Chapter 9: Allergies and immunologic diseases Flashcards
Transient lingual papillitis (lie bumps, tongue torches)
-‐ Localized: one to several enlarged fungiform papillae presenting as red papule that may ulcerate, on the dorsal tongue
-‐ Generalized: Affects large % of fungiform papillae on tip/lateral border of tongue dorsum
-‐ Diffuse (papulokeratotic): white to yellow asymptomatic papules (unusual frictional keratosis?)
Recurrent aphthous ulcers
-‐ T cell reaction: decreased CD4/CD8 ration, increased T-‐cell receptors and increased TNF
-‐ Minor (Mikulicz), major (Sutton, periadenitis mucosa necrotica recurrens) and herpetiform.
-‐ Simple (few lesions, heal 1-‐2 wks, few recurrences) or complex (>3 lesions, almost constant)
-‐ Silver nitrate tx: can cause massive necrosis and systemic argyria
Behçet’s syndrome (Adamantindes syndrome)
-‐ Multisystem disease linked to HLA B12 and B51. More in Middle East and Japan
-‐ Oral aphtae: seen in 99% of pts. Commonly first sign. More numerous (>6) and dif location (soft palate and oropharynx) than sporadic aphtous ulcer. Usually minor or major aphtae.
-‐ Genital: less frequent, deeper and more scarring than oral lesions
-‐ Pathergy: sterile pustule after insertion of sterile needle in skin
-‐ Dx: oral ulcers + 2 of: genital lesions, eye lesions (uveitis, retinal vasculitis, cells in vitrous), skin lesions (erythema nodosum, pseudofolliculitis or papulopustular lesions) or pathergy test
-‐ Histo: leukocytoclastic vasculitis (intramural invasion by neutrophils, karyorrhexis of neutrophils, RBCs extravasation and fibrinoid necrosis of vessel wall)
Sarcoidosis
-‐ 10-‐17x more in Blacks; bimodal (25-‐35yo, 45-‐65yo)
-‐ Predominant sites: lungs, LN, skin, eyes (anterior uveitis) and SG
-‐ Lupus pernio: chronic, violaceous, indurated skin lesions
-‐ Erythema nodosum: scattered, nonspecific, tender, erythematous nodules on lower legs
-‐ Lofgren’s syndrome: ertyhema nodosum, bilateral hilar lymphadenopathy, and arthralgia
-‐ Heerfordt’s syndrome (uveoparotid fever): parotid enlargment, ant uveitis, facial paralysis, fever
-‐ Oral: uncommon. Submucosal mass, papule, area of granularity or ulceration.
-‐ Schaumann bodies: laminated calcifications (degenerated lysosomes)
-‐ Asteroid bodies: stellate inclusion (entrapped fragment of collagen)
-‐ Hamazaki-‐Weisenberg bodies: small yellow-‐brown structures (large lymphocytes) in LN
-‐ Dx: clinical + histo + negative special stains + elevated ACE levels
-‐ Kveim test: sarcoid tissue is injected in skin (not widely used anymore)
-‐ Tx: 60% resolve within 2y. Observe 3-‐12m. If needed, corticoids. 4-‐10% mortality.
Orofacial granulomatosis
-‐ Non-‐tender, persistent swelling of one or both lips
-‐ R/O MRS, cheilits granulomatosa, Chron’s, sarcoid, TB, leprosy, foreign-‐body
-‐ Cheilitis granulomatosa (of Miescher): involvement of lips only (vs MRS)
-‐ May affect intraoral sites (if gingival only, R/O granulomatous gingivitis due to foreign material)
Wegener’s granulomatosis
-‐ Granulomatous lesions of respiratory tract, glomerulonephritis and systemic vasculitis
-‐ Classic WG: upper and lower respiratory tract + rapid renal lesions (aka generalized), limited (respiratory involvement w/o rapid renal lesions) and superficial (skin and mucosal lesions only, slowly develops systemic)
-‐ Saddle-‐nose deformity: destruction of nasal septum
-‐ Oral: strawberry gingivitis (hyperplatic gingival with hemorrhagic bulbous projections).
-‐ Others: ulcerations, facial paralysis, labial mucosa nodules, sinusitis-‐related toothache, TMJ arthralgia, jaw claudication, palatal ulceration, oral-‐antral fistula and poorly healing extraction
-‐ Histo: RBC extravasation close to surface. Sinonasal: necrosis, vasculitis and granulmatous infl
-‐ Dx: c-‐ANCA (also for monitoring); confirm with PR3 Elisa. Tx: prednisone + cyclophosphamide
Allergic mucosal reactions to systemic drug administration
-‐ Risk of adverse reaction: 6% (use of 2 drugs), 50% (5 drugs) and 100% (8+ drugs)
-‐ Aka stomatitis medicamentosa. Patterns: anaphylactic, fixed drug eruption, lichenoid, lupus-‐like, pemphigus-‐like and nonspecific vesiculo-‐ulcerative/aphthous-‐like
-‐ Patients on penicillamine therapy may develop oral lesions indistinguishable from PV
-‐ String of pearls: pattern of indirect IF for IgG (along basal cell layer)
-‐ Basal cell cytoplasmic antibody: name of detected circulating antibody
Allergic contact stomatitis (stomatitis venenata)
-‐ May be induced by a variety of products (rubber dam, gloves, dentifrices, etc)
Perioral dermatitis
-‐ Idiosyncratic response to exogenous substance, worsened by corticoids
-‐ Skin immediately adjacent to vermillion border is spared
Contact stomatitis from artificial cinnamon flavoring
-‐ Gingiva most frequent site affected if cinnamon is in toothpaste (~ PCG)
-‐ Buccal mucosa (~ morsicatio) and lateral border of tongue (~ OHL) if in chewing gum/candy
-‐ Histo: mixed infiltrate that obscures connective tissue/epith interface and perivascular infl
Lichenoid contact stomatitis from dental restorative materials
-‐ Usually assoc w/ old amalgams (undergo erosion and release metallic ions)
-‐ Difference to LP: no migration, directly related to dental material, improves upon removal, patch test to dental material positive
-‐ Koebner phenomenon: pts with contact reaction but negative patch test.
Angioedema (Quincke’s disease)
1) Mast cell degranulation (histamine and IgE-‐mediated) (allergic)
-2) Associated with ACE inhibitors and angiotensin II receptor blockers (most common in dental)
3) Activation of complement pathway. Deficiency of C1-‐INH activity. Hereditary-‐ type I (less C1-‐ INH) and type II (normal levels of C1-‐INH, but dysfunctional). Acquired-‐ lymproliferative disease (auto-‐Ab consumes C1-‐INH) or auto-‐immune (auto-‐Ab binds to and reduces C1-‐INH function).
-‐ Assoc w/ high levels of Ag-‐Ab complexes (lupus, viral/bacterial infections) and in pts with elevated peripheral blood eosinophils
-‐ Tx: allergic-‐ antihistamine; ACE and hereditary/acquired-‐ C1-‐INH concentrate; AI-‐ corticosteroid
