vesiculoerosive, derm mucosal diseases Flashcards
what is direct immunofluorescence
a way to stain tissues to search for antibodies by making them flourese. used to detect auto immune disease
how do you take a biopsy for immunoflouresence
• Submit half in Michel’s solution – ammonium sulfate solution; transport medium, not a fixative like formalin; allows for “fresh” tissue
what are good terms for intramural changes due to vesiculobullous conditions
desquamative gingivitis and desquamative mucosa
where is separation in pemphigus vulgaris
intraepithelial. the antibodies attack desmosomes
what is the positive nikolsky sign and what does it indicate
– Formation of bullae on previously unaffected skin after application of firm, lateral pressure – Characteristic of pemphigus vulgaris
what is usually the first sign of hemp vulgarisms
• Initial presentation may be oral lesions; 50% of patients have oral lesions 1 year or more before onset of skin lesions
what are the results of immunoflourecence in pemp vulgarisms
direct and indirect usually positive between epithelial cells. Indirect can also be used to asses tx
how do you tx temp vulgaris
Systemic corticosteroids (prednisone) • Combined with other immunosuppressive drugs (steroid sparing): azothioprine • High initial dosing schedule, followed by low maintenance doses for long-term control With corticosteroids, 5% to 10% mortality remains, often from long-term steroid use
what is cicatricial pemphigoid
• Autoimmune • Antibodies directed against components of the epithelial basement membrane (subepithelial splitting) • More common than pemphigus, better prognosis cicatrix means scar
what sites are usually affected by cicatricial pemphigoid
Oral lesions found in most patients, other sites often found as well (conjunctival, nasal, esophageal, vaginal, laryngeal) • Gingival involvement – desquamative gingivitis, also seen in other conditions
what is symblepharon
consequence of cicatricial pemphigoid Adhesion between bulbar and palpebral conjunctivae • Subconjunctival fibrosis – early change • Conjunctiva becomes inflamed and eroded • Repeated healing leads to scarring b/w bulbar and palpebral conjunctiva
in cicatricial pemphigoid where does separation usually occur
between the basement membrane and basal layer of epithelium
what is the usual immunoflouresent results with cicatricial pemphigod
• Direct immunofluorescence – Continuous linear band along basement membrane zone – 90% of patients – IgG, C3, possibly IgA and IgM • Indirect immunofluorescence – Only 5% of patients
Cicatricial Pemphigoid Treatment
• Immediately refer to an ophthalmologist • Treatment is varied, individual – Topical agents (if only oral lesions are present) – Systemic agents: corticosteroids plus other immunosuppressives (cyclophosphamide), dapsone, minocycline or niacinamide make sure ophthalmologist i involved
what are the two types of lichen planus
reticular and eosive
what are the immunoflouresent results of oral lichen planus
Direct is non specific. positive for fibrinogen along the basal layer
when do you treat oral lichen planus
when it is symptomatic
what is the tx for oral lichen planus
if concomitant candida present give 2 weeks of anti fungal. f LP still around give topical corticosteroids Lydex gel. if LP still present be concerned for dsplasia
What are the types of erythema multiforme
Minor, major TEN
Describe presentation of EM minor
target lesions of skin
what usually is the trigger of EM minor
secondary HSV
describe presentation of EM major
stevens johnson syndrome often in sick pt. Hemorrhagic crusting of lips. Dehydration
What is common trigger of EM major
usually medication, often a relatively common one such as tylenol
What is TEN
toxic epidermal necrolysis. its lose skin and must be treated like burn patients. no steroids as they are prone to infection
which form of candidiasis is associated tiwh invasion of tissues
hyphen form (yeast form is innocuous)
What factors determined clinical evidence of infection
• Host immune status • Oral environment • C. albicans strain
what are the four clinical patterns of candidiasis
• Pseudomembranous • Erythematous • Chronic hyperplastic • Mucocutaneous
PSEUDOMEMBRANOUS CANDIDIASIS
• Best recognized form of candidiasis • Aka “thrush” • White mucosal plaques (cottage cheese) • Plaques can be removed, usually revealing red, irritated tissue
Where are the most common sites for pseudomembranous candida
• Most common sites are buccal mucosa, dorsum of tongue, and palate
what are symptoms of pseudomembranous candidiasis
Symptoms may include mild chronic burning, bad taste (salty, bitter), “blisters”
What are the predisposing factors for candidiasis
Pre-disposing factors • Recent history of broad spectrum antibiotic • Immune dysfunction (HIV, leukemia) • Infants (underdeveloped immune system
what are the subtypes of erythematous candida
• Acute atrophic candidiasis • Median rhomboid glossitis • Chronic multifocal candidiasis • Angular cheilitis • Denture stomatitis
Acute atrophic candidiasis
• “Antibiotic sore mouth” – recent course of broad spectrum antibiotics • Burning, scalded sensation • Red, bald tongue due to diffuse loss of filiform papillae
Median rhomboid glossitis
• Aka central papillary atrophy • Found in adults, consistently associated with c. albicans • Well-outlined erythema in midline of posterior dorsal tongue • Loss of filiform papillae; may be smooth or lobulated • Often asymptomatic, may resolve with antifungal therapy
Chronic multifocal candidiasis
Involvement of dorsal tongue as well as other areas, usually junction of hard and soft palate (“kissing lesion”) and corners of the mouth
Angular cheilitis
• Red, fissured, scaling lesions at the mouth corners • Common patient: older, with reduced vertical dimension
what bacteria is usually connected with angular chelitis
s. aureus
Cheilocandidiasis
type of angular chelitis Involvement of perioral region, often due to lip or thumb sucking
Denture stomatitis
• Aka chronic atrophic candidiasis • Denture-bearing areas under maxillary removable prosthesis • The fungus shows very little invasion into tissue, and lesion is usually asymptomatic • Heavier fungal colonization on denture than tissue
CHRONIC HYPERPLASTIC CANDIDIASIS
• Aka candidal leukoplakia • White patch cannot be removed by rubbing • May represent secondary candidal infection of a leukoplakic lesion
location of chronic hyper plastic candidiasis and description
• Usually located on anterior buccal mucosa • May be speckled red and white • Hyphae are present • Diagnosis is confirmed by lesion resolution after antifungal therapy
MUCOCUTANEOUS CANDIDIASIS
• Seen within a rare group of immune disorders, usually sporadic or autosomal recessive • Candidiasis of mouth, nails, skin, etc from a young age • Thick white, foul-smelling plaques cannot be rubbed off, but can be controlled throughout life by anti-fungals
which candida may be associated with iron deficiency anemia
MUCOCUTANEOUS CANDIDIASIS
Endocrine-candidiasis syndrome:
• Hypothyroidism • Hypoparathyroidism • Hypoadrenocorticism (Addison’s) • Diabetes mellitus
CANDIDIASIS DIAGNOSIS • Combination of?
Clinical presentation • Exfoliative cytology • Biopsy • Level of response to anti-fungal treatment
CANDIDIASIS TREATMENT • Mucosal Tissue:
• Mycelex troches, 5x/day for 10 days. One in morning, then 30 minutes after each meal, and one more before bed.
treatment for candida on Complete dentures:
• 1 cup of water plus 1 teaspoon bleach, soak denture overnight
tx of candida on partials
• NO bleach. Use Nystatin elixir, 480 mL; place cup in refrigerator and instruct the patient to drop FPD’s in cup each night
