Diagnostic value of immunohistochemistry on formalin-fixed, paraffin-embedded skin biopsy specimens for bullous pemphigoid

BACKGROUND

Direct immunofluorescence microscopy (DIF) studies constitute the gold standard for diagnosis of bullous pemphigoid (BP) but depend on the availability of specialized laboratories and often on an additional skin biopsy specimen.

OBJECTIVES

To assess the value of immunohistochemical analyses (IHCA) in the diagnosis of BP using formalin-fixed, paraffin-embedded skin biopsy specimens as an alternative to DIF; and to study the correlation between the results of IHCA and the presence of histological subepidermal blister formation and of circulating autoantibodies by indirect immunofluorescence studies using split skin or by enzyme-linked immunosorbent assays.

METHODS

We included all patients newly diagnosed with BP evaluated between 2008 and 2010. There were 51 consecutive skin biopsy specimens obtained from 38 patients with BP with positive DIF.

RESULTS

By IHCA, deposits of immunoreactants were found in 45% of all tested cases. Deposits of C3d, IgG, IgM, IgE and IgA were found in 37%, 23%, 2%, 0% and 0% of cases, respectively. Deposits of C3d and/or IgG were found in 79% of the 24 cases with a blister and in 83% of the 12 cases with subepidermal blistering and positive immunoserological analyses, respectively.

CONCLUSIONS

In contrast to previous studies, our findings in an unselected patient cohort indicate that IHCA are not sufficiently sensitive to replace DIF studies for confirming the diagnosis of BP. IHCA sensitivity significantly increases in the presence of histological blistering and/or of circulating autoantibodies. IHCA represents a potential rescue diagnostic technique only if specialized laboratories and/or a second biopsy specimen for DIF are unavailable.

[Are inpatient rehabilitation or ambulatory physical therapy of patients with musculoskeletal problems effective and are patients referred to proper treatment?]

The aim of the present study was to investigate the effectiveness of an inpatient rehabilitation program and outpatient physiotherapy, respectively. Moreover, we wanted to know whether the referral to these two treatment paths was appropriate with regard to the patient's initial health status. According to the referring physician's indication patients with health problems in the cervical, lumbar spine, arm or leg were treated by an inpatient rehabilitation program or by outpatient physiotherapy. These two consecutively recruited patient cohorts were then compared. Those patients treated by the inpatient rehabilitation program differed from the outpatient group with regard to the initial health status and to age. Patients with musculoskeletal problems, who underwent an inpatient rehabilitation program, showed a significantly worse health and functional status than the outpatient group. Therefore, it can be concluded that the indication towards inpatient rehabilitation or outpatient physiotherapy was correctly given by the referring physicians. Patients treated by outpatient physiotherapy did also show a reduced health and functional status in comparison to the average population. Both types of treatment led to statistically significant and clinically relevant improvement of both the health and functional status in all patient groups.

A fractally coated, 1.3 mm2 high impedance pacing electrode

Minimizing the geometric surface area of pacing electrodes increases impedance and reduces the current drain during stimulation, provided that voltage (pulse-width) thresholds remain unchanged. This may be feasible by coating the electrode surface to increase the capacity of the electrode tissue interface and to diminish polarization. Ten unipolar, tined leads with a surface area of 1.3 mm2 and a "fractal" coating of iridium (Biotronik SD-V137) were implanted in the ventricle, and electrogram amplitude (unfiltered), slew-rate, pacing threshold (0.5 ms), and impedance (2.5 V; 0.5 ms) were measured by the 5311 PSA (Medtronic). On days 0. 2. 5. 10, 28, 90, 180, 360 postimplant, sensing threshold (up to 7.0 mV, measuring range 1-14 mV on day 360 only) and the strength duration curve (0.5-4.0 V; 0.03-1.5 ms; steps: 0.5 V; 0.01 ms, respectively) were determined, the minimum charge delivered per pulse (charge threshold), and the impedance were taken from pacemaker telemetry (Intermedics 294-03). Data were compared with those of an earlier series of 20 unipolar, tined TIR-leads (Biotronik) with a surface area of 10 mm2 and a @actal" coating of titanium nitride. With the model SD-V137 versus TIR, intraoperative electrogram amplitudes were 15.1 +/- 6.1 versus 14.4 +/- 3.9 mV (NS), slew rates 3.45 +/- 1.57 versus 1.94 +/- 1.06 V/s (P < 0.05), pacing thresholds 0.16 +/- 0.05 versus 0.52 +/- 0.15 V (P < 0.01) and impedance measurements 1,136 +/- 175 versus 441 +/- 73 omega (P < 0.0001), respectively. During follow-up, sensing thresholds were the same with both leads. Differences in pulse width thresholds lost its significance on day 28 but resumed on day 360 (SD-V137; 0.08 +/- 0.04 ms; TIR: 0.16 +/- 0.06 ms at 2.5 V; P < 0.01). With an electrode surface of 1.3 mm2, charge per pulse and impedance consistently differed from control, being 0.15 +/- versus 0.66 +/- 0.20 microC (P < 0.001) and 1,344 +/- 376 versus 538 +/- 79 omega respectively, one year after implantation (P < 0.0001). In summary, "fractally" coated small surface electrodes do not compromise sensing; by more than doubling impedance against controls they offer pacing thresholds (mainly in terms of charge) that are significantly lower than with the reference electrode.

[Radial nerve paralysis--causes, site and diagnosis. Analysis of 103 cases]

The results of a retrospective analysis of 103 patients presenting with a radial nerve palsy are reported. Among the traumatic injuries of peripheral nerves the radial nerve is the one most frequently affected due to its exposed anatomic site with close neighbourhood to the long bones of the arm. Fractures of the shaft of the humerus (18%) and proximal radius (12%) are the main causes of traumatic lesions (55%). Among the non-traumatic peripheral nerve injuries the radial nerve is less frequently affected than the median and the ulnar nerves. The most frequent site of radial nerve lesions in these cases is the upper arm (22%), the most frequent cause is pressure palsy (21%) during unphysiological deep sleep ("Saturday night paralysis").

[Bilateral radial nerve paralysis. Diagnostic and differential diagnostic aspects]

Bilateral radial nerve palsies are rare, and hence in this situation an underlying generalized peripheral neuropathy must always be considered. Among 103 patients with radial nerve palsies seen at our department during the last five years, there were three cases presenting with bilateral non-traumatic radial nerve palsies. These patients are presented in detail. One had a bilateral nerve entrapment in the supinator channel associated with a neuropathy of unclear origin, the second had bilateral sleep palsy, and the third had mononeuropathy multiplex associated with HIV infection. Following a summary of the cases reported in the literature, diagnostic considerations and additional investigations are discussed.