{"id":11875,"date":"2016-12-22T10:18:31","date_gmt":"2016-12-22T10:18:31","guid":{"rendered":"http:\/\/biomedpharmajournal.org\/?p=11875"},"modified":"2016-12-27T11:43:25","modified_gmt":"2016-12-27T11:43:25","slug":"diagnosis-of-vesicullo-bullous-lesions-simplified","status":"publish","type":"post","link":"https:\/\/biomedpharmajournal.org\/staging\/vol9no3\/diagnosis-of-vesicullo-bullous-lesions-simplified\/","title":{"rendered":"Diagnosis of Vesicullo Bullous Lesions – Simplified"},"content":{"rendered":"

Introduction<\/strong><\/p>\n

Vesiculo bullous lesions are a distinct group of oral disorders characterized by the formation of vesicle or bullae. And it is uncommon to see vesicle and bullae intra orally because due to constant masticatory pressure vesicles and bullae get ruptured and it becomes ulcers and erosions.1<\/sup> The diagnosis can be made histopathologically, clinically, and immunological methods. And thorough clinical history should be asked from the patient which includes presence of vesicles and bullous anywhere else in the body like skin, genitalia, and eyes. Since many oral lesions can cause lesions in the dermatological regions. Vesicle is defined as a superficial blister, 5 mm or less in diameterusually filled with clear fluid. And bulla is defined as a circumscribed collection of free fluid greater than 5 mm. In this article various procedures have been explained to diagnose the condition of vesiculo bullous lesions.<\/p>\n

There are three categories by which oral vesiculo bullous lesions can be diagnosed.<\/p>\n

Clinical<\/p>\n

Histological<\/p>\n

Molecular<\/p>\n

Diagnostic procedures for vesiculo bullous lesions-<\/p>\n

Nikolsky\u2019s Test<\/strong><\/p>\n

It was first described by Piotr Vasiliyevich Nikolsky, a Russian dermatologist.2<\/sup> He related that after rubbing the skin of the patient who was affected by pemphigus, there was a blistering or denudation of the epidermis with a glistening moist surface underneath.3<\/sup>this was later confirmed by Lyell who described Nikolsky\u2019s sign in patients with toxic epidermal necrolysis. It is classically seen in pemphigus vulgaris. However other lesions showing sign for this are pemphigus foliaceus, graft versus host disease, paraneoplastic pemphigus, epidermolysis bullosa, oral lichen planus, bullous pemphigoid, mucous membrane pemphigoid, chronic erythema multiforme, dermatomyositis .4<\/sup> this test cannot e performed in oral cavity because the blisters get ruptured. In oral cavity, after applying mucosal pressure, when ulceration or blisters appears, the test is said to be positive. Mucosal pressure can be by blowing air or using a blunt instrument or by finger.<\/p>\n

Method<\/strong><\/p>\n

Done by applying lateral pressure with the index finger which gives shearing force to disrupt the intercellular adhesion5<\/sup><\/p>\n

BIOPSY-6, 7<\/sup><\/strong><\/p>\n

Factors to be considered<\/strong><\/p>\n

Ulcerated tissue site to be avoided ( because roof will not be present and sometimes the site may be masked by secondary inflammation and necrosis)<\/p>\n

To stop topical steroid ( in order to prevent false negative results)<\/p>\n

Two biopsy specimens from the affected site ( one specimen to be kept in 10% neutral buffered formalin for H & E staining and other is submitted in michel\u2019s medium for DIF)<\/p>\n

Sample of the patients serum or blood<\/p>\n

Sample\/ lesions collected to be fresh (less than 24 to 48 hrs old)<\/p>\n

Tzanck Test8, 9<\/sup><\/strong><\/p>\n

Tzanck in 1947, used cytology for diagnosis of VB disorders particularly herpes simplex.<\/p>\n

It is a very simple and rapid technique<\/p>\n

Samples taken should be fresh<\/p>\n

Procedure for Tzanck test-<\/p>\n

Cleaned and dried area<\/p>\n

At the base of the blister a sterile needle is inserted<\/p>\n

Then smear is taken from the blister which contains acantholytic cells<\/p>\n

Smear is then prepared on a clean glass slide and stained using Leishman stain<\/p>\n

The smear shows the presence of Tzanck cells which are formed during detachment<\/p>\n

Tzanck cell is a large round keratinocyte with a hyperchromatic nucleus and peripheral condensation of the chromatin<\/p>\n

Indication<\/strong><\/p>\n

giant cells identificationthat accompany in viral infections<\/p>\n

Acantholysis, in case of pemphigus.<\/p>\n

Le Test or Le Cell Inclusion Phenomenon<\/strong><\/p>\n

Hargraves was the one who first explained this for SLE.typical LE cell will develop if the serum from the patient suffering from SLE is added to buffy coat of the normal blood. LE cell may be neutrophils or macrophages that has engulfed the denatured nucleus of an injured cell and contains LE body<\/p>\n

Immunofluorescence<\/strong><\/p>\n

IF is an antigen antibody reaction where the antibodies are labeled with the dye (fluorescent dye) and then the antigen antibody complex can be seen using UV microscope .10<\/sup> coons developed IF. Used for detection of antigens in the tisues. Gold standard technique for detection of autoimmune blistering diseases is through DIF.<\/p>\n

Two basic methods<\/p>\n

Direct immunofluorescence<\/p>\n

indirect immunofluorescence<\/p>\n

Principle of Fluorescence<\/strong><\/p>\n

An atom or molecule absorbs a quantum of light, an electron jumps to a higher energy level, thus displaces an electron from its shelf. When this displaced electron returns backs to its original ground state, it emits a quantum of light. This phenomenon is called photoluminescence and is of two types: Fluorescence and phosphorescence<\/p>\n

Fluorescence is the property by which when illuminated by a light certain substances of certain wavelength, reemit the light to a longer wavelength.<\/p>\n

In phosphorescence, even after the exciting light is cut off, emission continues to persist.<\/p>\n

Immunofluorescent Techniques<\/strong><\/p>\n

Direct Immunofluorescence<\/strong><\/p>\n

It is the one step procedure in which fluoresceinated antibodies are applied to the frozen section of the skin.<\/p>\n

Apply fluorescein- conjugated anti- human IG antibodies in patients tissue specimen<\/p>\n

Wash off excess<\/p>\n

View with UV microscope<\/p>\n

Indirect Immunofluorescence<\/strong><\/p>\n

Apply patients serum, antibodies bind to homologous structures in the section of monkey oesophagus<\/p>\n

Wash off excess<\/p>\n

Apply fluorescein-conjugated anti-human Ig antibodies<\/p>\n

Wash off excess<\/p>\n

View with UV microscope<\/p>\n

Salt Split Technique<\/strong><\/p>\n

The purpose of this technique is to differentiate between two similar immunologically mediated disease having similar clinical features (case of bullous pemphigoid and epidermolysis bullosa) 11<\/sup><\/p>\n

It is of two types- direct and indirect12<\/sup><\/p>\n

Direct technique is performed on freshly taken patient skin biopsy or by routine DIF, the one that has previously been investigated, whereas in indirect technique, substrate used is a normal human skin, cryocut sections are prepared after artificially inducing the junctional split, and then IDIF with patient’s serum is carried out.<\/p>\n

Elisa And Western Blot Technique<\/strong><\/p>\n

For diagnosis of pemphigus vulgaris and foliaceus. This technique can detect antibodies to desmoglein 1 and 3<\/p>\n

To the surface of plastic tubes, absorb antigen and then excess Ag is removed by washing<\/p>\n

Antiserum of the patient is added and excess Antibody is removed<\/p>\n

Enzyme linked alkaline phosphatase is added and excess removed and incubated at 37 c<\/p>\n

Finally corresponding substrate p- nitro phenyl phosphate is added<\/p>\n

Optical density of yellow product is measured by spectrophotometer<\/p>\n

Conclusion<\/strong><\/p>\n

Diagnosing autoimmune VB disease still remains in a dilemma.\u00a0 Immunoprecipitation, Western blot analysis, and elisa are the newer techniques which have evolved and gradually being used in the domain of immunobullous diseases. However, these investigations are complex, expensive, and more time consuming. The gold standard in diagnosing VB lesions is IF as it simple, reproducible, and less time is consuming technique.<\/p>\n

References<\/strong><\/p>\n

    \n
  1. Laskaris G. 2nd ed. Ch 4. Georg Thieme Verlag; 2006. Pocket atlas of oral diseases; pp. 101\u20136.<\/li>\n
  2. Uzun S, Durdu M. The specificity and sensitivity of Nikolsky sign in the diagnosis of pemphigus.\u00a0J Am Acad Dermatol.\u00a02006;54:411\u20135.\u00a0[PubMed]<\/li>\n
  3. Arndt KA, Feingold DS. The sign of Pyotr Vasilyewich Nikolsky.N Engl J Med.\u00a01970;282:1154\u20135.[PubMed]<\/li>\n
  4. Salopek TG. Nikolsky sign: Is it dry or is it wet?Br J Dermatol.\u00a01997;136:762\u20137.\u00a0[PubMed]<\/li>\n
  5. Massoume B, Valikhani M, Esmaili N. Microscopic Nikolsky’s sign: Is it useful for diagnosis of pemphigus vulgaris?\u00a0Iran J Dermatol.\u00a02008;11:64\u20136.<\/li>\n
  6. Habif TP, editor.Clinical Dermatology: A Color Guide to Diagnosis and Therapy.\u00a04th ed. New York: Mosby, Inc; 2004. Vesi cular and bullous diseases; pp. 547\u201354.<\/li>\n
  7. Jordan RC, Daniel TE, Greenspan JS, Regezi JA. Advanced diagnostic methods in oral and maxillofacial pathology (Part II): Immunohistochemistry and immunofluorescent methods.Oral Surg Oral Med Oral Pathol Oral Radiol Endod.\u00a02002;93:56\u201374.\u00a0[PubMed]<\/li>\n
  8. Ruocco V, Ruocco E. Tzanck smear, an old test for the new millennium: When and how?Int J Dermatol.\u00a01999;38:830\u20134.\u00a0[PubMed]<\/li>\n
  9. Gupta LK, Singhi MK. Tzanck smear: A useful diagnostic tool.Indian J Dermatol Venereol Leprol.2005;71:295\u20139.\u00a0[PubMed]<\/li>\n
  10. Vassileva S. Immunofluorescence of dermatology.Int J Dermatol.\u00a01993;32:153\u201361.\u00a0[PubMed]<\/li>\n
  11. Pang BK, Lee YS, Ratnam KV. Floor pattern in salt split cannot distinguish bullous pemphigoid from epidermolysis bullosa acquisita. Use of toad skin.Arch Dermatol.\u00a01993;129:744\u20136.\u00a0[PubMed]<\/li>\n
  12. Chhabra S, Minz RW, Saikia B. Immunofluorescence in dermatology.\u00a0Indian J Dermatol Venerol Leprol.\u00a02012;78:677\u201391.\u00a0[PubMed]<\/li>\n<\/ol>\n","protected":false},"excerpt":{"rendered":"

    Introduction Vesiculo bullous lesions are a distinct group of oral […]<\/p>\n","protected":false},"author":8,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[35],"tags":[],"class_list":["post-11875","post","type-post","status-publish","format-standard","hentry","category-vol9no3"],"_links":{"self":[{"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/posts\/11875","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/users\/8"}],"replies":[{"embeddable":true,"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/comments?post=11875"}],"version-history":[{"count":3,"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/posts\/11875\/revisions"}],"predecessor-version":[{"id":12123,"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/posts\/11875\/revisions\/12123"}],"wp:attachment":[{"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/media?parent=11875"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/categories?post=11875"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/tags?post=11875"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}