases of BP and 1 case of LAD were diagnosed by immunofluorescence [Table 5].
Thus in three cases (two cases of BP and onw LAD), immunofluorescence was absolutely essential to come to a final diagnosis, while in two cases of CP immunofluorescence helped in confirming the clinical diagnosis as histopathological finding was nonspecific. In the remaining cases it helped in confirming the diagnosis suggested by clinical examination and light microscopy and similar observation was seen in other studies also. ,
Therefore immunofluorescence should be considered as the gold standard for investigating autoimmune vesiculobullous disorders and we recommend immunofluorescence study in all cases of immunobullous disorders to arrive at a final definitive diagnosis.
| References|| |
|1.||Yancey KB. The pathophysiology of autoimmune blistering diseases. J Clin Invest 2005;115:825-8. |
|2.||Huilgol SC, Bhogal BS, Black MM. Immunofluorescence of the immunobullous disorders Part two: The clinical disorders. Indian J Dermatol Venereol Leprol 1995;61:255-64. |
|3.||Chhabra S, Minz RW, Saikia B. Immunofluorescence in dermatology. Indian J Dermatol Venereol Leprol 2012;78:677-91. |
|4.||Khandpur S, Verma P. Bullous pemphigoid. Indian J Dermatol Venereol Leprol 2011;77:450-5. |
|5.||Kippes W, Schmidt E, Roth A, Rzany B, Bröcker EB, Zillikens D. Immunopathologic changes in 115 patients with bullous pemphigoid. Hautarzt 1999;50:866-72. |
|6.||Egan CA, Zone JJ. Linear IgA bullous dermatosis. Int J Dermatol 1999;38:818-27. |
|7.||Ingen-Housz-Oro S. Linear IgA bullous dermatosis: A review. Ann Dermatol Venereol 2011;138:214-20. |
|8.||Bean SF. Cicatricial pemphigoid: A study of 15 cases. South Med J 1974;67:1187-90. |
|9.||Huda MM, Afsar MI. A clinicopathological study of pemphigus. Indian J Dermatol 2001;46:75-9. |
|10.||Zaraa I, Kerkeni N, Ishak F, Zribi H, El Euch D, Mokni M, et al. Spectrum of autoimmune blistering dermatoses in Tunisia: An 11-year study and a review of the literature. Int J Dermatol 2011;50:939-44. |
|11.||Daneshpazhooh M, Chams-Davatchi C, Payandemehr P, Nassiri S, Valikhani M, Safai-Naraghi Z. Spectrum of autoimmune bullous diseases in Iran: A 10-year review. Int J Dermatol 2012;51:35-41. |
|12.||Micali G, Musumeci ML, Nasca MR. Epidemiologic analysis and clinical course of 84 consecutive cases ofpemphigus in eastern Sicily. Int J Dermatol 1998;37:197-200. |
|13.||Arya SR, Valand AG, Krishna K. A clinico-pathological study of 70 cases of pemphigus. Indian J Dermatol Venereol Leprol 1999;65:168-71. |
|14.||Bernard P, Vaillant L, Labeille B, Bedane C, Arbeille B, Denoeux JP, et al. Incidence and distribution of subepidermal autoimmune bullous skin diseases in three French regions. Bullous Diseases French Study Group. Arch Dermatol 1995;131:48-52. |
|15.||Wong SN, Chua SH. Spectrum of subepidermal immunobullous disorders seen at the National Skin Centre, Singapore: A 2-year review. Br J Dermatol 2002;147:476-80. |
|16.||Bastuji-Garin S, Joly P, Lemordant P, Sparsa A, Bedane C, Delaporte E, et al. French Study Group for Bullous Diseases. Risk factors for bullous pemphigoid in the elderly: A prospective case-control study. J Invest Dermatol 2011;131:637-43. |
|17.||Jung M, Kippes W, Messer G, Zillikens D, Rzany B. Increased risk of bullous pemphigoid in male and very old patients: A population-based study on incidence. J Am Acad Dermatol 1999;41:266-8. |
|18.||Leena JB, Chandrashekhar M, Vijaya B, Sunila R, Manjunath GV. A clinicopathological study of immunobullous lesions of the skin. Adv Lab Med Int 2012;2:49-60. |
|19.||Minz RW, Chhabra S, Singh S, Radotra BD, Kumar B. Direct immunofluorescence of skin biopsy: Perspective of an immunopathologist. Indian J Dermatol Venereol Leprol 2010;76:150-7. |
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]