HR-HPV DNA to differentiate between cervical pemphigus and CIN: a case report

Abstract

A 50-year-old multiparous postmenopausal woman, attended our colposcopy clinic in April 2006 for severe dysplasia in pap smear. Her routine cervical smears tests were normal till 2002, when it showed severe dysplastic changes (Fig. 1). Colposcopic examination at that time also suspected high grade squamous intraepithelial lesion (HSIL) and she was treated with cervical conization. Interestingly, histology revealed acanthosis and suprabasal bulla formation, which was consistent with pemphigus vulgaris (PV). There was no sign of any intraepithelial neoplasia. A further immunocytochemistry test with MiB1 (Ki67) showed proliferation activity only in the basal epidermal layers, in keeping with cell regeneration (Fig. 4). She was a nonsmoker and had subtotal hysterectomy in 1999 for menorrhagia. She was allergic to iodine. Her PV was Wrst diagnosed in 1987 when she developed blisters in the oral cavity, vagina and anal mucosa following ingestion of iodine-based contrast for cholangiogram. An immunoXuorescence test of oral mucosal biopsy conWrmed PV. She was treated with prednisolone 5 mg/day since and was advised to use prednisolone douches and mouth washes for Xare-ups additionally. She took azathioprine for a short duration, which was stopped because she developed leucopenia. All her follow-up smears following conization were reported as abnormal except one in August 2004 and these appeared to coincide with Xare-ups of the pemphigus. At follow up in April 2006, colposcopy was normal but repeat smear was suggestive of HSIL. After multidisciplinary team discussion, a plan was made to follow her up for 6 months with colposcopy, repeat smear and HPV DNA test. Colposcopy in December 2006 showed no acetowhite changes and there was suggestion of active cervical pemphigus in the form of surface bullae/vesicles (Fig. 2). The repeat smear was again reported as showing severely dysplastic cells. HPV DNA test using hybrid capture (Digene HC II) was negative for high-risk HPV types. The smear was found to be similar to that of the initial one 4 years ago. The possibility of HSIL could not be excluded. A negative HPV DNA result was therefore extremely useful in ruling out HSIL. Normal colposcopic Wndings, negative HPV DNA and knowledge of past history were considered as reassuring factors and a decision was made to follow her up with HPV DNA test and colposcopy in future.