VESICULOBULLOUS LESIONS

PPDGS IPM & BM 2015

 Vesiculobullous ( VB ) diseases are a distinct group of oral
disorders characterized by the formation of vesicles or
bullae lesions.

Include viral diseases, autoimmune mucocutaneous

diseases , diseases that probably have an immunologically
mediated mechanism, and genetic diseases.

INTRODUCTION
 Herpes Simplex Infection
Varicella-Zoster Infection
VIRAL DISEASE

Hand-Foot-and-Mouth Disease
Herpangina
Measles (Rubeola)

Pemphigus Vulgaris
IMMUNOLOGIC

Mucous Membrane Pemphigoid
Bullous Pemphigoid
DISEASE Dermatitis Herpetiformis
Linear Immunoglobulin A Disease (LAD)

HEREDITARY Epidermolysis Bullosa

DISEASE
 Vesicle is defined as a superficial blister, 5
mm or less in diameter, usually filled with
clear fuild
Bulla is defined as a circumscribed collection
of free fluid greater than 0,5 cm in diameter

INTRODUCTION
 Diagnostic procedure for VB lesions can be
divided into 3 categories : Clinical ,
Histological and molecular techniques
Table 1. Diagnostic Procedure for
vesiculobullous lesions
CLINICAL MOLECULAR
TEST HISTOLOGICAL TEST TECHNIQUES
Biopsy Immunofluorescence
Nikolskys Tzanck test Salt split technique
test ELISA and western
LE cell test blotting
LE: Lupus erythematous; ELISA: Enzyme-linked
immunosorbent assay
DIAGNOSTIC PROCEDURE
NIKOLSKY S TEST

it was first described by Piotr Vasiliyevich Nikolsky

(1858 1940)
Rubbing the skin of patient who had pemphigus
foliaceous
The skin show a weak relationship and contact
between the corneal and granular cell layers on all
surfaces and even in places between lesions
CLINICAL TEST
NIKOLSKY S TEST
 Difficult to produce in the oral cavity
Positive when tissue ulceration or blistering is seen
after applying mucosal pressure either by blowing
air or using a blunt instrument or finger.

NIKOLSKYS TEST
Important factors :
1. The ulcerated tissue should be avoided when selecting the biopsy site
2. Stop topical steroid at least a month before biopsy procedure
3. Sample of the patients serum or blood is required for IDIF
4. A 3 -4 mm punch biopsy of uninvolved skin and unblistered
perilesional skintaken from an elliptical biopsy
5. In VB diseases choice of lesions for sampling is important

BIOPSY
 The vesicle should be The material is
For viral infections,
unroofed or the crust transferred to a glass
samples should be
removed, and the slide by touching the
taken from a fresh
base scraped with a spatula to the glass
vesicle, rather than a
scalpel or the edge of slide repeatedly but
crusted one
a spatula. gently.

The material thus

The slide should be
obtained is smeared
clean, since cells will
onto a microscopic
not adhere to a slide
slide, allowed to air
marred by
dry, and stained with
fingerprints.
Giemsa stain.

TZANCK
TEST
TZANCK TEST
 This is achieved by the use
To detect these antibodies,
of specific antibodies which
two techniques are used
when prepared appropriately,
direct immunofluorescence
may be used to detect subtle
(DIF) and indirect
differences at molecular
immunofluorescence (IIF).
level.

IF ( IMMUNOFLUORESCENT
TECHNIQUES )
 The DIF is a one step procedure

Used to detect and localize immunoreactants

deposited in vivo in the patient's skin or mucosa

The immunoreactants include antibodies,

complement components and fibrinogen

DIF ( DIRECT IMMUNOFLUORESCENT TECHNIQUES )

 Frozen sections 5m in thickness are cut with the
cryotome and placed on slides.

These are dried for ten minutes with an electric fan.

Inadequate drying of sections between processing

steps may lead to their detachment during washing.

The sections are washed in PBS to remove unbound

antisera, fan dried and mounted in a drop of buffered
glycerol.

They are then viewed with the fluorescence

microscope.

DIF ( DIRECT IMMUNOFLUORESCENT TECHNIQUES )

 The IIF is a two step procedure used to
identify circulating autoantibodies to
cutaneous or mucosal stuctures in a
patient's serum.

These antibodies are most commonly of

lgG or lgA classes.

In the first step, serial dilutions of the

patient's serum in PBS are incubated
with frozen sections of the substrate.

IDIF ( INDIRECT IMMUNOFLUORESCENT TECHNIQUES )

 At least two 5m thick sections are prepared by
being alternately air dried,washed in PBS and
fandried for ten minutes each.

The initial serum dilution to 1:10 or 1:80 is incubated

with the sections for thirty minutes at 37 C.

If positive, subsequent incubations are used with

increasingly higher dilutions of sera.

Autoantibodies in the serum bind to components of

the epidermis and basement membrane zone.

Three washings of ten minutes each in PBS are carried

out to remove unbound serum.

IDIF ( INDIRECT IMMUNOFLUORESCENT TECHNIQUES )

 In the second step, the bound autoantibodies
are labelled with fluorescein isothiocyanate
(FITC)conjugated antihuman immunoglobulins.

Class specific antibodies are routinely used

but subclass specific antibodies are also
available.

Incubation with the antisera for thirty minutes

at 37 C is followed by three washings in PBS
often minutes each.

The sections are then mounted in a drop of

buffered glycerol and viewed with the
fluorescence microscope.

IDIF ( INDIRECT IMMUNOFLUORESCENT

TECHNIQUES )
IF ( IMMUNOFLUORESCENT TECHNIQUES )
 For diagnosis of pemphigus vulgaris and foliaceous,
sensitive and specific commercial ELISA for detection of
antibodies are available.

This technique can detect circulating antibodies to

desmoglein 1 and 3, and the titer directly correlate with
disease activity.

ELISA TEST
ELISA TEST
 Few primary infections Acyclovir and analogs

CLINICAL FEATURES

TREATMENT
result in clinical may control virus.
disease. Treatment must be
Oral and perioral provided early to be
vesicles rupture, effective.
forming ulcers.
Intraoral lesions may
be found on any
surface.
Systemic
signs/symptoms
include fever and
malaise.
Self-limited disorder;
symptomatic care is
provided.
PRIMARY HERPES SIMPLEX
Immunocompromised
 DIFFEREN
CLINICAL TREATME TIAL
ETIOLOGY
FEATURES NT DIAGNOSI
Reactivation of
latent herpes S
simplex virus type Pemphigus vulgaris
1 Possible control
Triggers: sunlight, Affects perioral with acyclovir
stress, skin, lips, and analogs Erosive lichen planus
immunosuppressio gingiva, palate
n Linear
Must be immunoglobulin (Ig)A
Reactivation disease
common;
administered
frequency early Contact allergy
decreases with Systemic
aging treatment much Discoid lupus
Self-limited erythematosus
Prodromal more effective
symptoms: tingling than topical Epidermolysis bullosa
and burning treatment acquisita

SECONDARY HERPES SIMPLEX

PRIMARY HERPES SIMPLEX
HERPES SIMPLEX
LABIALIS

SECONDARY HERPES
SIMPLEX
Herpes simplexinduced vesicle. Virus-infected multinucleated keratinocytes in the
wall of a vesicle
 PRIMARY DISEASE SECONDARY
(VARICELLA, DISEASE (ZOSTER,
CHICKENPOX) SHINGLES)
Self-limiting Self-limiting

Adults
Historically common in children
Rash, vesicles, ulcers unilateral along
dermatome
Vesicular eruption of trunk and head
and neck occurring in crops Possibly severe post-herpetic pain
(~15% of cases)
Systemic signs/symptoms: fever,
malaise, other Immunocompromised and lymphoma
patients at risk

Symptomatic treatment Treated with acyclovir and analogs

VARICELLA-ZOSTER
VARICELLA
HAND-FOOT-AND-MOUTH DISEASE
Etiology and
Clinical Features Histopathology
Pathogenesis

Signs and symptoms are

usually mild to moderate, The vesicles of this
low-grade fever, malaise, condition are found
lymphadenopathy. within the epithelium
Coxsackie virus type A16
or enterovirus 71 because of obligate viral
Pain from oral lesions is replication in
often the patients chief keratinocytes.
complaint.

The virus is transferred Eosinophilic inclusions

Begin as vesicles that
through airborne spread may be seen within some
quickly rupture to
or fecal-oral of the infected epithelial
become ulcers
contamination. cells.

A yellow fibrinous As the keratinocytes are

Predilection for mucous membrane surrounded destroyed by virus, the
membranes of the by an erythematous halo. vesicle enlarges as it
mouth and cutaneous becomes filled with
regions of the hands and proteinaceous debris and
Multiple, can occur
feet. inflammatory cells.
anywhere in the mouth,
HAND-FOOT-AND-MOUTH
DISEASE
 Etiology
and Clinical
Treatment
Pathogenes Features
is More common in children Because
Herpangina is an acute than in adults.
viral infection caused herpangina is
by another Coxsackie
type A virus (types A1-
Malaise, fever, dysphagia,
and sore throat
self-limiting, is
6, A8, A10, A22, B3, mild and of
and possibly others). Intraorally,soft palate,
faucial pillars, and tonsils short duration,
and causes
A diffuse erythematous
pharyngitis is also present. few
It is transmitted by
contaminated saliva No associated exanthem is
complications,
and occasionally typically seen. treatment
through contaminated
feces. Signs and symptoms are usually is not
usually mild to moderate required.

HERPANGINA
HERPANGINA
Etiology and Clinical
Pathogenesis Features
Risk of infection are
Measles is a highly
individuals who have not
contagious viral infection
been vaccinated.
caused by a member of
the paramyxovirus family
of viruses. After an incubation period
of 7 to 10 days, prodromal
symptoms of fever,
Spread by airborne malaise, coryza,
droplets through the conjunctivitis,
respiratory epithelium of photophobia, and cough
the nasopharynx develop.
In 1 to 2 days,
The incubation period is pathognomonic small
between 10 and 11 days erythematous macules
with a 1- to 7-day with white necrotic centers
prodromal period. appear in the buccal
mucosa .
MEASLES (RUBEOLA)
Histopatholo
gy
Infected epithelial cells,
which eventually become
necrotic, overlie an
inflamed connective tissue
that contains dilated
vascular channels and a
focal inflammatory
response.
Lymphocytes are found in
a perivascular distribution.
In lymphoid tissues, large
characteristic
multinucleated
macrophages, known as
Warthin-Finkeldey giant
cells, are seen
MEASLES (RUBEOLA)
PEMPHIGUS
VULGARIS CLINICA
ETIOLOG L TREATME
Y FEATUR NT
Autoimmune
reaction to
ES
Affects skin and/or
Controlled with
immunosuppressives
mucosa (corticosteroids/
intercellular azathioprine/cyclopho
50% or more of cases
keratinocyte protein sphamide/mycopheno
begin in the mouth
(desmoglein 3) (first to show, last to late/biologics/IVIg/plas
go) mapheresis)
Presents as ulcers High mortality when
preceded by vesicles untreated
Intraepithelial or bullae (dehydration,
blisters caused by electrolyte imbalance,
antibodies Persistent and malnutrition,
progressive infection)

IMMUNOLOGIC DISEASE
PEMPHIGU
S immunofluorescence pattern

VULGARIS
Tzanck cells
 CLINICAL TREATME
ETIOLOGY
FEATURES NT
Oral mucosa (gingiva often
only site) and conjunctiva; Controlled with
skin rarely affected corticosteroids;
sometimes resistant to
systemic therapy; topical
Subepithelial blisters agents useful
Autoimmune reaction to caused by autoantibodies
basement membrane
proteins (laminin 5,
BP180, and others) Present as ulcers/redness
in older adults (over 50
years of age) Significant morbidity if
untreated, including pain
and scarring, especially of
Persistent, uncomfortable eye
to painful

MUCOUS MEMBRANE
PEMPHIGOID
 Histopathology and
Immunopathology

MMP is a subepithelial clefting disorder with no

acantholysis. In early stages, few lymphocytes are
seen, but over time, the infiltrate becomes more dense
and mixed.

DIF studies of intact oral mucosa demonstrate a linear

pattern of homogeneous IgG fluorescence.
demonstrated.

MUCOUS MEMBRANE
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