Immunological diseases Kumar Flashcards
What is this clinical finding?
Urticaria
Well defined erythematous papules/plaques which are pruritic (itchy)
We’ll see them on the skin ‐ Not found intraorally
What is this clinical finding?
Urticaria
(HIVES)
this person was exposed to extreme temperature developed hives (
not really
red but very itchy)
no skin scarring is noted
it goes in about a day
Urticaria
Etiology
❖ Medications ► causing rash
❖ Foods ► like peanuts
❖ Airborne allergens ► pollen
❖ Physical stimuli ► ex cold weather
Urticaria
Treatment
❖Avoid known triggers avoid
the penicillin, any of
the triggers
❖ Antihistamines ( to prevent it
from happening in the first
place)
Corticosteroids (prevents the
inflammatory effect)
Urticaria
DDX
- erythema multiforme
- morbilliform drug eruption
What is this clinical finding?
Angioedema
❖ Diffuse edematous swelling of the soft tissues that most commonly
involves the subcutaneous and submucosal connective tissues
❖ Results from local vasodilatation and increased vascular
permeability of DEEPER blood vessels
What is this clinical finding?
Angioedema
Angioedema
Etiology
Causes include:
❖ IgE mediated ( most common types are allergy related)
- Hypersensitivity reaction
- drugs, foods, plants, dust
- Contact allergic reactions
- foods, cosmetics, topical medications, rubber dam
- Physical stimuli
- heat, cold, exercise, emotional stress, solar exposure, vibration
❖ Drug reaction to ACE inhibitors
- Does not respond well to antihistamines
❖ Hereditary or acquired activation of the complement
pathway
❖ Other (high levels of antigen‐antibody complexes and in
elevated blood eosinophil counts)
- Complexes in lupus, viral and bacterial infections
- Patients with grossly elevated blood eosinophilia
Angioedema
Treatment
❖ Antihistamine/IM epinephrine/IV corticosteroids ( typical treatment for allergy)
❖ Intubation and tracheostomy ( if the patient can’t breathe, so we can get air in)
❖ Avoid medications in ACE Inhibitor class of drugs ( for people who has Ace inhibitor induced angieodema)
❖ C1 esterase inhibitor concentrate and esterase inhibiting drugs
What is this clinical finding?
Cinnamon Contact
Stomatitis
- It can present similar to leukoplakia
- So you’d think it is pre‐malignant lesion
- But after asking the patients ► you’ll realize they are chewing like 10 cinnamon gums every day.
Cinnamon Contact
Stomatitis
DDx
- Oral hairy leukoplakia
- hyperplastic candidiasis
What is this clinical finding?
Allergic Contact
Stomatitis
❖ Mild‐severe redness, edema, vesicles, erosions, ulcerations
❖ Burning, itching, stinging, tingling
●We can’t know what is this right away.
Patients may say it burns, tingles, there could be peeling
(desquamation). We might think it’s a vesiculobullous diseases.
● So these cases require more consulative‐investigative work.
What is this clinical finding?
Allergic Contact
Stomatitis‐Clinical
- slight vesicales and diffused erythemya
- we wouldn’t always know this is Allergic contact stomatitis
- This occured due to allumnium chloride on gingival retraction cord.
What is this clinical finding?
Mucosal sloughing
Allergic Contact Stomatitis
caused by tooth paste (Colagate Total)
white area‐like a film peeling out slowly
Wipeable
could be confused with candidasis
White wipeable plaque in the mouth
DDx
● pseudomembranous candidiasis
● Mucosal sloughing‐ Allergic Contact Stomatitis
● Food particles
Allergic Contact
Stomatitis
Treatment
- *❖ Remove the suspected antigen**
- *❖** Severe cases‐Antihistamine (combined with a topical anaesthetic) ( because it’s an allergy)
- *❖** Chronic cases‐Apply topical corticosteroid
❖ Recommendations to AVOID:
- ❖ Mouthwash
- ❖ Gum/mints
- ❖ Cinnamon
- ❖ Excessive salty, spicy, acidic
❖ Patch testing (we send them to allergist )
What are List of
Agents that causes Allergic Contact
Stomatitis
❖ Foods
❖ Food additives
❖ Chewing gums
❖ Candies
❖ Dentifrices
❖ Mouthwashes
❖ Gloves
❖ Rubber dam material
❖ Topical anaesthetics
❖ Restorative metals
❖ Acrylic denture materials
❖ Dental impression materials
❖ Denture adhesive
preparations
❖ Cinnamon (mainly artificial flavoring)
What is this clinical finding?
Exfoliative cheilitis
Allergic Contact
Reactions‐ Non‐
Mucosal
dry, scaly, fissured, cracking lips
This is a mild case that affect the non‐mucosal around the the
skin
What is this clinical finding?
Exfoliative Cheilitis
caused by titanium implants and
some mercury in amalgam.
Exfoliative cheilitis
causes
Medications, lipsticks,
sunscreens, toothpaste
floss, cosmetics
What is this clinical finding?
Perioral Dermatitis
Allergic Contact
Reactions‐ Non‐
Mucosal
erythematous
papules/vesicles
– papules ( raised) & vesicles
(actual blisters)
What is this clinical finding?
Fixed Drug Eruption
–This case has both the skin and oral appearance.
This happened every time this person took NSAIDs that’s not used in
the USA.
A person gets a reaction to a medication they take. It occurs at the
same place each time because there’s some memory T cell at these
sites.
What is this clinical finding?
Erythema
Multiforme
Acute, vesiculobullous, ulcerative
mucocutaneous disorder
Immunologically mediated
Target lesions on skin (typical board question)
Healthy young adults in 20‐40’s
What is this clinical finding?
Erythema
Multiforme
Rapidly rupturing vesicles/bullae forming erosions/ulcerations and
hemorrhagic encrusted lip lesions, with greyish pseudomembrane
Fast expansion, ► the skin is just peeling off.
Type 4 hypersensitivity.
Has prodrome phasesudden
Rapid onset, crusted
hemorrhagic swollen
lips, and
desquamative
gingivitis.
Erythema
Multiforme
Treatment
❖Self‐limiting, resolves in a few weeks (It will go away on its own, you just have to manage symptomatically.)
❖Symptomatic management, IV rehydration, corticosteroids (topical and oral), antivirals in recurrent cases (We may use antivirals if they tell us they get cold sores every now and then this means they do have a history of herpes simplex.)
❖ Avoid causative drug (If drug‐related)
❖ Other second‐line systemic therapies (like cyclosporin,
azathioprine and other serious drugs)
❖ Usually not life threatening unless in major form.
Erythema
Multiforme
Triggers
❖ 50% of cases precipitating cause is identified
- Infectious Agents: Herpes simplex virus, Mycoplasma pneumonia, Adenovirus, Enterovirus, Coccidiomycosis
- Most of the time, erythema multiforme is related to a previous infection with herpes simplex virus.
- Drugs: Penicillin, Cephalosporins, Sulphonamides, NSAID’s, Phenytoin
- Other: Foods (Benzoates, Nitrobenzene), Chemicals (Perfumes)
❖ it’s not an infection, it’s our body reacting to the infectious
organism or pieces of it in a wrong way
What is this histological finding?
Granuloma
This is a granuloma. It’s composed of histeocytes that looks
epithelioid. This is a collection of epithelioid histeocytes
Found in:
- TB (They’ll be holding TB inside. But in TB you have caseous necrosis of granuloma.
- Deep fungal infections (they holding? fungal organisms)
- GRANULOMATOUS DISEASES ( if with Asteroid bodies & Schaumann Bodies)
In these granulomas we don’t know why they are forming.
What is this clinical finding?
Orofacial
Granulomatosis
Cheilitis granulomatosa=Involvement of lips alone
Non‐tender, persistent swelling
NEED To BIOPSY to RULE OUT
angioedema
What is this clinical finding?
Orofacial
Granulomatosis
Papules, slightly raised areas, fissures, cobblestone appearance
DDx
We could suspect
a traumatic injury
early signs of Crohn’s
What is this clinical finding?
Orofacial
Granulomatosis
Orofacial
Granulomatosis
Etiology
❖ Idiopathic
❖ Abnormal immune reaction
❖ in orofacial granulomatosis, people form granulomas and it’s
idiopathic
❖ we don’t know why they’re forming them so that’s an abnormal
immune reaction.
Orofacial
Granulomatosis
Treatment
❖ Discover cause ( we need to find out the cause.)
❖ Topical or intralesional corticosteroids (maybe try steroids)
❖ Other (topical tacrolimus, sulfazalazine, methotrexate, etc)
❖ Some cases resolve spontaneously
(This photo shows a person has puffiness because of granulomas.
Sometimes it goes away on its own. We can use injection steroids on
the lips too.)
What is this clinical finding?
Sarcoidosis‐Organ
Systems
❖ Lungs
❖ Lymph Nodes (bilateral hilar
lymphadenopathy)
❖ Skin (25% of time)
❖ Eyes
❖ Salivary Glands
❖ Other (endocrine,
gastrointestinal, heart, kidney, liver, nervous system, spleen, skeletal
What is this radiological finding?
Sarcoidosis‐Hilar
Lymph Node
Enlargement
popcorn‐like calcifications in the hilar lymph nodes.
granulomas from
sarcoidosis being inside
.
What is this clinical finding?
Sarcoidosis‐Skin
Lesions
Lupus pernio (nose, ears, lips and
face)
‐ when we have these erythematous
indurated, hard on face.
What is this histological finding?
Sarcoidosis
discrete clear
granulomas.
2nd
schaumann body in a giant cell (3rd to the right)
Asteroid bodies ( right)
What is this clinical finding?
Sarcoidosis
DDX
in the oral cavity. It could be one of the three P’s:
❖ pyogenic granuloma
❖ peripheral ossifying fibroma
❖ peripheral giant cell granuloma.
Sarcoidosis
Etiology
❖ Granulomatous disorder
❖ Multisystem
❖ Unknown cause
Sarcoidosis
Treatment
Depends on the case!
❖ 60% of cases resolve within 2 years
❖ Initial diagnosis 3‐12 mo. observationàactive intervention as needed
❖ First line tx: corticosteroids
❖ Refractory dx:
- Cytotoxic drugs (methotrexate, azithioprne)
- TNF blockers
- Hydroxychloroquine
❖ 4‐10% die of pulmonary, cardiac or CNS complications
What is this clinical finding?
Granulomatosis with
Polyangiitis
extra-oral
Joint pain, weakness, tiredness
❖ Known as Saddle nose deformity
❖ First signs may be recurrent
respiratory infection, cough or
runny nose
❖ Oral lesions initial presentation in 2% of patients
What is this clinical finding?
❖ This is Strawberry gingivitis
Granulomatosis with
Polyangiitis “Wegener’s”
Orally
❖ Ulceration,
❖ Mucosal nodules
❖ Facial paralysis
❖ Enlarged major gland
from granulomas
- we need to biopsy, as this also looks like a deep fungal
infection. *
What is this clinical finding?
Granulomatosis with
Polyangiitis
Orally
We want to
biopsy to confirm because it Could be contact mucositis.
Granulomatosis with
Polyangiitis
Etiology
First line: oral prednisone
❖ After remission immunosuppressive drugs:
❖ Methotrexate
❖ Cyclosporine
❖ Rituximab
❖ Treatment induces prolonged remission
❖ May have relapses
Granulomatosis with
Polyangiitis
Treatment
First line: oral prednisone
❖ After remission immunosuppressive drugs:
❖ Methotrexate
❖ Cyclosporine
❖ Rituximab
❖ Treatment induces prolonged remission
❖ May have relapses
What is this clinical finding?
‐ Cinnamon contact mucositis
This could be oral hairy leukoplakia.
It could be hyperplastic candidiasis
it could be tongue chewing
it could be a leukoplakia.
We’ll know what it is by biopsy and investigate
What is this clinical finding?
Urticaria.
What is this clinical finding?
Erythema multiforme
What is this clinical finding?
* Erythema multiforme
What is this clinical finding?
‐ Orofacial granulomatosis.
We make sure there’s no tb, no fungal, no foreign material in the
granulomas
What is this clinical finding?
Sarcoidosis
*Erythemous papules (grey circle)
Asteroid bodies ( blue arrow)
Hilar lymph nodes (green circle)
What is this clinical finding?
Granulomatosis with polyangiitis
What is this clinical finding?
orofacial granulomatosis.
What is
the common way to
describe this?
Cobblestone. This is the classic cobblestone.
Cobblestone and fissuring
DDx: people with Crohn’s with oral manifestations it looks like this
too.
What is this clinical finding?
Sarcoidosis
What is this clinical finding?
Urticaria
developed after bites from an imported fire ant.
What is this clinical finding?
Sarcoidosis
large red nodule on the lower lip.
What is this clinical finding?
Erythema multiforme
multiple erosions on the lips and tongue.
What is this clinical finding?
Erythema multiforme
The concentric erythematous
pattern of the cutaneous lesions on the fingers resembles a target or
bull’s-eye.
What is this clinical finding?
Erythema Multiforme
Focal hemorrhagic crusting of
the lips is seen in conjunction with diffuse shallow ulcerations and
erosions involving this patient’s mandibular labial mucosa
What is this clinical finding?
angioedema
What is this clinical finding?
(Granulomatosis with polyangiitis)
formerly Wegener Granulomatosis.
Hyperplastic and hemorrhagic
mucosa of the facial mandibular gingiva on the left side. ((strawberry gingivitis).
