J Cutan Pathol 2015: 42: 587–590 doi: 10.1111/cup.12520 John Wiley & Sons. Printed in Singapore
© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Journal of Cutaneous Pathology
Letter to the Editor
Adnexal involvement in bullous pemphigoid Keywords: adnexal involvement, bullous pemphigoid, floating adnexal epithelium, subepidermal bulla To the Editor , Clinical manifestation of tense blisters and histopathologic finding of subepidermal bulla are the hallmarks of bullous pemphigoid (BP). With the increasing use of serological examinations in the diagnosis of BP, histopathologic findings appear to be becoming less important. However, serologic examination may not be commercially available and may be difficult to perform in many hospitals. In this study, we reevaluated the histopathologic findings of 110 BP cases to identify other clues of BP. All patients with BP who visited the Department of Dermatology of Kurume University School of Medicine between May 2006 and September 2014 were enrolled in this study. All patients enrolled had blisters on the skin and showed positive results on direct immunofluorescence (DIF) [IgG and/or C3 deposition at the basement membrane zone (BMZ)] and/ or indirect immunofluorescence (IIF) (IgG reactivity to the BMZ of normal skin and/or to the epidermal side of 1 M NaCl split skin) examinations. In addition, BP autoantibodies including anti-BP180 NC16a antibodies, anti-BP180 C-terminal antibodies and/or anti-BP230 antibodies were detected by enzyme-linked immunosorbent assay in all patients. Patients with mucous membrane pemphigoid, pemphigoid vegetans and pemphigoid nodularis were excluded. This study was approved by the Ethics Committee of Kurume University. Paraffin-embedded biopsy specimens of the enrolled patients were retrieved from the archives of the Department of Dermatology of Kurume University School of Medicine. One dermatopathologist (CO) and one dermatologist (NI), who were specialists in autoimmune
Table 1. General features of bullous pemphigoid (BP) cases (N = 110) Gender, male/female Age at onset, mean ± SD (years) Male Female Comorbidities, n (%) Hypertension Diabetes mellitus Cerebral stroke Malignancies Dementia Ischemic heart disease Chronic renal disease Hyperlipidemia Thyroid disease Schizophrenia Psoriasis Parkinson disease Epilepsy Presence of anti-BP180 NC16a antibodies, n (%) Deposition of immunoglobulins on BMZ in DIF, (n = 104) IgG, n (%) IgA, n (%) IgM, n (%) C3, n (%) Negative Expression of immunoglobulins on BMZ in IIF or epidermal side of BMZ in ssIIF, (n = 109) IgG, n (%) Histopathological subepidermal bulla, n (%)
44/66 73.3 ± 15.8 71.4 ± 12.0 74.6 ± 17.9 61 (55.5) 36 (32.7) 17 (15.5) 14 (12.7) 10 (9.1) 7 (6.4) 7 (6.4) 6 (5.5) 5 (4.5) 3 (2.7) 3 (2.7) 2 (1.8) 1 (0.9) 101 (91.8)
86 (82.7) 13 (12.5) 20 (19.2) 100 (96.2) 3 (2.9)
109 (100.0) 98 (89.1)
BMZ, basement membrane zone; DIF, direct immunofluorescence; IIF, indirect immunofluorescence; ssIIF, indirect immunofluorescence of 1 M NaCl split skin.
587
Letter to the Editor
Table 2. Histopathologic features of bullous pemphigoid (BP) cases (n = 110)
Intraepidermal bulla, n (%) Cornified layer Normal, n (%) Compact orthokeratosis, n (%) Parakeratosis, n (%) Compact orthokeratosis and parakeratosis, n (%) Cell rich pattern, n (%) Acanthosis, n (%) Rough contour of bottom line of bulla roof, n (%) Dyskeratotic cell, n (%) Basal cell necrosis, n (%) Linear necrosis of basal cells, n (%) Single cell necrosis, n (%) Festooning, n (%) Adnexal involvement, n (%) Floating adnexal epithelium within the bulla, n (%) Eccrine duct, n (%)* Sebaceous lobule, n (%)* Follicular epithelium, n (%)* Predominant inflammatory cells in the epidermis Eosinophils, n (%) Neutrophils, n (%) Eosinophils and neutrophils, n (%) Lymphocytes, n (%) Eosinophilic spongiosis, n (%) Confluent epidermal necrosis, n (%) Acantholysis, n (%) Vacuolar alteration, n (%) Predominant inflammatory cells in the bulla Eosinophils, n (%) Neutrophils, n (%) Eosinophils and neutrophils, n (%) Lymphocytes, n (%) Papillary abscess Eosinophils, n (%) Neutrophils, n (%) Eosinophils and neutrophils, n (%) Eosinophils aligned along the BMZ of the epidermis, n (%) Eosinophils aligned along the BMZ of the adnexa, n (%) Neutrophils aligned along the BMZ of the epidermis, n (%) Neutrophils aligned along the BMZ of the adnexa, n (%) Predominant inflammatory cells in the dermis Eosinophils, n (%) Neutrophils, n (%) Eosinophils and neutrophils, n (%) Lymphocytes, n (%) Inflammatory cells in the capillary Eosinophils, n (%) Neutrophils, n (%) Eosinophils and neutrophils, n (%) Flame figure, n (%) BMZ, basement membrane zone; NA, not available. *Details of floating adnexal epithelium.
588
Subepidermal bulla positive (n = 98)
Subepidermal bulla negative (n = 12)
25 (25.5)
0 (0.0)
54 (55.1) 17 (17.3) 2 (2.0) 25 (25.5) 96 (98.0) 33 (33.7) 96 (98.0) 72 (73.5) 68 (69.4) 65 (66.3) 47 (48.0) 74 (75.5) 26 (26.5) 24 (24.5) 19 (19.4) 5 (5.1) 4 (4.1)
7 (58.3) 3 (25.0) 1 (8.3) 1 (8.3) 11 (91.7) 6 (50.0) NA 1 (8.3) 0 (0.0)
47 (48.0) 15 (15.3) 2 (2.0) 34 (34.7) 11 (11.2) 5 (5.1) 20 (20.4) 34 (34.7)
10 (83.3) 1 (8.3) 0 (0.0) 1 (8.3) 2 (16.7) 0 (0.0) 0 (0.0) 8 (66.7)
57 (58.2) 16 (16.3) 16 (16.3) 9 (9.2)
NA NA NA NA
16 (16.3) 1 (1.0) 2 (2.0) 16 (16.3) 4 (4.1) 5 (5.1) 0 (0.0)
2 (16.7) 0 (0.0) 1 (8.3) 6 (50.0) 0 (0.0) 0 (0.0) 0 (0.0)
32 (32.7) 0 (0.0) 3 (3.1) 63 (64.3)
7 (58.3) 0 (0.0) 0 (0.0) 5 (41.7)
6 (6.1) 34 (34.7) 40 (40.8) 0 (0.0)
0 (0.0) 5 (41.7) 4 (33.3) 0 (0.0)
0 (0.0) NA 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)
Letter to the Editor
A
B
C
D
Fig. 1. A) Eccrine duct pulled up into the bulla [hematoxylin and eosin (HE), original magnification ×100]. B) Floating eccrine ductal epithelium within the bulla (HE, ×100). C) Floating sebaceous lobule within the bulla (HE, ×40). D) Floating hair follicle within the bulla (HE, ×100). Arrow indicates hair shaft.
bullous diseases, reviewed the histopathologic slides of all patients to confirm the presence or absence of bulla, and changes in the cornified layer, bulla, epidermis and dermis. Clinical data regarding age, gender, comorbidities, autoantibodies and DIF and IIF examination results were also collected. Although anti-BP180 NC16a antibody was measured in all patients, anti-BP180 C-terminal and anti-BP230 antibodies were measured in patients who did not have anti-BP180 NC16a antibodies and in some patients who had anti-BP180 NC16a antibodies. The general features of the evaluated patients are presented in Table 1. Ninety-eight biopsy specimens showed subepidermal bulla. Because the presence or absence of subepidermal bulla in a biopsy specimen leads to some differences in histopathologic evaluation, we subdivided the cohort into two groups, i.e. a group with subepidermal bulla (SB+ group) and a group without subepidermal bulla (SB− group). The histopathologic features of both groups are detailed in Table 2. Basal cell necrosis was seen
in 68 cases in the SB+ group, of which 65 showed linear necrosis of basal cells in the roof epidermis. Acantholysis, including that between keratinocytes and acrosyringeal cells, was found in 20 cases in the SB+ group. Single cell or the aggregates of two to several cells floating within the bulla were also considered to represent acantholysis of the epidermis. Regarding these 20 cases, DIF did not reveal intercellular surface deposition of IgG, IgA, IgM or C3, and IIF did not detect any anti-cell surface antibodies. However, anti-desmoglein (Dsg)1 and Dsg3 antibodies were positive in one of nine cases tested and two of eight cases tested, respectively. Vacuolar alteration was seen more frequently in the SB− group than in the SB+ group. As a novel feature, adnexal involvement was seen in 26 of 98 cases in the SB+ group, of which 24 had floating adnexal epithelium, including the eccrine duct, sebaceous lobule and follicular epithelium, within the bulla (Fig. 1). According to the textbooks of dermatopathology, common histopathologic characteristics
589
Letter to the Editor of BP include subepidermal bulla as well as eosinophilic infiltration including eosinophilic spongiosis and eosinophilic papillary abscess.1 – 3 In addition to these well-known characteristic features, this study also revealed that other underrecognized histopathologic features of BP, such as linear necrosis of basal cells, vacuolar alteration and acantholysis, were not rare phenomenon. With regard to acantholysis, cases with anti-Dsg1 and/or anti-Dsg3 antibodies did not show positive results suggesting acantholytic autoimmune bullous disease in DIF or IIF. Therefore, anti-Dsg1 and Dsg3 antibodies were not considered pathognomonic. As a novel feature in BP, adnexal involvement should be highlighted. Adnexal involvement in pemphigus vulgaris and pemphigus foliaceus, another common autoimmune bullous disease, is well-known;2,4 however, it has never been
reported in BP. A distinct feature of adnexal involvement in BP was floating adnexal epithelium within the bulla. Considering the presence of BP antigens in the BMZ of the upper portion of the hair follicle,5 follicular involvement is quite natural. Although no study has been conducted regarding the presence of BP antigens in the BMZ of the eccrine duct and sebaceous lobules, the findings in this study suggest their possible existence. Chika Ohata, MD, PhD Norito Ishii, MD Minao Furumura, MD, PhD Takekuni Nakama, MD Department of Dermatology, Kurume University School of Medicine, Fukuoka, Japan e-mail: [email protected]
References 1. McKee PH, Calonje E, Granter SR. Inherited and autoimmune subepidermal blistering diseases. In McKee PH, Calonje E, Granter SR, eds. Pathology of the skin. St. Louis: Elsevier Mosby, 2005; 81. 2. Wu H, Brandling-Bennett HA, Harrist TJ. Noninfectious vesiculobullous and vesiculopustular diseases. In Elder DE, Elenitsas R, Murphy GF, Johnson BL, Xu X, eds.
590
Lever’s histopathology of the skin. Philadelphia: Lippincott Williams & Wilkins, 2009; 235. 3. Weedon D. The vesiculobullous reaction pattern. In Weedon D, ed. Weedon’s skin pathology. London: Churchill Livingstone, 2010; 123. 4. Ohata C, Ishii N, Furumura M. Locations of acantholysis in pemphigus vulgaris and
pemphigus foliaceus. J Cutan Pathol 2014; 41: 880. 5. Joubeh S, Mori O, Owaribe K, Hashimoto T. Immunofluorescence analysis of the basement membrane zone components in human anagen hair follicles. Exp Dermatol 2003; 12: 365.
© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Journal of Cutaneous Pathology
Letter to the Editor
Adnexal involvement in bullous pemphigoid Keywords: adnexal involvement, bullous pemphigoid, floating adnexal epithelium, subepidermal bulla To the Editor , Clinical manifestation of tense blisters and histopathologic finding of subepidermal bulla are the hallmarks of bullous pemphigoid (BP). With the increasing use of serological examinations in the diagnosis of BP, histopathologic findings appear to be becoming less important. However, serologic examination may not be commercially available and may be difficult to perform in many hospitals. In this study, we reevaluated the histopathologic findings of 110 BP cases to identify other clues of BP. All patients with BP who visited the Department of Dermatology of Kurume University School of Medicine between May 2006 and September 2014 were enrolled in this study. All patients enrolled had blisters on the skin and showed positive results on direct immunofluorescence (DIF) [IgG and/or C3 deposition at the basement membrane zone (BMZ)] and/ or indirect immunofluorescence (IIF) (IgG reactivity to the BMZ of normal skin and/or to the epidermal side of 1 M NaCl split skin) examinations. In addition, BP autoantibodies including anti-BP180 NC16a antibodies, anti-BP180 C-terminal antibodies and/or anti-BP230 antibodies were detected by enzyme-linked immunosorbent assay in all patients. Patients with mucous membrane pemphigoid, pemphigoid vegetans and pemphigoid nodularis were excluded. This study was approved by the Ethics Committee of Kurume University. Paraffin-embedded biopsy specimens of the enrolled patients were retrieved from the archives of the Department of Dermatology of Kurume University School of Medicine. One dermatopathologist (CO) and one dermatologist (NI), who were specialists in autoimmune
Table 1. General features of bullous pemphigoid (BP) cases (N = 110) Gender, male/female Age at onset, mean ± SD (years) Male Female Comorbidities, n (%) Hypertension Diabetes mellitus Cerebral stroke Malignancies Dementia Ischemic heart disease Chronic renal disease Hyperlipidemia Thyroid disease Schizophrenia Psoriasis Parkinson disease Epilepsy Presence of anti-BP180 NC16a antibodies, n (%) Deposition of immunoglobulins on BMZ in DIF, (n = 104) IgG, n (%) IgA, n (%) IgM, n (%) C3, n (%) Negative Expression of immunoglobulins on BMZ in IIF or epidermal side of BMZ in ssIIF, (n = 109) IgG, n (%) Histopathological subepidermal bulla, n (%)
44/66 73.3 ± 15.8 71.4 ± 12.0 74.6 ± 17.9 61 (55.5) 36 (32.7) 17 (15.5) 14 (12.7) 10 (9.1) 7 (6.4) 7 (6.4) 6 (5.5) 5 (4.5) 3 (2.7) 3 (2.7) 2 (1.8) 1 (0.9) 101 (91.8)
86 (82.7) 13 (12.5) 20 (19.2) 100 (96.2) 3 (2.9)
109 (100.0) 98 (89.1)
BMZ, basement membrane zone; DIF, direct immunofluorescence; IIF, indirect immunofluorescence; ssIIF, indirect immunofluorescence of 1 M NaCl split skin.
587
Letter to the Editor
Table 2. Histopathologic features of bullous pemphigoid (BP) cases (n = 110)
Intraepidermal bulla, n (%) Cornified layer Normal, n (%) Compact orthokeratosis, n (%) Parakeratosis, n (%) Compact orthokeratosis and parakeratosis, n (%) Cell rich pattern, n (%) Acanthosis, n (%) Rough contour of bottom line of bulla roof, n (%) Dyskeratotic cell, n (%) Basal cell necrosis, n (%) Linear necrosis of basal cells, n (%) Single cell necrosis, n (%) Festooning, n (%) Adnexal involvement, n (%) Floating adnexal epithelium within the bulla, n (%) Eccrine duct, n (%)* Sebaceous lobule, n (%)* Follicular epithelium, n (%)* Predominant inflammatory cells in the epidermis Eosinophils, n (%) Neutrophils, n (%) Eosinophils and neutrophils, n (%) Lymphocytes, n (%) Eosinophilic spongiosis, n (%) Confluent epidermal necrosis, n (%) Acantholysis, n (%) Vacuolar alteration, n (%) Predominant inflammatory cells in the bulla Eosinophils, n (%) Neutrophils, n (%) Eosinophils and neutrophils, n (%) Lymphocytes, n (%) Papillary abscess Eosinophils, n (%) Neutrophils, n (%) Eosinophils and neutrophils, n (%) Eosinophils aligned along the BMZ of the epidermis, n (%) Eosinophils aligned along the BMZ of the adnexa, n (%) Neutrophils aligned along the BMZ of the epidermis, n (%) Neutrophils aligned along the BMZ of the adnexa, n (%) Predominant inflammatory cells in the dermis Eosinophils, n (%) Neutrophils, n (%) Eosinophils and neutrophils, n (%) Lymphocytes, n (%) Inflammatory cells in the capillary Eosinophils, n (%) Neutrophils, n (%) Eosinophils and neutrophils, n (%) Flame figure, n (%) BMZ, basement membrane zone; NA, not available. *Details of floating adnexal epithelium.
588
Subepidermal bulla positive (n = 98)
Subepidermal bulla negative (n = 12)
25 (25.5)
0 (0.0)
54 (55.1) 17 (17.3) 2 (2.0) 25 (25.5) 96 (98.0) 33 (33.7) 96 (98.0) 72 (73.5) 68 (69.4) 65 (66.3) 47 (48.0) 74 (75.5) 26 (26.5) 24 (24.5) 19 (19.4) 5 (5.1) 4 (4.1)
7 (58.3) 3 (25.0) 1 (8.3) 1 (8.3) 11 (91.7) 6 (50.0) NA 1 (8.3) 0 (0.0)
47 (48.0) 15 (15.3) 2 (2.0) 34 (34.7) 11 (11.2) 5 (5.1) 20 (20.4) 34 (34.7)
10 (83.3) 1 (8.3) 0 (0.0) 1 (8.3) 2 (16.7) 0 (0.0) 0 (0.0) 8 (66.7)
57 (58.2) 16 (16.3) 16 (16.3) 9 (9.2)
NA NA NA NA
16 (16.3) 1 (1.0) 2 (2.0) 16 (16.3) 4 (4.1) 5 (5.1) 0 (0.0)
2 (16.7) 0 (0.0) 1 (8.3) 6 (50.0) 0 (0.0) 0 (0.0) 0 (0.0)
32 (32.7) 0 (0.0) 3 (3.1) 63 (64.3)
7 (58.3) 0 (0.0) 0 (0.0) 5 (41.7)
6 (6.1) 34 (34.7) 40 (40.8) 0 (0.0)
0 (0.0) 5 (41.7) 4 (33.3) 0 (0.0)
0 (0.0) NA 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)
Letter to the Editor
A
B
C
D
Fig. 1. A) Eccrine duct pulled up into the bulla [hematoxylin and eosin (HE), original magnification ×100]. B) Floating eccrine ductal epithelium within the bulla (HE, ×100). C) Floating sebaceous lobule within the bulla (HE, ×40). D) Floating hair follicle within the bulla (HE, ×100). Arrow indicates hair shaft.
bullous diseases, reviewed the histopathologic slides of all patients to confirm the presence or absence of bulla, and changes in the cornified layer, bulla, epidermis and dermis. Clinical data regarding age, gender, comorbidities, autoantibodies and DIF and IIF examination results were also collected. Although anti-BP180 NC16a antibody was measured in all patients, anti-BP180 C-terminal and anti-BP230 antibodies were measured in patients who did not have anti-BP180 NC16a antibodies and in some patients who had anti-BP180 NC16a antibodies. The general features of the evaluated patients are presented in Table 1. Ninety-eight biopsy specimens showed subepidermal bulla. Because the presence or absence of subepidermal bulla in a biopsy specimen leads to some differences in histopathologic evaluation, we subdivided the cohort into two groups, i.e. a group with subepidermal bulla (SB+ group) and a group without subepidermal bulla (SB− group). The histopathologic features of both groups are detailed in Table 2. Basal cell necrosis was seen
in 68 cases in the SB+ group, of which 65 showed linear necrosis of basal cells in the roof epidermis. Acantholysis, including that between keratinocytes and acrosyringeal cells, was found in 20 cases in the SB+ group. Single cell or the aggregates of two to several cells floating within the bulla were also considered to represent acantholysis of the epidermis. Regarding these 20 cases, DIF did not reveal intercellular surface deposition of IgG, IgA, IgM or C3, and IIF did not detect any anti-cell surface antibodies. However, anti-desmoglein (Dsg)1 and Dsg3 antibodies were positive in one of nine cases tested and two of eight cases tested, respectively. Vacuolar alteration was seen more frequently in the SB− group than in the SB+ group. As a novel feature, adnexal involvement was seen in 26 of 98 cases in the SB+ group, of which 24 had floating adnexal epithelium, including the eccrine duct, sebaceous lobule and follicular epithelium, within the bulla (Fig. 1). According to the textbooks of dermatopathology, common histopathologic characteristics
589
Letter to the Editor of BP include subepidermal bulla as well as eosinophilic infiltration including eosinophilic spongiosis and eosinophilic papillary abscess.1 – 3 In addition to these well-known characteristic features, this study also revealed that other underrecognized histopathologic features of BP, such as linear necrosis of basal cells, vacuolar alteration and acantholysis, were not rare phenomenon. With regard to acantholysis, cases with anti-Dsg1 and/or anti-Dsg3 antibodies did not show positive results suggesting acantholytic autoimmune bullous disease in DIF or IIF. Therefore, anti-Dsg1 and Dsg3 antibodies were not considered pathognomonic. As a novel feature in BP, adnexal involvement should be highlighted. Adnexal involvement in pemphigus vulgaris and pemphigus foliaceus, another common autoimmune bullous disease, is well-known;2,4 however, it has never been
reported in BP. A distinct feature of adnexal involvement in BP was floating adnexal epithelium within the bulla. Considering the presence of BP antigens in the BMZ of the upper portion of the hair follicle,5 follicular involvement is quite natural. Although no study has been conducted regarding the presence of BP antigens in the BMZ of the eccrine duct and sebaceous lobules, the findings in this study suggest their possible existence. Chika Ohata, MD, PhD Norito Ishii, MD Minao Furumura, MD, PhD Takekuni Nakama, MD Department of Dermatology, Kurume University School of Medicine, Fukuoka, Japan e-mail: [email protected]
References 1. McKee PH, Calonje E, Granter SR. Inherited and autoimmune subepidermal blistering diseases. In McKee PH, Calonje E, Granter SR, eds. Pathology of the skin. St. Louis: Elsevier Mosby, 2005; 81. 2. Wu H, Brandling-Bennett HA, Harrist TJ. Noninfectious vesiculobullous and vesiculopustular diseases. In Elder DE, Elenitsas R, Murphy GF, Johnson BL, Xu X, eds.
590
Lever’s histopathology of the skin. Philadelphia: Lippincott Williams & Wilkins, 2009; 235. 3. Weedon D. The vesiculobullous reaction pattern. In Weedon D, ed. Weedon’s skin pathology. London: Churchill Livingstone, 2010; 123. 4. Ohata C, Ishii N, Furumura M. Locations of acantholysis in pemphigus vulgaris and
pemphigus foliaceus. J Cutan Pathol 2014; 41: 880. 5. Joubeh S, Mori O, Owaribe K, Hashimoto T. Immunofluorescence analysis of the basement membrane zone components in human anagen hair follicles. Exp Dermatol 2003; 12: 365.
