Cutaneous immunofluorescent microscopy: a practical diagnostic technique
Assistant professor, division of dermatology, department of medicine, faculty of medicine, University of British Columbia, Vancouver Reprint requests: Dr. Roberta C. Ongley, 865 W 10th Ave., Vancouver, BC V5Z 1L7
of 20% of patients with this condition contain IgG in addition to IgA; in biopsy specimens from four patients IgG alone has been demonstrated. In addition to its being found in lesions, IgA can often be found in clinically uninvolved skin, particularly in biopsy specimens from the buttocks. In many centres positive results of immunofluorescent microscopy are essential in establishing the diagnosis of dermatitis herpetiformis, a negative result being considered incompatible with the diagnosis. Herpes gestationis
Herpes gestationis, a rare bullous disorder of pregnancy, can best be diagnosed by immunofluorescent microscopy, which shows deposition of the C3 component of complement at the dermoepidermal junction.7 Connective tissue disorders Lupus erythematosus Direct immunofluorescent microscopy of skin biopsy specimens was applied first to the investigation of lupus erythematosus,1 and in our laboratory this is the condition for which immunofluorescent microscopy is most often requested; it accounted for 89 of our biopsy specimens that yielded positive results. In both discoid lupus erythematosus (DLE) and systemic lupus erythematosus (SLE) IgG is found at the dermoepidermal junction in 90% of biopsy specimens of active lesions.8'9 In addition we have been able to confirm the persistence of IgG at the site of previous discoid lesions; we have found it to be present 8 weeks after apparent clinical clearing. In SLE, but not DLE, IgG may also be found at the dermoepidermal junction of clinically normal skin;9 we have found 71% of SLE patients to have IgG deposits in areas of normal skin. This pattern is detected most commonly in areas exposed to the sun, such as the wrist, and will occur even in the absence of cutaneous involvement. Dermatoinyositis
This condition has recently been shown to have associated cutaneous deposits of immunoglobulin, IgG at the dermoepidermal junction being present in 50% of patients with this disease.10 We have been able to demonstrate IgG deposition in the lesions of three of five patients. Vasculitis
The vasculitides are an unpredictable group of diseases in terms of results of immunofluorescent microscopy.11
Rheumatoid vasculitis has been associated with 1gM deposits in the dermal blood vessels. Other varieties of vasculitis have shown occasional deposition of immunoglobulin, positive results of immunofluorescent microscopy being more frequent with very early lesions. and our studies have revealed a variable mixture of immunoglobulins and complement.
Comments The diseases discussed above are those in which immunofluorescent microscopy is established and useful in diagnosis. The technique is readily available and is a rapid method of assessment. There have been reports of immunoglobulin deposition in many other disorders, including drug reactions,12 granuloma annulare" and lichen planus,14 but further studies will be required to determine the significance and diagnostic value of these findings. With increasing knowledge of immunopathology, immunofluorescent microscopy will undoubtedly gain even greater prominence as a diagnostic investigation. I thank Louise Roelofs for her expert technical assistance. The laboratory was established by means of a grant (74/12) from the British Columbia Medical Services Foundation.
References 1. BURNHAM TK, NEBLETT TR, FINE G: The
application of the fluorescent antibody technic to the investigation of lupus erythematosus and various dermatoses. I Invest Dermatol 41: 451, 1963 2. Co-operative Study: Uses for immunofluorescence tests of skin and sera. Arch Dermatol 111: 371, 1975 3. MICHEL B, MILNER Y, DAVID K: Preservation
of tissue-fixed immunoglobulins in skin biopsies of patients with lupus erythematosus and bullous diseases - preliminary report. I Invest Dermatol 59: 449, 1972 4. BEUTNER ELI (ed): Defined immunofluorescent staining. Ann NY Acad Sc! 177: June 21, 1971 5. JORDON RE, TRIFrSHAUSER CT, SCHROETER AL: Direct immunofluorescent studies of
pemphigus and bullous pemphigoid. Arch Dermatol 103: 486, 1971 6. SEAH PP, FRY L: Immunoglobulins in the skin in dermatitis herpetiformis and their relevance in diagnosis. Br I Dermatol 92: 157, 1975 7. Kocsls M, EEO TL, Hussy G, et al: Immunofluorescence studies in herpes gestationis. Acta Derm Venereol (Stockh) 55: 25, 1975
8. BURNHAM TK, FINE G, NEBLETr TR: Immu-
nofluorescent "band" test for lupus erythematosus. Arch Dermatol 102: 42, 1970
9. ULLMAN 5, HALBERO P, WOLF-JORGENSEN P:
Deposits of immunoglobulins and complement C3 in clinically normal skin of patients with lupus erythematosus. Acta Derm Venereol (Siockh) 55: 109, 1975
10. WINKELMANN RK, JORDON RE, DE MORAGAS
JM: Immunofluorescent studies of dermatomyositis. Dermatologica 145: 42, 1972 11. PARISH WE: Studies on vasculitis. Clin Allergy 1: 97, 1971 12. SHELLEY WB, SCHLAPPNER OLA, HEISS LIB: Demonstration of intercellular immunofluorescence and epidermal hysteresis in bullous fixed drug eruption due to phenolphthalein. Br I Dermatol 86: 118, 1972 13. UMBERT P, WINKELMANN RK: Granuloma annulare: direct immunofluorescence study. Br I Dermatol 95: 487, 1976 14. MICHEL B, Sv EK, DAvID K, et al: Immunofluorescent studies in lichen planus (abstr). I Invest Dermatol 54: 428, 1970
152 GMA JOURNAL/JANUARY 21, 1978/VOL. 118
SEPTRA
* sequentially blocks two different bacterial enzymes (both vital for bacterial survival) * double blockade activity discourages development of resistance * achieves rapid, high blood levels; significant levels in lung tissue and sputum * well tolerated by most patients * convenient b.i.d. tablet dosage * licorice-flavored suspension well accepted by children i. SEPTRA F. Summary (Trimethoprim + Sultamethoxazole)
INDICATIONS AND CLINICAL USES: Indicated for the following
infections when caused by susceptible organisms: URINARY TRACT INFECTIONS - acute, recurrent and chronic. GENITAL TRACT INFECTIONS - uncomplicated gonococcal urethritis. UPPER AND LOWER RESPIRATORY TRACT INFECTIONS particularly chronic bronchitis and acute and chronic otilis media. GASTROINTESTINAL TRACT INFECTIONS. SKIN AND SOFT TISSUE INFECTIONS. SEPTRA is not indicated in infections caused by Pseudomonas, Mycoplasma or viruses. This drug has not yet been fully evaluated in streptococcal infections. CONTRAINDICATIONS: Patients with evidence 01 marked liver parenchymat damage, blood dyscrasias, known hypersensitivity to trimethoprim or sultonamides, marked renal impairment where repeated serum .says cannot be carried out; premature or newborn babies during the first few weeks 01 tile. For the time being SEPTRA is contraindicated during pregnancy. If pregnancy cannot be excluded, the possible risks should be balanced against the expected therapeutic etfect. PRECAUTIONS: As with other sulfonamide preparations, critical appraisal of benefit versus risk should be made in patients with liver damage, renal damage, urinary obstruction, blood dyscrasias, allergies or bronchial asthma. The possibility of a superinfection with a non-sensitive organism should be borne in mind.
DOSAGE AND ADMINISTRATION: Adults and children over 12
years. Standard dosage: Two Septra tablets or one Septra OS tablet twice daily (morning and evening). Minimum dosage and dosage for long-term treatment: One Septra tablet or one-half Septra OS tablet twice daily. Maximum dosage: Overwhelming infections: Three Seplra tablets or one and one-hall Septra OS tablets twice daily. Uncomplicated gonorrhea: Two Septra tablets or one Seplra OS tablet tour times daily for 2 days. Children 12 years and under.t Young children should receive a dose according to biological age: Children under 2 years: 2.5 ml pediatric suspension twice daily. Children 210 5 years: One to two pediatric tablets or 2.5 to 5 ml pediatric suspension twice daily. Children 610 12 years: Two to tour pediatric tablets or 510 10 ml pediatric suspension or one adult tablet twice daily. (Septra OS tablets should not be used for children under 12 years.) tin children this corresponds to an approximate dose 01 6 mg trimethoprim/kg body weight/day, plus 30mg sulfamethoxazole/kg body weight/day, divided into two equal doses. DOSAGE FORMS: SEPTRA TABLETS, each containing 80 mg trimethoprim and 400 mg sulfamethoxazote, and coded WELLCOME Y2B. Bottles of 100 and 500, and unit dose packs of 100. SEPTRA OS TABLETS, each containing 160 mg trimethoprim and BOO mg sultamethoxazote, and coded WELLCOME 02C. Bottles of 50 and 250. SEPTRA PEDIATRIC SUSPENSION, each teaspoontul (5 ml) containing 40 mg trimethoprim and 200 mg sultamethoxazole. Bottles of 100 and 400 ml. SEPTRA PEDIATRIC TABLETS, each containing 20 mg trimethoprim and 100 mg suttamethoxazote, and coded WELLCOME H4B. Bottles of 100. Product monograph available on request
I BurroughsWellcome Salle, Qu6. Trade Mark
Ltd.
W-7002
Assistant professor, division of dermatology, department of medicine, faculty of medicine, University of British Columbia, Vancouver Reprint requests: Dr. Roberta C. Ongley, 865 W 10th Ave., Vancouver, BC V5Z 1L7
of 20% of patients with this condition contain IgG in addition to IgA; in biopsy specimens from four patients IgG alone has been demonstrated. In addition to its being found in lesions, IgA can often be found in clinically uninvolved skin, particularly in biopsy specimens from the buttocks. In many centres positive results of immunofluorescent microscopy are essential in establishing the diagnosis of dermatitis herpetiformis, a negative result being considered incompatible with the diagnosis. Herpes gestationis
Herpes gestationis, a rare bullous disorder of pregnancy, can best be diagnosed by immunofluorescent microscopy, which shows deposition of the C3 component of complement at the dermoepidermal junction.7 Connective tissue disorders Lupus erythematosus Direct immunofluorescent microscopy of skin biopsy specimens was applied first to the investigation of lupus erythematosus,1 and in our laboratory this is the condition for which immunofluorescent microscopy is most often requested; it accounted for 89 of our biopsy specimens that yielded positive results. In both discoid lupus erythematosus (DLE) and systemic lupus erythematosus (SLE) IgG is found at the dermoepidermal junction in 90% of biopsy specimens of active lesions.8'9 In addition we have been able to confirm the persistence of IgG at the site of previous discoid lesions; we have found it to be present 8 weeks after apparent clinical clearing. In SLE, but not DLE, IgG may also be found at the dermoepidermal junction of clinically normal skin;9 we have found 71% of SLE patients to have IgG deposits in areas of normal skin. This pattern is detected most commonly in areas exposed to the sun, such as the wrist, and will occur even in the absence of cutaneous involvement. Dermatoinyositis
This condition has recently been shown to have associated cutaneous deposits of immunoglobulin, IgG at the dermoepidermal junction being present in 50% of patients with this disease.10 We have been able to demonstrate IgG deposition in the lesions of three of five patients. Vasculitis
The vasculitides are an unpredictable group of diseases in terms of results of immunofluorescent microscopy.11
Rheumatoid vasculitis has been associated with 1gM deposits in the dermal blood vessels. Other varieties of vasculitis have shown occasional deposition of immunoglobulin, positive results of immunofluorescent microscopy being more frequent with very early lesions. and our studies have revealed a variable mixture of immunoglobulins and complement.
Comments The diseases discussed above are those in which immunofluorescent microscopy is established and useful in diagnosis. The technique is readily available and is a rapid method of assessment. There have been reports of immunoglobulin deposition in many other disorders, including drug reactions,12 granuloma annulare" and lichen planus,14 but further studies will be required to determine the significance and diagnostic value of these findings. With increasing knowledge of immunopathology, immunofluorescent microscopy will undoubtedly gain even greater prominence as a diagnostic investigation. I thank Louise Roelofs for her expert technical assistance. The laboratory was established by means of a grant (74/12) from the British Columbia Medical Services Foundation.
References 1. BURNHAM TK, NEBLETT TR, FINE G: The
application of the fluorescent antibody technic to the investigation of lupus erythematosus and various dermatoses. I Invest Dermatol 41: 451, 1963 2. Co-operative Study: Uses for immunofluorescence tests of skin and sera. Arch Dermatol 111: 371, 1975 3. MICHEL B, MILNER Y, DAVID K: Preservation
of tissue-fixed immunoglobulins in skin biopsies of patients with lupus erythematosus and bullous diseases - preliminary report. I Invest Dermatol 59: 449, 1972 4. BEUTNER ELI (ed): Defined immunofluorescent staining. Ann NY Acad Sc! 177: June 21, 1971 5. JORDON RE, TRIFrSHAUSER CT, SCHROETER AL: Direct immunofluorescent studies of
pemphigus and bullous pemphigoid. Arch Dermatol 103: 486, 1971 6. SEAH PP, FRY L: Immunoglobulins in the skin in dermatitis herpetiformis and their relevance in diagnosis. Br I Dermatol 92: 157, 1975 7. Kocsls M, EEO TL, Hussy G, et al: Immunofluorescence studies in herpes gestationis. Acta Derm Venereol (Stockh) 55: 25, 1975
8. BURNHAM TK, FINE G, NEBLETr TR: Immu-
nofluorescent "band" test for lupus erythematosus. Arch Dermatol 102: 42, 1970
9. ULLMAN 5, HALBERO P, WOLF-JORGENSEN P:
Deposits of immunoglobulins and complement C3 in clinically normal skin of patients with lupus erythematosus. Acta Derm Venereol (Siockh) 55: 109, 1975
10. WINKELMANN RK, JORDON RE, DE MORAGAS
JM: Immunofluorescent studies of dermatomyositis. Dermatologica 145: 42, 1972 11. PARISH WE: Studies on vasculitis. Clin Allergy 1: 97, 1971 12. SHELLEY WB, SCHLAPPNER OLA, HEISS LIB: Demonstration of intercellular immunofluorescence and epidermal hysteresis in bullous fixed drug eruption due to phenolphthalein. Br I Dermatol 86: 118, 1972 13. UMBERT P, WINKELMANN RK: Granuloma annulare: direct immunofluorescence study. Br I Dermatol 95: 487, 1976 14. MICHEL B, Sv EK, DAvID K, et al: Immunofluorescent studies in lichen planus (abstr). I Invest Dermatol 54: 428, 1970
152 GMA JOURNAL/JANUARY 21, 1978/VOL. 118
SEPTRA
* sequentially blocks two different bacterial enzymes (both vital for bacterial survival) * double blockade activity discourages development of resistance * achieves rapid, high blood levels; significant levels in lung tissue and sputum * well tolerated by most patients * convenient b.i.d. tablet dosage * licorice-flavored suspension well accepted by children i. SEPTRA F. Summary (Trimethoprim + Sultamethoxazole)
INDICATIONS AND CLINICAL USES: Indicated for the following
infections when caused by susceptible organisms: URINARY TRACT INFECTIONS - acute, recurrent and chronic. GENITAL TRACT INFECTIONS - uncomplicated gonococcal urethritis. UPPER AND LOWER RESPIRATORY TRACT INFECTIONS particularly chronic bronchitis and acute and chronic otilis media. GASTROINTESTINAL TRACT INFECTIONS. SKIN AND SOFT TISSUE INFECTIONS. SEPTRA is not indicated in infections caused by Pseudomonas, Mycoplasma or viruses. This drug has not yet been fully evaluated in streptococcal infections. CONTRAINDICATIONS: Patients with evidence 01 marked liver parenchymat damage, blood dyscrasias, known hypersensitivity to trimethoprim or sultonamides, marked renal impairment where repeated serum .says cannot be carried out; premature or newborn babies during the first few weeks 01 tile. For the time being SEPTRA is contraindicated during pregnancy. If pregnancy cannot be excluded, the possible risks should be balanced against the expected therapeutic etfect. PRECAUTIONS: As with other sulfonamide preparations, critical appraisal of benefit versus risk should be made in patients with liver damage, renal damage, urinary obstruction, blood dyscrasias, allergies or bronchial asthma. The possibility of a superinfection with a non-sensitive organism should be borne in mind.
DOSAGE AND ADMINISTRATION: Adults and children over 12
years. Standard dosage: Two Septra tablets or one Septra OS tablet twice daily (morning and evening). Minimum dosage and dosage for long-term treatment: One Septra tablet or one-half Septra OS tablet twice daily. Maximum dosage: Overwhelming infections: Three Seplra tablets or one and one-hall Septra OS tablets twice daily. Uncomplicated gonorrhea: Two Septra tablets or one Seplra OS tablet tour times daily for 2 days. Children 12 years and under.t Young children should receive a dose according to biological age: Children under 2 years: 2.5 ml pediatric suspension twice daily. Children 210 5 years: One to two pediatric tablets or 2.5 to 5 ml pediatric suspension twice daily. Children 610 12 years: Two to tour pediatric tablets or 510 10 ml pediatric suspension or one adult tablet twice daily. (Septra OS tablets should not be used for children under 12 years.) tin children this corresponds to an approximate dose 01 6 mg trimethoprim/kg body weight/day, plus 30mg sulfamethoxazole/kg body weight/day, divided into two equal doses. DOSAGE FORMS: SEPTRA TABLETS, each containing 80 mg trimethoprim and 400 mg sulfamethoxazote, and coded WELLCOME Y2B. Bottles of 100 and 500, and unit dose packs of 100. SEPTRA OS TABLETS, each containing 160 mg trimethoprim and BOO mg sultamethoxazote, and coded WELLCOME 02C. Bottles of 50 and 250. SEPTRA PEDIATRIC SUSPENSION, each teaspoontul (5 ml) containing 40 mg trimethoprim and 200 mg sultamethoxazole. Bottles of 100 and 400 ml. SEPTRA PEDIATRIC TABLETS, each containing 20 mg trimethoprim and 100 mg suttamethoxazote, and coded WELLCOME H4B. Bottles of 100. Product monograph available on request
I BurroughsWellcome Salle, Qu6. Trade Mark
Ltd.
W-7002
