[501] Histopathologic Features Most Suggestive of Prodromal/Urticarial Bullous Pemphigoid

Vivian S Snyder, Christopher L Kinonen, Briana C Gleason, Antoinette B Thomas, Thomas L Cibull. NorthShore University HealthSystem, Evanston, IL; Diagnostic Pathology Medical Group, Sacramento, CA

Background: The clinical presentation of bullous pemphigoid (BP) can be highly variable, especially in early stages of the disease or in atypical variants such as urticarial BP. Definitive diagnosis of BP requires correlation between clinical impression, histopathology, immunofluorescence (IF), and sometimes ELISA studies. When the presentation is atypical, these patients are occasionally biopsied without concurrent IF studies. If there are features suggestive of BP, a follow-up biopsy for IF is recommended. We compared histopathologic features of cases where the initial H&E findings were suggestive of BP and follow-up IF was either positive or negative.
Design: 20 patients with skin biopsies from NorthShore University HealthSystem (2003-2012) had IF performed following an initial H&E biopsy. Patient demographics and histologic characteristics were reviewed and compared to IF findings.
Results: Patient demographics and results are listed in tables 1 and 2. None of the cases had a sub-epidermal blister.

Table1: Patient Demographics
Total PatientsMean AgeFemaleMale
2072 (range 41-90)14 (70%)6 (30%)

Table 2: Data Summary
IFCasesSpongiosisExocytosis of EosinophilsDyskeratosisVacuolization at DEJEosinophils at DEJVasculitis
IgG, C3 at Basement Membrane101071750

Clinically, BP was suspected in 4/10 cases where IF was positive and 5/10 cases where IF was negative. Most histopathologic features, including the presence/absence of spongiosis, dyskeratosis, vacuolization at the dermal-epidermal junction (DEJ), and vasculitis, were non-specific. However, eosinophils at the DEJ were found in 5/10 cases where IF was positive vs 0/10 cases where IF was negative. Exocytosis of eosinophils was present in 7/10 cases where IF was positive vs only 2/10 cases where IF was negative.
Conclusions: 1. Spongiosis, vacuolization at the DEJ, and an eosinophilic infiltrate are common histopathologic features of BP, but are non-specific.
2. The presence of eosinophils at the DEJ was found only in cases where subsequent IF was positive (5/10). Additionally, exocytosis of eosinophils was more common in cases where IF was positive vs negative (7/10 vs 2/10).
3. Even without a sub-epidermal blister, a spongiotic dermatitis with an eosinophil rich infiltrate, particularly in older individuals, should prompt consideration of BP as a differential diagnosis. If the eosinophils are present at the DEJ and within the epidermis, BP should be more strongly considered and IF should be recommended if clinically indicated.
Category: Dermatopathology

Monday, March 4, 2013 9:30 AM

Poster Session I Stowell-Orbison/Surgical Pathology/Autopsy Awards Poster Session # 68, Monday Morning


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