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Magro CM, Mo JH, Kerns MJ. Leukocytoclastic vasculitis in association with linear epidermal basement membrane zone immunoglobulin deposition: Linear vasculitis. Clin Dermatol 2022; 40:639-650. [PMID: 35907580 DOI: 10.1016/j.clindermatol.2022.07.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Cutaneous leukocytoclastic vasculitis (LCV) has a distinctive clinical and light microscopic presentation; however, the etiologic basis of LCV is varied. Most cases are attributable to immune complex deposition within a vessel wall and represent an Arthus type III immune complex reaction. The prototypic immunoreactant profile is characterized by granular deposits of components of complement activation in concert with immunoglobulin within the cutaneous vasculature. We encountered nine patients with vasculitic and/or vesiculobullous clinical presentations exhibiting an LCV in association with an immunoreactant profile characterized by homogeneous linear deposits of immunoglobulin along the dermal epidermal junction in a fashion resembling an autoimmune vesiculobullous disease. Among the clinical presentations were palpable purpura, urticarial vasculitis, and vesiculobullous eruptions with supervening purpura. Two patients with Crohn disease presented with classic palpable purpura with biopsy-proven LCV, and direct immunofluorescence (DIF) studies demonstrated linear immunoglobulin G (IgG) with floor localization on the salt-split skin assay. Four patients with systemic lupus erythematosus (SLE) showed purpuric vesiculobullous lesions, with evidence of a neutrophilic interface dermatitis and LCV in three of the four. The remaining patient had urticarial nonbullous lesions showing small-vessel vasculitiswith a neutrophilic interface dermatitis. In all of the patients with SLE, DIF studies showed linear immunoglobulin deposits within the basement membrane zone (BMZ). These constellation of findings clinically, light microscopically, and by immunofluorescence were those of a vasculitic presentation of bullous systemic lupus erythematosus. Two patients had linear IgA disease, which was drug induced in one and paraneoplastic in the other, and the dominant morphology on biopsy in both cases was an LCV. One patient microscopically demonstrated drug-associated and eosinophilic enriched LCV with DIF studies showing striking linear deposits of IgG suggestive of bullous pemphigoid, which was consistent with a vasculitic presentation of drug-induced bullous pemphigoid. In all cases, typical granular vascular immunoglobulin and complement deposition compatible with immune complex mediated vasculitis was observed. It is likely that local immune complexes derived from BMZ antigen bound to antibody are pathogenically relevant. We propose the designation of linear vasculitis for this unique scenario of LCV and linear immunoglobulin epidermal BMZ staining, which in some cases represents a vasculitic presentation of conventional autoimmune vesiculobullous disease.
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Affiliation(s)
- Cynthia M Magro
- Division of Dermatopathology, Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, New York, USA.
| | - Joshua H Mo
- Division of Dermatopathology, Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Mary Jo Kerns
- Dermatologists of Southwest Ohio, Office 3555 Olentangy River Rd Suite 4000, 43214, Columbus, Ohio, USA
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Narkhede ND, Nikham B, Jamale V, Hussain A, Kale M. Evaluation of Dermoscopic Patterns of Vesiculobullous Disorders. Indian J Dermatol 2021; 66:445. [PMID: 34759418 PMCID: PMC8530039 DOI: 10.4103/ijd.ijd_294_20] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Background: Clinical diagnosis of vesiculobullous disorders (VBD) is not always straightforward. It is a challenge for a dermatologist to make the right diagnosis noninvasively in a short time. Objective: To evaluate dermoscopic patterns associated with vesiculobullous disorders. Methods: A total of 230 patients, irrespective of age and gender, with a history and clinical presentation suggestive of VBD (including primarily infectious, inflammatory, genetic, antibody-mediated, mechanical, environmental, metabolic, and drug-related) were recruited into the study. Patients with secondarily infected lesions were excluded. Dermoscopic examination along with Tzanck smear/skin biopsy smear test was performed on the most representative lesions. Data were compiled and statistically analyzed using SPSS version 21.0. Results: Lesions with erythematous (vascular) and yellowish (serum) translucent background with regular margins were seen in most of the VBD studied. Chickenpox (CP) and herpes zoster (HZ) lesions evolved with the progress of their clinical stages. Follicular and eccrine openings were commonly seen, but the pigmentation around them was specific to pemphigus vulgaris. A distorted pigment network was noted in bullous pemphigoid. White rosettes (keratin blockage) were characteristic of epidermolysis bullosa, Wickham striae (orthokeratosis) of lichen planus, and crumpled fabric appearance (flaccidity) of Hailey-Hailey disease. Globules/dots (microvesicles) of different colors were also seen in various VBD. Blue/black color usually corresponded to retained melanin. Conclusion: Some dermoscopic patterns are observed consistently with certain diseases, and these can be used for their diagnosis, complementary to histopathological examination.
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Affiliation(s)
- Namita D Narkhede
- Department of Dermato-Venereo-Leprology, Krishna Institute of Medical Sciences, Karad, Maharashtra, India
| | - Balakrishna Nikham
- Department of Dermato-Venereo-Leprology, Krishna Institute of Medical Sciences, Karad, Maharashtra, India
| | - Varsha Jamale
- Department of Dermato-Venereo-Leprology, Krishna Institute of Medical Sciences, Karad, Maharashtra, India
| | - Asma Hussain
- Department of Dermato-Venereo-Leprology, Krishna Institute of Medical Sciences, Karad, Maharashtra, India
| | - Mohan Kale
- Department of Dermato-Venereo-Leprology, Krishna Institute of Medical Sciences, Karad, Maharashtra, India
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Bitar C, Menge TD, Chan MP. Cutaneous manifestations of lupus erythematosus: A practical clinicopathologic review for pathologists. Histopathology 2021; 80:233-250. [PMID: 34197657 DOI: 10.1111/his.14440] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Accepted: 06/30/2021] [Indexed: 11/27/2022]
Abstract
Accurate diagnosis of connective tissue diseases is often challenging and relies on careful correlation between clinical and histopathologic features, direct immunofluorescence studies, and laboratory workup. Lupus erythematosus (LE) is a prototype of connective tissue disease with a variety of cutaneous and systemic manifestations. Microscopically, cutaneous LE is classically characterized by an interface dermatitis, although other histopathologic patterns also exist depending on the clinical presentation, location, and chronicity of the skin lesions. In this article, we review the clinical, serologic, histopathologic, and direct immunofluorescence findings in LE-specific and LE-nonspecific skin lesions, with an emphasis on lesser known variants, newly described features, and helpful ancillary studies. This review will guide general pathologists and dermatopathologists in accurately diagnosing and subclassifying cutaneous LE.
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Affiliation(s)
- Carole Bitar
- Department of Pathology, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA.,Department of Dermatology, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Tyler D Menge
- Department of Pathology, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA.,Department of Dermatology, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - May P Chan
- Department of Pathology, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA.,Department of Dermatology, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
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Abstract
PURPOSE OF REVIEW Cutaneous vasculitis reflects a spectrum ranging from skin limited to severe systemic forms. To date, there is still no generally acknowledged nomenclature for cutaneous vasculitis. This review aims to summarize the recent advances in the nomenclature of cutaneous vasculitis. RECENT FINDINGS The most widely adopted vasculitis classification system is the one of 2012 Revised Chapel Hill Consensus Conference (CHCC) which represent not such a classification but a nomenclature system that name vasculitis on the basis of the size of the vessel affected. The CHCC 2012 did not deal with the special features of cutaneous vasculitis and did not explicitly discuss the presence of skin-limited or skin-dominant forms of vasculitis. Therefore, a consensus group was formed to propose an Addendum to CHCC 2012, focusing on cutaneous vasculitis. The Addendum better clarify the main aspects of some single-organ vasculitis, including IgM/IgG vasculitis, nodular vasculitis, erythema elevatum et diutinum and recurrent macular vasculitis in hypergammaglobulinemia. Moreover, it differentiated normocomplementemic from hypocomplementemic urticarial vasculitis. Finally, it recognized cutaneous polyarteritis nodosa as a distinct subtype of polyarteritis nodosa. SUMMARY Classification criteria are useful tools to standardize names and definitions for cutaneous vasculitis; however, they do not represent diagnostic criteria. Collaborative efforts are still needed to get a shared classification and valid diagnostic criteria for cutaneous vasculitis.
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Magdaleno-Tapial J, Valenzuela-Oñate C, Pitarch-Fabregat J, Marín-Jiménez M, Almela CM, Gutiérrez-Salcedo JI, Calvo-Catalá J, Sánchez-Carazo JL, Miquel VAD. Purpura fulminans–like lesions in antiphospholipid syndrome with endothelial C3 deposition. JAAD Case Rep 2018; 4:956-958. [PMID: 30364713 PMCID: PMC6197947 DOI: 10.1016/j.jdcr.2018.09.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Jorge Magdaleno-Tapial
- Department of Dermatology, Hospital General Universitario de Valencia, Valencia, Spain
- Correspondence to: Jorge Magdaleno Tapial, MD, Department of Dermatology, Hospital General Universitario de Valencia, Av. Tres Creus, 2, 46014, Valencia, Spain.
| | | | | | - María Marín-Jiménez
- Department of Hematology, Hospital General Universitario de Valencia, Valencia, Spain
| | - Clara Molina Almela
- Department of Rheumatology, Hospital General Universitario de Valencia, Valencia, Spain
| | | | - Javier Calvo-Catalá
- Department of Rheumatology, Hospital General Universitario de Valencia, Valencia, Spain
| | | | - V. Alegre-de Miquel
- Department of Dermatology, Hospital General Universitario de Valencia, Valencia, Spain
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Feasel P, Billings SD, Bergfeld WF, Piliang MP, Fernandez AP, Ko JS. Direct immunofluorescence testing in vasculitis-A single institution experience with Henoch-Schönlein purpura. J Cutan Pathol 2017; 45:16-22. [DOI: 10.1111/cup.13054] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Revised: 09/21/2017] [Accepted: 09/29/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Patrick Feasel
- Departments of Pathology and Dermatology; Cleveland Clinic Foundation; Cleveland Ohio
| | - Steven D. Billings
- Departments of Pathology and Dermatology; Cleveland Clinic Foundation; Cleveland Ohio
| | - Wilma F. Bergfeld
- Departments of Pathology and Dermatology; Cleveland Clinic Foundation; Cleveland Ohio
| | - Melissa P. Piliang
- Departments of Pathology and Dermatology; Cleveland Clinic Foundation; Cleveland Ohio
| | - Anthony P. Fernandez
- Departments of Pathology and Dermatology; Cleveland Clinic Foundation; Cleveland Ohio
| | - Jennifer S. Ko
- Departments of Pathology and Dermatology; Cleveland Clinic Foundation; Cleveland Ohio
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Dart JK. The 2016 Bowman Lecture Conjunctival curses: scarring conjunctivitis 30 years on. Eye (Lond) 2017; 31:301-332. [PMID: 28106896 DOI: 10.1038/eye.2016.284] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Accepted: 11/07/2016] [Indexed: 12/22/2022] Open
Abstract
This review is in two sections. The first section summarises 35 conditions, both common and infrequent, causing cicatrising conjunctivitis. Guidelines for making a diagnosis are given together with the use of diagnostic tests, including direct and indirect immunofluorescence, and their interpretation. The second section evaluates our knowledge of ocular mucous membrane pemphigoid, which is the commonest cause of cicatrizing conjunctivitis in most developed countries. The clinical characteristics, demographics, and clinical signs of the disease are described. This is followed by a review and re-evaluation of the pathogenesis of conjunctival inflammation in mucous membrane pemphigoid (MMP), resulting in a revised hypothesis of the autoimmune mechanisms causing inflammation in ocular MMP. The relationship between inflammation and scarring in MMP conjunctiva is described. Recent research, describing the role of aldehyde dehydrogenase (ALDH) and retinoic acid (RA) in both the initiation and perpetuation of profibrotic activity in MMP conjunctival fibroblasts is summarised and the potential for antifibrotic therapy, using ALDH inhibition, is discussed. The importance of the management of the ocular surface in MMP is briefly summarised. This is followed with the rationale for the use of systemic immunomodulatory therapy, currently the standard of care for patients with active ocular MMP. The evidence for the use of these drugs is summarised and guidelines given for their use. Finally, the areas for research and innovation in the next decade are reviewed including the need for better diagnostics, markers of disease activity, and the potential for biological and topical therapies for both inflammation and scarring.
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Affiliation(s)
- J K Dart
- Ocular Biology and Therapeutics, UCL Institute of Ophthalmology, London, UK.,National Institute of Health Research (NIHR) Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and The UCL Institute of Ophthalmology, London, UK.,Corneal and External Disease Service, Moorfields Eye Hospital, London, UK
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