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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 37  |  Issue : 2  |  Page : 62-68

A retrospective study of the clinical, histopathological, and direct immunofluorescence spectrum of immunobullous disorders


1 PG Resident, Department of Dermatology, Venereology and Leprosy, Father Muller Medical College, Kankanady, Mangalore, Karnataka, India
2 Senior Resident, Department of Dermatology, Venereology and Leprosy, Father Muller Medical College, Kankanady, Mangalore, Karnataka, India
3 Professor, Department of Dermatology, Venereology and Leprosy, Father Muller Medical College, Kankanady, Mangalore, Karnataka, India
4 Professor & HOD, Department of Dermatology, Venereology and Leprosy, Father Muller Medical College, Kankanady, Mangalore, Karnataka, India

Date of Submission29-Jan-2017
Date of Acceptance16-Mar-2017
Date of Web Publication4-Aug-2017

Correspondence Address:
Viraktamath Chanabasayya
Department of Dermatology, Venereology and Leprosy, Father Muller Medical College, Mangalore, Karnataka 575002
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ejdv.ejdv_3_17

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  Abstract 


Context
Immunobullous disorders are a heterogenous group of dermatoses with a variety of frequently changing manifestations. They have remarkable impact on the patients and their family, and have severe economic consequences. The diseases have been the subject of intensive investigation in recent years.
Aim
The aim of this study was to investigate the clinical spectrum of immunobullous disorders and to analyze the correlation between clinical, histopathological, and direct immunofluorescence (DIF) diagnosis in immunobullous disorders of the skin.
Patients and methods
This cross-sectional, descriptive, chart-based, retrospective study was conducted on 91 clinically suspected immunobullous disorder patients who attended the Outpatient Department of Dermatology, Father Muller Medical College, Mangalore, Karnataka, India, between 1 January 2015 and 31 October 2016.
Results
In 91 cases of suspected immunobullous disorders (50 male and 41 female), bullous pemphigoid was the most common condition (46.15%), followed by pemphigus vulgaris (18.68%) and pemphigus foliaceus (10.98%). Of the 91 patients, histopathological diagnosis was positive in 67 (73.62%) patients and DIF was confirmatory in 55 (60.44%) patients.
Conclusion
We recommend that clinical, histopathological, and DIF features be taken into consideration to arrive at final diagnosis in immunobullous disorders, as these methods may not be diagnostic individually in each and every case.

Keywords: direct immunofluorescence, histopathology, immunobullous disorders


How to cite this article:
Chanabasayya V, Jyothi J, Jacintha M, Sukumar D. A retrospective study of the clinical, histopathological, and direct immunofluorescence spectrum of immunobullous disorders. Egypt J Dermatol Venerol 2017;37:62-8

How to cite this URL:
Chanabasayya V, Jyothi J, Jacintha M, Sukumar D. A retrospective study of the clinical, histopathological, and direct immunofluorescence spectrum of immunobullous disorders. Egypt J Dermatol Venerol [serial online] 2017 [cited 2017 Dec 18];37:62-8. Available from: http://www.ejdv.eg.net/text.asp?2017/37/2/62/212225




  Introduction Top


Immunobullous disorders are a heterogenous group of dermatoses with a variety of frequently changing manifestations. If left untreated, these immunobullous disorders may be associated with significant morbidity and mortality. Hence, accurate diagnosis and treatment are necessary. The diseases have been the subject of thorough investigation in recent years [1].

Pathological evaluation involves systematic analysis, which includes the blister separation plane, the mechanism of blister formation, and the character of the inflammatory infiltrate, including its presence or absence.

Recent advances in investigative dermatology have introduced newer techniques for the investigation of patients with immunobullous diseases, which include conventional histopathology examination and confirmative tests such as direct immunofluorescence (DIF) and indirect immunofluorescence [2].

Immunofluorescence has significantly contributed in the diagnosis, treatment, and understanding of the pathophysiology of vesiculobullous lesions of the skin. DIF was initially performed only in a few centers in developing countries such as India. However, with the availability of transport media such as Michel’s media, the majority of dermatologists now have access to DIF.

This study was undertaken to evaluate the clinical, histopathological, and DIF spectrum of various immunobullous disorders of the skin [1].


  Patients and methods Top


This cross-sectional, descriptive, chart-based, retrospective study was conducted on 91 immunobullous disorder patients who attended the Outpatient Department of Dermatology, Father Muller Medical College, Mangalore, Karnataka, India, over a period of 21 months (between 1 January 2015 and 31 October 2016).

Medical records of all patients with clinically suspected immunobullous disorders who attended the Outpatient Department of Dermatology were screened, after obtaining institutional ethical committee clearance. Nonimmune-mediated vesiculobullous lesions secondary to mechanical injury, infections, eczemas, and burns (chemical or thermal) were excluded from the study as these conditions present with characteristic clinical features, and histopathology and DIF are not the main diagnostic methods.

From these medical records, demographic data of patients, such as age, sex, provisional clinical diagnosis, histopathological and DIF findings, and final diagnosis, were collected. In all patients, excisional biopsy from the lesional skin or oral mucosa, preferably including intact vesicle/bulla, was obtained for histopathological study and another biopsy from perilesional normal-appearing skin or oral mucosa was obtained for DIF. Histopathological diagnosis was made on the basis of the level of split, inflammatory infiltrate, altered keratinocytes and dyskeratotic cells, and pattern of arrangement of epidermal keratinocytes (e.g. dilapidated brick wall appearance and row of tombstone). On the basis of these features, the vesiculobullous diseases were divided into subcorneal [pemphigus foliaceus (PF), pemphigus erythematosus (PE), and subcorneal pustular dermatosis], suprabasal [pemphigus vulgaris (PV) and Hailey–Hailey disease], and subepidermal [bullous pemphigoid (BP), dermatitis herpetiformis (DH), and bullous systemic lupus erythematosis (BSLE)] blistering disorders. The DIF result was based on the site [intercellular, along basement membrane zone (BMZ), or dermal papillae], type (IgG, IgM, IgA, or C3), pattern (granular or linear), and intensity of deposition of immune reactants.

Inclusion criteria

All patients with suspected immunobullous diseases who had undergone both histopathological and DIF tests were included in the study.

Exclusion criteria

All cases of nonimmune-mediated vesicobullous disorders were excluded from the study.


  Results Top


Biopsy specimens from 91 patients with suspected immunobullous disorders were sent for histopathology and DIF investigations over a period of 21 months. Of these, 42 (46.15%) cases were of BP, 17 (18.68%) cases were of PV, 10 (10.98%) cases were of PF, nine (9.89%) cases were of vasculitis, five (5.5%) cases were of DH, three (3.3%) cases were of lichen planus pemphigoides (LPP), two (2.2%) cases were of pemphigus vegetans (PVg), and one (1.1%) case each of PE, BSLE, and epidermolysis bullosa acquisita (EBA) ([Table 1]).
Table 1 Types of immunobullous disorders

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Of the 91 patients, 53 (58.24%) patients were in the age group of 40–70 years, 25 (27.47%) were below 40 years of age, and 13 (14.29%) patients were above 70 years of age. The youngest patient was 2 years of age and the oldest patient was 85 years of age. BP was seen more commonly in patients between 61 and 70 years of age (12 cases), followed by those between 51 and 60 years of age. Most of the patients with PV (nine cases) were below 40 years of age and nine cases were between 51 and 60 years of age. PF was the most common type in the age group of 51–60 years. Six patients with vasculitis and three patients with DH were below 40 years of age ([Table 2]).
Table 2 Age-wise distribution of immunobullous disorders

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There was a slight male preponderance in the ratio of 1.22 : 1 (51 male and 41 female). BP (30.8%), vasculitis (6.6%), PE, and EBA (1.1%) were slightly more common in male patients, whereas PV (9.9%), DH (4.39%), LPP (3.3%), PVg (2.2%), and BSLE (1.1%) were common in female patients. PF showed no sex predilection ([Table 3]).
Table 3 Sex-wise distribution of immunobullous disorders

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Histopathology of all cases of BP showed subepidermal bulla, with eosinophils seen in bulla cavity in 88.2% of cases ([Figure 1]). All cases of PV showed suprabasal bulla and in 94.4% cases acantholytic cells were present. Row of tombstone appearance was seen in 66.7% of cases ([Figure 2]). Five cases of PF on histopathology showed subcorneal bullae with acantholytic cells in 60% of cases and villi in 40% cases ([Table 4]).
Figure 1 Pemphigus vulgaris. Suprabasal blister, acantholytic cells and row of tomb stone appearance (H & E).

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Figure 2 Bullous pemphigoid. Subepidermal bulla filled with eosinophils (H & E).

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Table 4 Histopathological findings in immunobullous disorders

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As regards immunofluorescence in BP, 19 cases showed linear deposition of both IgG and C3 at the BMZ, whereas only IgG deposition was seen in four cases and only C3 deposition was seen in eight cases ([Figure 3]).
Figure 3 Bullous pemphigoid. Linear deposition of IgG and C3 along the basement membrane zone (DIF).

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In PV, DIF of eight cases showed both IgG and C3 deposition in intercellular substance, whereas only IgG deposition in intercellular substance was seen in five cases ([Figure 4]).
Figure 4 Pemphigus vulgaris. Deposition of IgG in intercellular spaces giving a fishnet appearance (DIF).

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In PF, DIF showed deposition of both IgG and C3 in three cases and only IgG deposition in two cases.

As regards DIF in vasculitis patients, two cases showed only IgA deposition, two cases showed only C3 deposition, two cases showed deposition of both IgG and C3, and one patient showed only IgG deposition ([Table 5]).
Table 5 Antibody and complement deposition in direct immunofluorescence

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In 67 (73.62%) clinically suspected cases, histopathological diagnosis was consistent with clinical diagnosis (clinicohistopathological correlation), and in 24 (26.38%) cases discordance was seen ([Table 6]).
Table 6 Clinical and histopathological discordance

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Similarly, 55 (60.44%) clinically suspected cases were found to have the same condition on DIF (clinicoimmunological correlation), and in 36 (39.56%) cases discordance was seen ([Table 7]).
Table 7 Clinical and direct immunofluorescence discordance

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In 42 cases, BP was diagnosed clinically, but histopathological confirmation was made only in 34 cases and confirmation using DIF was made only in 31 cases. In PV, 17 cases were suspected clinically, but histopathological and DIF confirmation was made only in 13 cases. However, one case of BP and four cases of PF that were clinically diagnosed were diagnosed as PV on histopathology. In 10 cases of PF, histopathological and DIF confirmation was made only in five cases. All cases of clinically suspected vasculitis were confirmed histopathologically, but seven cases were confirmed using DIF. In DH, out of five clinically diagnosed cases, three cases were confirmed histopathologically and two cases were confirmed using DIF ([Table 8]).
Table 8 Discordance between clinical, histopathological, and direct immunofluorescence findings

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  Discussion Top


Immunobullous disorders are characterized by antibody-mediated vesicles and bullae affecting the skin and or mucosa [3]. They can be classified on the basis of level of split, which includes intraepidermal blistering disorders, such as PV, PF, and PE, and subepidermal blistering disorders, such as BP, linear IgA disease, DH, LPP, EBA, and BSLE [4].

Although various primary cutaneous diseases present clinically with vesiculobullous lesions, their etiology, pathogenesis, severity, and course differ. Therefore, accurate diagnosis of these diseases is essential for appropriate management to avoid or minimize associated morbidity and mortality. Clinically, all patients with immunobullous disorders may not present with classical morphology and distribution of the lesions as observed in various studies conducted in India [5]. These differences may be due to the prevalence, stage, and severity of the disease at presentation and status of the treatment. In these clinical conditions in which clinical diagnosis is difficult, histopathology and DIF of biopsy specimen will help in arriving at final diagnosis.

Histopathology is a simple method for the diagnosis of immunobullous disorders and should be correlated with clinical findings. However, DIF is required to make a definitive diagnosis and is considered as the gold standard. DIF is performed using perilesional skin or mucosa as substrate [6]. PV is characterized by flaccid bullae and erosions showing no tendency of healing. Histopathological finding was suprabasal split and acantholysis and DIF showing IgG in the intercellular space in nearly 100% of cases and C3 in 50–100% of cases [4],[6]. BP is commonly seen in the elderly with tense bullae on the 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 [7],[8]. PF also presents with flaccid bullae erosions but showing tendency for healing.

In our study, BP, which was diagnosed clinically in 42 cases and by means of histopathology and DIF in 34 cases was the most common immunobullous disorder followed by PV (17 cases clinically and 18 cases by means of histopathology examination). Similar findings were noted in other studies [9],[10]. The maximum number of cases of BP (54.76%) was seen in the age group of 51–70 years, whereas 66.67% of PV cases were seen in the age group of 17–50 years.

BP (30.769%), vasculitis (6.5934%), PE, and EBA (1.0989%) showed slight male preponderance, similar to the observations in the study by Arya et al. [5], whereas PV (9.89%), DH (4.39%), LPP (3.29%), PVg (2.19%), and BSLE (1.098%) were common in female population. PF showed no sex predilection.

In BP, subepidermal separation with eosinophilic infiltration was observed in 88.23% of specimen, which is less compared with that reported in the study by Nishioka et al. [11]. These variations in findings may be due to differences in the site or type of lesion selected for biopsy.

In PV, suprabasal separation with a row of tombstone appearance was seen in 66.67% of cases [5] and acantholysis in 94.44% of cases, similar to that reported in other studies [5],[12].

In PF, acantholysis and hyperkeratosis were seen in 60% of the cases, villi and parakeratosis in 40% of cases, and dyskeratosis in 20% of cases.

In DH, on histopathological examination, 66.67% of patients had infiltrate in blister cavity and 33.33% had acantholysis and spongiosis.Discordance between clinical, histopathological, and DIF findings was observed. Clinical examination and histopathology helped in diagnosing the majority of cases, but five cases of PV and one case each of BP and PF were diagnosed additionally by means of histopathology ([Table 6]). Thus, in seven cases (as explained earlier), histopathology was absolutely essential to come to a final diagnosis.

Similarly, four cases of PV and one case each of BP and PF were diagnosed additionally by means of DIF ([Table 7]).

In one case each of BP, PV, PF, and PVg, immunofluorescence helped in confirming the clinical diagnosis, as histopathological findings were inconclusive ([Table 9]). In 17 cases ([Table 10]), histopathology helped in making final diagnosis. In the remaining cases both histopathology and DIF helped in confirming the diagnosis suggested by clinical examination and similar observation was seen in other studies also [13],[14].
Table 9 Direct immunofluorescence findings as diagnostic

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Table 10 Histopathology as diagnostic

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  Conclusion Top


Clinical examination is the initial step in making a diagnosis of immunobullous disorders. Histopathological examination and DIF are needed for making a definitive diagnosis. Therefore, both histopathology and immunofluorescence should be considered as the gold standard for investigating immunobullous disorders. DIF is helpful in situations where clinical and/or histopathological features are inconclusive. Hence, we recommend that clinical, histopathological, and DIF features be taken into consideration to arrive at final diagnosis, as these methods may not be diagnostic individually in each and every case.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Wojnarowska F, Venning VA. Immunobullous diseases. In: Burns T, Brethnach S, Cox N, Griffiths C, editors. Rook’s textbook of dermatology. 8th ed. 40. Oxford: Wells Blackwell; 2010. pp. 1–62.  Back to cited text no. 1
    
2.
Arundhati S, Ragunatha S, Mahadeva KCA. Cross-sectional study of clinical, histopathological and direct immunofluorescence spectrum of vesiculobullous disorders. J Clin Diagn Res 2013; 7:2788–2792.  Back to cited text no. 2
    
3.
Yancey KB. The pathophysiology of autoimmune blistering diseases. J Clin Invest 2005; 115:825–828.  Back to cited text no. 3
    
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Huilgol SC, Bhogal BS, Black MM. Immunofluorescence of the immunobullous disorders. Part two: the clinical disorders. Indian J Dermatol Venereol Leprol 1995; 61:255–264.  Back to cited text no. 4
    
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Arya SR, Valand AG, Krishna K. A clinico-pathological study of 70 cases of pemphigus. Indian J Dermatol Venereol Leprol 1999; 65:168–171.  Back to cited text no. 5
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Khandpur S, Verma P. Bullous pemphigoid. Indian J Dermatol Venereol Leprol 2011; 77:450–455.  Back to cited text no. 7
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Kippes W, Schmidt E, Roth A, Rzany B, Bröcker EB, Zillikens D. Immunopathologic changes in 115 patients with bullous pemphigoid. Hautarzt 1999; 50:866–872.  Back to cited text no. 8
    
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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.  Back to cited text no. 9
    
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Nishioka K, Hashimoto K, Katayama I, Sarashi C, Kubo T, Sano S. Eosinophilic spongiosis in bullous pemphigoid. Arch Dermatol 1984; 120:1166–1168.  Back to cited text no. 11
    
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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.  Back to cited text no. 13
    
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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; 76:150–157.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10]



 

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