Acantholytic Cells Research Articles

The deception of acantholysis: The painful and overlooked story of ocular surface squamous neoplasia in a red eye

A painful red eye can be extremely distressing and can be caused by various ophthalmological or dermatological disorders. We hereby report a case of a red, painful eye in a 55-year-old woman suspected to have pemphigus or ocular cicatricial pemphigoid. Acantholytic cells were seen on conjunctival biopsy, and treatment with prednisolone 60 mg/day with the preliminary diagnosis of ocular pemphigus showed no improvement. Reevaluation of the tissue block showed full-thickness dysplasia within the conjunctival epithelium and acantholytic cells. A diffuse subtype of ocular surface squamous neoplasia, formerly called Bowen’s disease of the eye, is an extremely rare condition and is often misdiagnosed as conjunctivitis, leading to delayed diagnosis. Our case posed an additional diagnostic dilemma due to the uncertainty caused by acantholysis in histology. She was finally treated with external beam radiotherapy, showing resolution of redness and pain. There was no recurrence over the next 1 year.

Comparison of selected cytomorphological features of canine pemphigus foliaceus and superficial pyoderma.

Cytological detection of acantholytic keratinocytes (acantholytic cells [AC]) helps to identify canine pemphigus foliaceus (cPF) yet AC also occurs in superficial pyoderma (SP), the main differential diagnosis. To compare selected cytomorphological features of cPF and SP and to establish cytological diagnostic criteria that could differentiate cPF from SP. 40 and 51 client-owned dogs with PF and SP, respectively. Impression smears from cPF (64), impetigo (40) and exfoliative superficial pyoderma (ESP) (17) samples were stained with Romanowsky stain, randomised, blinded and evaluated by two investigators independently. The entire sample was screened (×500 or ×1000 magnification) for round (AC1), boat (AC2) and raft AC, eosinophils and bacteria. Interobserver agreements were calculated. The average number of the 10 highest ×500 fields for AC1 and AC2 was significantly higher in PF than SP (p < 0.0001; Kruskal-Wallis test). Rafts and eosinophils were more common in PF than SP (p < 0.0001; chi-square test), while bacteria were rare in PF (5%; p < 0.0001; chi-square test). Observations between the experienced and novice investigators were highly correlated. An ROC analysis identified five AC1/×500-magnification field as a suitable cut-off value for predicting PF diagnosis. This cut-off value was tested by two additional investigators, who identified sensitivity of 84%-100%, specificity of 95%-97% and accuracy of 95%-96% for the diagnosis of cPF. Criterion-based impression smear cytological evaluation can provide strong evidence to support the clinical diagnosis. Acantholytic cell morphology varies in cPF and SP, and experience can improve accuracy in cytological differentiation.

A Case of Herpes Zoster Simulating Pemphigus Vulgaris Flare

Pemphigus vulgaris is an autoimmune bullous disorder caused by autoantibodies directed against desmogleins. There is an increased risk for developing herpes zoster in pemphigus vulgaris due to the prolonged and high doses immunosuppressant therapy. Here, we present a 52-year-old female patient with extensive pemphigus vulgaris who developed herpes zoster while on treatment which resulted in a diagnostic confusion and a Tzanck smear acted as a lifesaver revealing both multinucleated giant cells and acantholytic cells. Hence, a prompt decision of reducing the immunosuppressant and initiation of IV acyclovir helped the patient to recover faster. This case highlights the relevance of simple bedside investigation like Tzanck smear and reminds the clinician once again to be open to all possibilities.

Kaposi’s Varicelliform Eruption in a Patient with Darier’s Disease: A Rare Case Report

Darier's disease is a rare autosomal dominant disorder, characterized clinically by the appearance of multiple, pruritic, discrete, and scaly papules affecting seborrheic areas coupled with palmar pits, nail changes, and mucosal involvement. Histologically, the lesions show supra-basal clefts with acantholytic and dyskeratotic cells. Kaposi's varicelliform eruption (KVE) is the dissemination of the herpes simplex virus in the setting of preexisting skin disease, presenting with disseminated vesico-pustules. Darier's disease presenting as KVE is a rare occurrence. If misdiagnosed or left untreated can increase the rate of mortality. Here, we report the case of a 25-year-old male patient who presented with multiple vesicles and crusted lesions over the face, neck, chest, and upper back. After thorough cutaneous examination, he was found to have multiple hyperkeratotic, dirty-warty papules over seborrheic areas, present since childhood. With detailed clinical and laboratory evaluation, we arrived at the diagnosis of KVE with underlying Darier disease.

Unusual Localization of Eczema Herpeticum to Tinea Corporis and Cruris

Abstract Eczema herpeticum (EH), known as Kaposi varicelliform eruption presents with multiple vesiculopustular lesions localized to areas of preexisting eczematous or erosive dermatoses. Most commonly seen in atopic dermatitis but colocalization with tinea cruris and corporis is atypical. In our case, multiple vesicles, pustules, and small crusted erosions associated with pain were seen confined to the areas of dermatophytosis. Tzanck smear from vesicles showed multiple multinucleated giant cells and acantholytic cells. In view of strong clinical suspicion and the presence of multinucleated giant cells, she was prescribed oral acyclovir 400 mg thrice a day for 7 days. She was reviewed after a week with complete clearance of the vesicles and crusting.

Histopathological characterisation of trunk-dominant canine pemphigus foliaceus, and comparison with classic facial and insecticide-triggered forms.

While the clinical features were described recently, the histopathological characterisation of trunk-dominant canine pemphigus foliaceus (PF) is lacking, and whether it differs from classic facial or insecticide-triggered PF is unknown. This study describes the histopathological findings of trunk-dominant PF, and compares the results to classic facial and insecticide-triggered PF. Skin biopsies from 103 dogs with clinically characterised trunk-dominant (n = 33), classic facial (n = 26) and insecticide-triggered PF (n = 44) were included. Histological sections, randomised and blinded, were scored for over 50 morphological parameters of pustules, epidermis, dermis, adnexa and crusts. Intact pustule area and width were measured by digital microscopy. In trunk-dominant PF, 77 intact pustules were predominantly subcorneal (0.0019-1.940 mm2 area, 0.0470-4.2532 mm wide), and contained from one to over 100 acantholytic keratinocytes. Pustules had boat acantholytic cells, corneocytes, perinuclear eosinophilic rings, neutrophil rosettes, acantholytic cell necrosis, rafts, cling-ons and/or eosinophils. Peripustular epidermal spongiosis, necrosis and lymphocyte exocytosis occurred, as did follicular pustules. Mixed dermal inflammation often contained eosinophils. Trunk-dominant PF did not differ from the other PF groups except for few parameters, such as having fewer rafts (p = 0.003). Additional autoimmune inflammatory patterns occurred in all PF groups. Trunk-dominant PF and other canine PF variants are histologically similar, which indicates shared pathomechanisms. The identification of common boat acantholytic cells and corneocyte separation has implications for the mechanisms of acantholysis. The diversity of histopathological and polyautoimmunity features support complicated immune mechanisms. Finally, results indicate that diagnostic biopsies cannot differentiate between these PF variants in dogs.

TZANCK SMEAR: A USEFUL DIAGNOSTIC TOOL IN SPECTRUM OF VESICULOBULLOUS DISEASES OF SKIN.

Introduction: The pemphigus group of autoimmune bullous disorders and mucocutaneous herpesvirus infections are generally diagnosed with the Tzanck smear. Only a few research have looked into its diagnostic value in the literature. To evaluate tzanck smear ndings in patients Objectives: with vesiculobullous skin lesions and histopathological correlation. All recei Material and Methods: ved Samples received between 01/08/2021 to 31/01/2022 were stained with May-Grunwald-Giemsa. In some patients, methylene blue staining and ZN staining were done. Tzanck Results: smear was performed on a total of 25 patients with skin lesions. The sensitivities of multinucleated giant cells and acantholytic cells in herpetic infections, dyskeratotic acantholytic cells,inammatory cells and cocci in bullous impetigo, acantholytic cells with neutrophils and lymphocytes in pemphigus foliaceous, acantholytic cells and plenty of neutrophils in drug-induced pemphigus, no acantholytic cells with neutrophils and lymphocytes in IgA pemphigus, cluster of acantholytic cells in pemphigus vulgaris, only lymphocytes with no acantholytic cells in bullous pemphigoid and dyskeratotic acantholytic cells without inammation in staphylococcal scalded skin syndrome, intracytoplasmic HendersonPatterson bodies and anucleated squamous cells in molluscum contagiosum and broblast, leucocytes with necrotic basal cells in Toxic epidermal necrolysis. The tzanck smear test is an inexpensive, useful, quick, reliable Conclusion: and an easy diagnostic tool for certain vesiculobullous skin diseases.

Lymphocyte-predominant lesional inflammatory infiltrates of the skin are associated with mucosal-dominant phenotype in pemphigus.

Pemphigus is a potentially life-threatening autoimmune blistering disease. To date, studies assessing the association of histopathology with clinical phenotype are lacking. We sought to evaluate the main histopathologic findings and, also, the potential links between cutaneous inflammatory infiltrates and clinical characteristics in pemphigus. We conducted a retrospective cohort study in patients diagnosed with pemphigus vulgaris (PV) and pemphigus foliaceus (PF) in a referral center for autoimmune blistering diseases. A total of 124 patients were included in the study (97 had PV and 27 had PF). On biopsy specimens, PV was more frequently associated with the "row of tombstones" feature (36.1% vs. 11.1%, p=0.013), and PF was associated with acanthosis (44.4% vs. 23.7%, p=0.034). Acantholysis was found in the upper half of the epidermis in PF (96.3% vs. 5.15%, p < 0.001), as opposed to the lower half in PV (75.2% vs. 0%, p=0.002). Patients with lymphocyte-predominant inflammatory infiltrates in lesional skin specimens presented with a higher frequency of the mucosal-dominant phenotype (25.5% vs. 9.1%, p=0.014), higher-density cellular infiltrate (100% vs. 41.6%, p < 0.001), and more frequent acantholytic cells (42.6% vs. 23.4%, p=0.025). Neutrophil-predominant infiltrates in specimens from lesional skin were linked to a milder disease based on median Pemphigus Disease Area Index (38.9% vs. 13.2%, p=0.036) and Autoimmune Bullous Skin Disorder Intensity Score (20.2 vs. 36.3, p=0.019), while eosinophil-predominant inflammatory infiltrates were more often associated with eosinophilic spongiosis (100% vs. 23.1%, p=0.014). Lymphocyte-predominant infiltrates in lesional skin specimens of pemphigus patients predict a mucosal-dominant phenotype, while neutrophil-predominant infiltrates are associated with a milder disease.

Rituximab in the Management of a Child with Pemphigus Vulgaris: Case Study

Background. Pemphigus vulgaris is an autoimmune bullous dermatosis. Its management generally involves lifelong administration of maintenance dose of systemic glucocorticosteroids, that leading to serious adverse effects especially in children.Clinical case description. Patient is the 16 years old boy with severe course of pemphigus vulgaris. The diagnosis was confirmed by the results of cell smear study from fresh erosions (&gt; 50 acantholytic cells were revealed), histological examination of the skin biopsy from the lesion with the vesicle element (suprabasal vesicle was localized in the center, it included fibrin, neutrophil granulocytes, and acantholytic cells), skin biopsy from the area near the lesion (visually healthy skin), via direct immunofluorescence methods (IgG deposition was detected on keratinocytes’ surface throughout the epidermis), and enzyme-linked immunosorbent assay (desmoglein 1 IgG autoantibodies — 121 U/mL (reference value &lt; 20 U/mL) and desmoglein 3 — &gt; 200 U/mL (reference value &lt; 20 U/mL)). Genetically engineered biologic drug, rituximab, and systemic glucocorticosteroid, methylprednisolone, were prescribed as first-line therapy with gradual dose reduction to permanent discontinuation in 8 months. Complete remission maintained after the completion of therapy course and discontinuation of systemic glucocorticosteroid.Conclusion. Combined therapy with systemic glucocorticosteroids and rituximab can be considered as first-line therapy in pediatric patients with pemphigus vulgaris due to relatively low risk of recurrence after rather rapid and complete drugs’ discontinuation.

Adenoid (Acantholytic) squamous cell carcinoma of the alveolar ridge: A rare case report

Adenoid squamous cell carcinoma (ASCC) is a one of the histological variants of oral squamous cell carcinoma with a rare occurrence of less than 4% of all the cases. The tumour has a slight male predilection with lower lip being the most affected site. ASCC is said to have a varied biologic behaviour which accounts for its ability to metastasize to distant sites and hence has poor prognosis. The histopathology shows numerous duct-like structures with central acantholytic cells. Distinct cytological atypia is seen which aids in diagnosis of SCC. Special stains help in differentiating the tumour from other variants of SCC. The presented case of a 70-year-old female emphasizes the importance of histopathogical examination of the unusual and rarely observed ASCC which can be missed due to similarities with other entities. Recurrence rates being very high, proper treatment starting with definitive diagnosis is imperative.

Nonpruritic hypopigmented macules on an immunocompromised patient

Nonpruritic hypopigmented macules on an immunocompromised patient

Oral Warty Dyskeratoma-A Systematic Review of the Literature.

Objective: To systematically review the clinicopathological features of oral warty keratoma based on published literature. Materials and Methods: PubMed and Scopus databases were searched for reports of oral warty dyskeratoma. Of the 52 identified articles, only 25 articles (43 cases) satisfied the selection criteria (case report/series in the English language reporting clinicopathologically diagnosed oral warty dyskeratoma/oral focal acantholytic keratosis/oral isolated dyskeratosis follicularis in humans). Risk of bias was assessed using the Joanna Briggs institute critical appraisal checklist for case reports and case series. Results: Most cases had well-circumscribed, white, nodular verruco-papillary lesions with a central depressed/crater-like area. Alveolar ridges were the most frequent sites of occurrence and tobacco was the most commonly associated risk factor. Histopathologically, the most pathognomonic feature was the supra-basal clefting. The cleft had dyskeratotic acantholytic cells (corps ronds, and grains). Below the cleft were projections of the connective tissue villi lined by basal cells. The basal cells in a few cases exhibited hyperplasia in the form of budding into the stroma, but epithelial dysplasia was not reported. The surface epithelium had crypts filled with keratin debris. Conclusion: Oral warty dyskeratoma is a rare solitary self-limiting benign entity, which due to its clinical and histopathological resemblance and associated habit history could be misdiagnosed as leukoplakia or carcinoma. None of the assessed articles provided molecular data, which in turn could be the reason for the lack of insight into the etiopathogenesis of this enigmatic lesion.

M290 Dynamics of cytomorphological changes in acantholytic cells during treatment of acantholytic pemphigus

M290 Dynamics of cytomorphological changes in acantholytic cells during treatment of acantholytic pemphigus

TZANCK TEST, A TOOL SUPPORTS QUICK DIAGNOSIS ON SUSPECTED PEMPHIGUS CASE

Abstract: A 60-year-old female patient came to our clinic with manifestation of pemphigus vulgaris. The Tzanck test and histopathology showed results consistent with the diagnosis of this disease. Tzanck test is a simple test, easy to perform with the quick result and this patient is the first case applied Tzanck test in diagnosing pemphigus in Hue city Key words: pemphigus, cytology, Tzanck test, acantholytic cells.

A relapse of pemphigus vulgaris in pemphigus herpetiformis or a phenotypic “switch”

Sir, Pemphigus herpetiformis (PH) was originally described by Jablonska et al. in 1975. Clinically, PH presents itself as a herpetiform dermatitis with immunopathological characteristics of pemphigus [1,2]. We report an exceptional case of typical pemphigus vulgaris (PV) relapsing after 36 years in PH. A 65-year-old patient, followed for PV for 36 years and treated with corticosteroid therapy with a remission for more than thirty years, consulted for pruriginous lesions evolving for the previous eight months. A dermatological examination revealed urticariform pruriginous ring lesions surmounted by small peripheral vesicles spread throughout the body (Fig. 1), sparing the mucous membranes, and without Nikolsky’s sign. After two non-specific skin biopsies, the histological examination revealed an intraepidermal bubble with acantholytic cells and eosinophilic spongiosis (Figs. 2a and 2b). Direct immunofluorescence confirmed the diagnosis of pemphigus and indirect immunofluorescence was at the upper limit. The diagnosis of a PV relapse in PH was retained and a dapsone-based treatment was initiated at a dose of 150 mg/day and stopped seven days later when met with hemolytic anemia. Oral corticosteroid therapy involving prednisone at a dose of 1 mg/kg/day was initiated but, given the persistence of the pruritus, the decision was to combine methotrexate at a dose of 12.5 mg/week. A good evolution and a decline within eight months were observed. An improved pruritus and the disappearance of the skin lesions were achieved after one month of treatment. PV and PH are two different anatomical and clinical entities of the autoimmune disease pemphigus, with distinct clinical, histopathological, and immunopathological characteristics [1,2]. Our observation documents a complete phenotypic “switch” of pemphigus with a transition from PV to PH both clinically, histologically, and immunologically. Several rare cases of PV switching to superficial pemphigus (SP) (“phenotypic switch”) have, since 1991, been reported, with a higher frequency this direction than otherwise; the transition period varies from six months to twenty years [3]. To the best of our knowledge, no case has been described of a progression from PV to PH. Having observed one firsthand, we are first to describe the case of a complete phenotypic switch from PV to PH. The mechanism of such a transition remains poorly understood and is often observed during a relapse. Some authors suggest that the effect of immunosuppressants on the desmoglein DSG3 more marked than on DSG1 could explain the relapse of PS in PH [3,4]. Future studies on the immunological factors and predictors of PV relapses after the discontinuation of treatment would be useful to better understand the mechanisms of a relapse in pemphigus, with or without a phenotypic transition.

Acantholytic Squamous Cell Carcinoma

A 63-year-old Filipino man presented with a one-month history of painful ulceration on the alveolar socket of a molar tooth of the right hemimandible. The patient consulted at a tertiary hospital, where he underwent incisional biopsy.&#x0D; &#x0D; Microscopically, the biopsy specimen showed neoplastic cells arranged in a pseudoglandular alveolar pattern with cystic spaces lined with atypical polygonal cells. (Figure 1) Detached “glassy” keratinocytes which are dyskeratotic acantholytic cells were seen within these cystic spaces. (Figure 2) Areas with features of more conventional squamous cell carcinoma, i.e., intercellular bridges and abundant eosinophilic cytoplasm, were also present. (Figure 3) Immunohistochemical staining for p40 showed diffuse nuclear positivity. (Figure 4) Given these findings, a diagnosis of acantholytic squamous cell carcinoma (ASCC) was made.1&#x0D; &#x0D; Acantholytic squamous cell carcinoma (historically known as adenomatoid squamous cell carcinoma or adenoacanthoma) is a histologic variant of squamous cell carcinoma (SCC) that most often presents as an ulcer on sun-exposed areas, mostly in elderly males.1,2 ASCCs of the oral cavity are rare, with fewer than 60 cases reported in the literature.3 In a series of 55 cases describing intraoral ASCCs, the most common sites of ASCC were the tongue (24/55) and the maxilla/maxillary gingiva and/or palate (11/55).3&#x0D; &#x0D; The presence of a pseudoglandular or alveolar pattern might suggest the diagnosis of an adenocarcinoma. However, the findings of tumor lobules with a distinctly squamoid morphology, along with the presence of intercellular bridges, will point to the correct diagnosis. Furthermore, ASCC does not present with intracellular mucin, clear cells, and intermediate cells – an important distinguishing point with mucoepidermoid carcinoma. The absence of true glands also militates against the differential diagnosis of an adenosquamous carcinoma.1&#x0D; &#x0D; Although the diagnosis of ASCC may be established through histomorphology alone, p40 immunohistochemistry – a useful marker for squamous cell differentiation - strengthens the diagnosis.4 Loss of E-Cadherin expression – a protein involved in cell adhesion and binding - is usually seen in the discohesive cells but may be retained in the well differentiated areas.2 Absence of staining with mucicarmine and CD34 will help rule out mucoepidermoid carcinoma and angiosarcoma, respectively.1,2 The authors felt that the latter two differential diagnoses could be excluded on the basis of the light microscopic features present in the case along with the demonstration of diffuse p40 positivity. It is granted however that in resource-rich settings, these other ancillary diagnostic tests may prove helpful especially for morphologically ambiguous cases or cases with less tissue volume.&#x0D; &#x0D; Current studies show no statistically significant difference in the overall survival rate of ASCCs versus that of conventional SCC.3 ASCC is treated in the same manner as conventional SCC.1 The importance of recognizing this variant lies in ensuring that it is not mistaken for its other non-squamous morphological mimics.

Diagnostic Concordance between Optical Coherence Tomography and Histological Investigations for Immune-Mediated Desquamative Gingivitis: Observational Study.

Desquamative gingivitis (DG) denotes a heterogeneous immune-mediated disease for which early diagnosis represents a great challenge. The main aim of this study is to validate diagnostic concordance between specific Optical Coherence Tomography (OTC) patterns for DG related to oral Lichen Planus (OLP), Pemphigus Vulgaris (PV), and Mucous Membrane Pemphigoid (MMP) and definitive histological diagnosis. Forty-three patients with suspected immune-mediated DGs, were progressively recruited. Before biopsy, an OCT preliminary evaluation was performed using specific pre-determined OCT diagnostic patterns (i.e., morphology and localization of blisters, status of the basal membrane, epithelial thickness, presence/absence of acantholytic cells into blister and/or inflammatory infiltrate) related to OLP, PV and MMP. After histological confirmation, OCT and histological diagnoses were compared. Using pre-determined patterns, OCT diagnoses of DGs were: 22 (51%) OLP, of which 11 (26%) were with the bullous variant, 4 (9%) PV and 6 (14%) MMP. The same diagnoses were found by histological investigations (with the main OCT discriminatory potential for the bullous variant of OLP). The concordance between the two diagnostic methods was confirmed by the Fisher exact test (p-value < 0.01). These specific OCT patterns show a diagnostic reliability in 100% of the cases investigated, suggesting their accuracy to support the complex diagnosis and management of immune-mediated DGs.

Immune-Mediated Desquamative Gingivitis and Optical Coherence Tomography Diagnostic Patterns: Clinical Implication from a Systematic Review.

Desquamative Gingivitis (DG) comprises heterogeneous clinical manifestations of numerous immune-mediated muco-cutaneous diseases. Optical Coherence Tomography (OCT) has been proposed as a valuable diagnostic support even if, to date, there are no standardized OCT-diagnostic patterns applicable to DGs. A systematic review was performed to detect existing data on in vivo OCT diagnostic patterns of the most common immune-mediated DGs (i.e., pemphigus vulgaris, mucous membrane pemphigoid and oral lichen planus). It has been found that OCT exhibits specific patterns that address the diagnosis of DG by pemphigus vulgaris (i.e., intraepithelial unilocular blister, reduced epithelial thickness, presence of acantholytic cells in the blister) and by mucous membrane pemphigoid (i.e., subepithelial multilocular blister, presence of inflammatory infiltrate), but not by oral lichen planus. These patterns could offer an attractive diagnostic OCT framework to support the clinical preliminary assessment and monitoring of these complex pathological conditions.

English

BACKGROUND Pemphigus is a group of rare, life-threatening autoimmune bullous diseases of the skin and mucosa which result in intraepidermal blistering. Associated autoimmune conditions and the extensive mucocutaneous detachment impair the quality of life. Immunosuppressive treatment adds to the morbidity in patients. We wanted to assess the clinical presentation of pemphigus among the study subjects along with the outcome of pemphigus patients with the extent of the disease and results of pus culture. METHODS Retrospective analysis of case records of patients with pemphigus in a tertiary care hospital during a period of 3 years was done in 2015. Demographic data, clinical findings, underlying medical disorders, details of deaths, investigation reports and treatment details were recorded. RESULTS Common age group affected was 51-60 years (31.5 %) among a total of 54 pemphigus patients. There were 26 males and 28 (51. 9 %) females and in majority of the patients (44.4 %) duration was less than 6 months. Out of 47 patients, oral mucosal involvement was grade 1 in 20 (37 %) cases, grade 2 in 12 (22.2 %) and in 15 (27.8 %) patients it was grade 3.Histopathological examination showed suprabasal cleft in 82.1 %, subcorneal blister in 5.7 %, acantholytic cells in 48.6 % and row of tombstone appearance in 9.4 %. Out of 36 patients, DIF test reported intercellular IgG in 65 % and C3 in 50 % .Diabetes was found in 14 (25.9 %), candidiasis in 12 (22.2 %), thyroid disease in 6 (11.1 %) and hypertension in 3 patients. Three patients died. Among 10 patients with more than 30 % body surface area involvement, 1 (10 %) patient died. Two (13 %) deaths occurred among 15 patients in whom pus C&amp;S was positive. CONCLUSIONS Pemphigus patients were of slightly higher (51 - 70 years) age group and the 3 patients died were females. Autoimmune disorders like diabetes and thyroid disorders were found among many patients and their family members. Infection could be an important cause of death, but no statistically significant association was found in the present study. KEYWORDS Pemphigus, Steroids, Comorbidity, Deaths

Simultaneous immunofluorescence and histology in pemphigus vulgaris using ex vivo confocal laser scanning microscopy.

Ex vivo confocal laser scanning microscopy (ex vivo CLSM) provides rapid, high-resolution imaging and immunofluorescence examinations of the excised tissues. We aimed to evaluate the applicability of ex vivo CLSM in histomorphological and direct immunofluorescence (DIF) examination of pemphigus vulgaris (PV). 20 PV sections were stained with fluorescent-labeled anti-IgG and anti-C3 using various dilutions and incubation periods. Subsequently, the determined ideal staining protocol was applied on 20 additional PV and 20 control sections. Ex vivo CLSM identified intraepidermal blisters and acantholytic cells in 80% and 60% of PV patients, respectively. The sensitivity of ex vivo CLSM in detecting intraepidermal fluorescence was 90% both with IgG and C3. The specificity of staining for IgG and C3 was 70% and 90%, respectively. Histomorphological and immunofluorescence features of PV could be detected within the same ex vivo CSLM session showing a comparable performance to conventional histopathology and DIF microscopy.