The optimal oral biopsy site for diagnosis of mucous membrane pemphigoid and pemphigus vulgaris.
Journal
The British journal of dermatology
ISSN: 1365-2133
Titre abrégé: Br J Dermatol
Pays: England
ID NLM: 0004041
Informations de publication
Date de publication:
03 2020
03 2020
Historique:
accepted:
22
04
2019
pubmed:
26
4
2019
medline:
15
5
2021
entrez:
26
4
2019
Statut:
ppublish
Résumé
Accepted 'standard practice' for the diagnosis of immunobullous disease is a perilesional sample for direct immunofluorescence (DIF). To compare diagnostic outcomes of a normal buccal punch biopsy (NBPB) with a perilesional biopsy (PLB) for mucous membrane pemphigoid (MMP) and pemphigus vulgaris (PV). A retrospective analysis of 251 DIF-positive patients with MMP and 77 DIF-positive patients with PV was undertaken. Parameters analysed included the intraoral sites of involvement and histopathological, DIF and indirect immunofluorescence (IIF) findings. For MMP, PLB was positive in 134 of 143 (93·7%) samples, compared with 129 of 144 (89·6%) by NBPB. The diagnostic sensitivities for PLB (81%, 39 of 48) and NBPB (77%, 37 of 48) among 48 patients who underwent both techniques were not significantly different (P = 0·62). In gingival-only MMP, PLB was positive in 63 of 69 (91%) and NBPB was positive in 63 of 75 (84%). For multisite MMP, PLB was positive in 71 of 74 (96%) and NBPB was positive in 66 of 69 (96%). In gingival-only MMP, biopsies from reflected alveolar mucosa in 17 consecutive patients were positive in 17 of 17 cases (100%). For PV, PLB was positive in 42 of 43 (98%), compared with 42 of 42 (100%) by NBPB. Histopathology was diagnostic in 93 of 134 (69·4%) cases of MMP and 38 of 41 (93%) cases of PV. IIF was positive in 126 of 197 (64·0%) MMP and 68 of 74 (92%) PV patient sera. In the largest series of combined oral DIF results in patients with MMP and PV, we have shown that NBPB is equivalent to PLB for the diagnosis of PV and multisite MMP, and is more sensitive than both histology and IIF. What's already known about this topic? The variation in sensitivity of oral biopsy sites for direct immunofluorescence (DIF) in the diagnosis of oral MMP and PV has not been studied in detail in large series of patients. Biopsy can be challenging due to difficult access and fragility of the oral mucosa. The diagnostic biopsy technique is therefore critical. What does this study add? We have shown that a normal buccal punch biopsy (NBPB) from uninvolved oral mucosa is as sensitive as a perilesional biopsy (PLB) for diagnosis of oral PV, and superior to serology and histology. For multisite MMP, NBPB is equivalent to PLB and is more sensitive than serology and histology. The oral punch biopsy technique on uninvolved buccal mucosa tissue is a simple and safe practical method for diagnosing oral PV and MMP.
Sections du résumé
BACKGROUND
Accepted 'standard practice' for the diagnosis of immunobullous disease is a perilesional sample for direct immunofluorescence (DIF).
OBJECTIVES
To compare diagnostic outcomes of a normal buccal punch biopsy (NBPB) with a perilesional biopsy (PLB) for mucous membrane pemphigoid (MMP) and pemphigus vulgaris (PV).
METHODS
A retrospective analysis of 251 DIF-positive patients with MMP and 77 DIF-positive patients with PV was undertaken. Parameters analysed included the intraoral sites of involvement and histopathological, DIF and indirect immunofluorescence (IIF) findings.
RESULTS
For MMP, PLB was positive in 134 of 143 (93·7%) samples, compared with 129 of 144 (89·6%) by NBPB. The diagnostic sensitivities for PLB (81%, 39 of 48) and NBPB (77%, 37 of 48) among 48 patients who underwent both techniques were not significantly different (P = 0·62). In gingival-only MMP, PLB was positive in 63 of 69 (91%) and NBPB was positive in 63 of 75 (84%). For multisite MMP, PLB was positive in 71 of 74 (96%) and NBPB was positive in 66 of 69 (96%). In gingival-only MMP, biopsies from reflected alveolar mucosa in 17 consecutive patients were positive in 17 of 17 cases (100%). For PV, PLB was positive in 42 of 43 (98%), compared with 42 of 42 (100%) by NBPB. Histopathology was diagnostic in 93 of 134 (69·4%) cases of MMP and 38 of 41 (93%) cases of PV. IIF was positive in 126 of 197 (64·0%) MMP and 68 of 74 (92%) PV patient sera.
CONCLUSIONS
In the largest series of combined oral DIF results in patients with MMP and PV, we have shown that NBPB is equivalent to PLB for the diagnosis of PV and multisite MMP, and is more sensitive than both histology and IIF. What's already known about this topic? The variation in sensitivity of oral biopsy sites for direct immunofluorescence (DIF) in the diagnosis of oral MMP and PV has not been studied in detail in large series of patients. Biopsy can be challenging due to difficult access and fragility of the oral mucosa. The diagnostic biopsy technique is therefore critical. What does this study add? We have shown that a normal buccal punch biopsy (NBPB) from uninvolved oral mucosa is as sensitive as a perilesional biopsy (PLB) for diagnosis of oral PV, and superior to serology and histology. For multisite MMP, NBPB is equivalent to PLB and is more sensitive than serology and histology. The oral punch biopsy technique on uninvolved buccal mucosa tissue is a simple and safe practical method for diagnosing oral PV and MMP.
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
747-753Commentaires et corrections
Type : CommentIn
Informations de copyright
© 2019 British Association of Dermatologists.
Références
Mihai S, Sitaru C. Immunopathology and molecular diagnosis of autoimmune bullous diseases. J Cell Mol Med 2007; 11:462-81.
Fleming TE, Korman NJ. Cicatricial pemphigoid. J Am Acad Dermatol 2000; 43:571-91.
Rashid KA, Gurcan HM, Ahmed AR. Antigen specificity in subsets of mucous membrane pemphigoid. J Invest Dermatol 2006; 126:2631-6.
Lazarova Z, Hsu R, Yee C, Yancey KB. Antiepiligrin cicatricial pemphigoid represents an autoimmune response to subunits present in laminin 5 (α3β3γ2). Br J Dermatol 1998; 139:791-7.
Ahmed AR, Hombal S. Cicatricial pemphigoid. Int J Dermatol 1986; 25:90-6.
Person JR, Rogers R. Bullous and cicatricial pemphigoid: clinical histopathologic, and immunopathologic correlations. Mayo Clin Proc 1977; 52:54-64.
Setterfield J, Shirlaw P, Kerr-Muir M et al. Mucous membrane pemphigoid: a dual circulating antibody response with IgG and IgA signifies a more severe and persistent disease. Br J Dermatol 1998; 138:602-10.
Sklavounou A, Laskaris G. Frequency of desquamative gingivitis in skin diseases. Oral Surg Oral Med Oral Pathol 1983; 56:141-4.
Challacombe SJ, Setterfield J, Shirlaw P et al. Immunodiagnosis of pemphigus and mucous membrane pemphigoid. Acta Odontol Scand 2001; 59:226-34.
Scully C, Paes De Almeida O, Porter SR et al. Pemphigus vulgaris: the manifestations and long-term management of 55 patients with oral lesions. Br J Dermatol 1999; 140:84-9.
Mustafa MB, Porter SR, Smoller BR, Sitaru C. Oral mucosal manifestations of autoimmune skin diseases. Autoimmun Rev 2015; 14:930.
Altun E, Yayli S, Selçuk LB et al. Clinical and demographic characteristics of pemphigus vulgaris patients. Acta Dermatovenerol Croat 2018; 26:119-24.
Orlowski WA, Bressman E, Doyle JL, Chassens AI. Chronic pemphigus vulgaris of the gingiva. J Periodontol 1983; 54:685-9.
Chan LS, Ahmed AR, Anhalt GJ et al. The first international consensus on mucous membrane pemphigoid: definition, diagnostic criteria, pathogenic factors, medical treatment, and prognostic indicators. Arch Dermatol 2002; 138:370-9.
Setterfield J, Shirlaw PJ, Bhogal BS et al. Cicatricial pemphigoid: serial tires of circulating IgG and IgA antibasement membrane antibodies correlate with disease activity. Br J Dermatol 1999; 140:645-50.
Schmidt E, Zillikens D. Modern diagnosis of autoimmune blistering skin diseases. Autoimmun Rev 2010; 10:84-9.
Arvind Babu RS, Chandrasekar P, Lalith Prakash Chandra K et al. Immunofluorescence and its application in dermatopathology with oral manifestations: revisited. J Orofac Sci 2013; 5:2-8.
Harman KE, Brown D, Exton LS et al. British Association of Dermatologists’ guidelines for the management of pemphigus vulgaris 2017. Br J Dermatol 2017; 177:1170-201.
Bhogal B, Wojnarowska F, Black MM et al. The distribution of immunoglobulins and the C3 component of complement in multiple biopsies from the uninvolved and perilesional skin in pemphigus. Clin Exp Dermatol 1986; 11:49-53.
Giurdanella F, Diercks GF, Jonkman MF, Pas HH. Laboratory diagnosis of pemphigus: direct immunofluorescence remains the gold standard. Br J Dermatol 2016; 175:185-6.
Helander SD, Rogers RS III. The sensitivity and specificity of direct immunofluorescence testing in disorders of mucous membranes. J Am Acad Dermatol 1994; 30:65-75.
Rogers RS III, Perry HO, Bean SF et al. Immunopathology of cicatricial pemphigoid: studies of complement deposition. J Invest Dermatol 1977; 68:39-43.
Bean SF, Waisman M, Michel B et al. Cicatricial pemphigoid. Immunofluorescent studies. Arch Dermatol 1974; 110:552-5.
Gilvetti C, Collyer J, Gulati A, Barrett AW. What is the optimal site and biopsy technique for the diagnosis of oral mucosal autoimmune blistering disease? J Oral Pathol Med 2019; 48:239-43.
Grau AE, Setterfield J, Saw VPJ. How to do conjunctival and buccal biopsies to investigate cicatrising conjunctivitis: improving the diagnosis of ocular mucous membrane pemphigoid. Br J Ophthalmol 2013; 97:530-1.
Sano SM, Quarracino MC, Aguas SC et al. Sensitivity of direct immunofluorescence in oral diseases. Study of 125 cases. Med Oral Pathol Oral. Cir Bucal 2008; 13:E287-91.
Mutasim DF, Adams BB. Immunofluorescence in dermatology. J Am Acad Dermatol 2001; 45:803-22.
Mysorekar VV, Sumathy TK, Shyam Prasad AL. Role of direct immunofluorescence in dermatological disorders. Indian Dermatol Online J 2015; 6:172-80.
Daniels TE, Quadra-White C. Direct immunofluorescence in oral mucosal disease: a diagnostic analysis of 130 cases. Oral Surg Oral Med Oral Pathol 1981; 51:38-47.
Zillikens D. Diagnosis of autoimmune bullous skin diseases. Clin Lab 2008; 54:491-503.
Yancey KB, Egan CA. Pemphigoid: clinical, histologic, immunopathologic, and therapeutic considerations. JAMA 2000; 284:350-6.
Abasq C, Mouquet H, Gilbert D et al. ELISA testing of anti-desmoglein 1 and 3 antibodies in the management of pemphigus. Arch Dermatol 2009; 145:529.
Cheng SW, Kobayashi M, Kinoshita-Kuroda K et al. Monitoring disease activity in pemphigus with enzyme-linked immunosorbent assay using recombinant desmogleins 1 and 3. Br J Dermatol 2002; 147:261.
Judd KP, Lever WF. Correlation of antibodies in skin and serum with disease severity in pemphigus. Arch Dermatol 1979; 115:428-32.
Lever WF. Pemphigus and pemphigoid. A review of the advances made since 1964. J Am Acad Dermatol 1979; 1:2-31.
Vaughn Jones SA, Palmer I, Bhogal BS et al. The use of Michel's transport medium for immunofluorescence and immunoelectron microscopy in autoimmune bullous diseases. J Cutan Pathol 1995; 22:365-70.
Vodegel RM, de Jong MC, Meijer HJ et al. Enhanced diagnostic immunofluorescence using biopsies transported in saline. BMC Dermatol 2004; 4:10.
Black MM, Bhogal BS. Diagnosis, diagnostic and research techniques. In: Management of Blistering Diseases (Briggaman RA, Wojnarowska F, eds). New York: Raven Press, 1990; 15-34.
Setterfield J. Clinicopathological associations in mucous membrane pemphigoid. MD thesis, University of London, 2009.
Woodley D, Saunder D, Talley MJ et al. Localisation of basement membrane components after dermal-epidermal junction separation. J Invest Dermatol 1983; 81:149-53.
Rogers RS, Sheridan PJ, Nightingale SH. Desquamative gingivitis: clinical, histopathologic, immunopathologic, and therapeutic observations. J Am Acad Dermatol 1982; 7:729-35.
Siegel MA, Anhalt GJ. Direct immunofluorescence of detached gingival epithelium for diagnosis of cicatricial pemphigoid. Report of five cases. Oral Surg Oral Med Oral Pathol 1993; 75:296-302.
Casiglia J, Woo SB, Ahmed AR. Oral involvement in autoimmune blistering diseases. Clin Dermatol 2001; 19:737-41.
Dayan S, Simmons RK, Ahmed AR. Contemporary issues in the diagnosis of oral pemphigoid: a selective review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999; 88:424-30.
Payne AS, Stanley JR. Pemphigus. In: Fitzpatrick's Dermatology in General Medicine (Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Leffell DJ, Wolff K, eds), 8th edn, Vol. 1. New York: McGraw Hill, 2012; 586.
Harman KE, Gratian MJ, Seed PT et al. Diagnosis of pemphigus by ELISA: a critical evaluation of two ELISAs for the detection of antibodies to the major pemphigus antigens, desmoglein 1 and 3. Clin Exp Dermatol 2000; 25:236-40.
Ng PP, Thng ST, Mohamed K et al. Comparison of desmoglein ELISA and indirect immunofluorescence using two substrates (monkey oesophagus and normal human skin) in the diagnosis of pemphigus. Australas J Dermatol 2005; 46:239-41.
Jordan RC, Daniels TE, Greenspan JS, Regezi JA. Advanced diagnostic methods in oral and maxillofacial pathology part II: immunohistochemical and immunofluorescent methods. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002; 93:56-74.
Rogers RS III, Van Hale HM. Immunopathologic diagnosis of oral mucosal inflammatory diseases. Australas J Dermatol 1986; 27:51-7.
Shimanovich I, Nitz JM, Zillikens D. Multiple and repeated sampling increases the sensitivity of direct immunofluorescence testing for the diagnosis of mucous membrane pemphigoid. J Am Acad Dermatol 2017; 77:700-5.
Sirois DA, Fatahzadeh M, Roth R et al. Diagnostic patterns and delays in pemphigus vulgaris: experience in 99 patients. Arch Dermatol 2000; 136:1569-70.
Xu HH, Werth VP, Parisi E, Sollecito TP. Mucous membrane pemphigoid. Dent Clin North Am 2013; 57:611-30.