38 Tzanck Smear, Auspitz Sign, Nikolsky Sign, Le Cell $ Koebners Phenonmenon d5128

SUBMITTED BY: KRITIKA KOUL BDS 3rD YEAR ROLL NO 38

Skin lesions and oral lesions in particular may be identified as viral diseases by cytologic smears and finding of characterstic multinucleated giant cells and intranuclear inclusions known as tzanck test.

TZANCK SMEAR IS DONE IN :  Viral infections  HERPES SIMPLEX  VARICELLA AND HERPES ZOSTER  CYTOMEGALOVIRUS  Vesiculobullous lesions  PEMPHIGUS VULGARIS  PEMPHIGOIDS

FEATURES OF HERPES SIMPLEX:  MULTINUCLEATED CELLS  BALOONING DEGENERATION  LIPSCHUTZ BODIES

 INTRANUCLEAR INCLUSION BODIES  EOSINOPHILIC OVOID AND

HOMOGENOUS STRUCTURE WITHIN NUCLEUS

HISTOPATHOLOGY:  INTRAEPITHELIAL

VESICLE FORMATION  ACANTHOLYSIS  BALOONING DEGENRATION  MULTINUCLEAR GIANT CELLS

Definition: It is a cutaneous response seen in dermatoses, which appears on uninvolved skin of lesions typical of the skin disease at the site of trauma or scars. •Sometimes just rubbing the skin can cause a lesion to develop.

Koebner's phenomenon is seen most often in psoriasis, eczema, lichen planus, and vitiligo. Also Known As: isomorphic phenomenon, isomorphic reaction

Koebner’s phenomenon in psoriasis vulgaris

What traumas can trigger the Koebner phenomenon? Various traumas can trigger this response:Abrasions Lacerations Burns Scars dermatitis

 In the case of psoriasis, lesions due to the Koebner

phenomenon may be concentrated on pressure areas.  Sunburn can also lead to psoriasis spreading massively

over the body, known as the photo Koebner phenomenon.  Many dermatoses can cause the Koebner

phenomenon, including psoriasis, dermatitis, eczema, herpes, lichen planus, chickenpox and vitiligo.

FEATURES  There is no effect of sex and age distribution in

koebner’s phenomenon.  Fresh lesions may appear on scratch marks or at sites of other non-specific traumas.(Koebner phenomenon)

KOEBNER’S PHENOMENON IN LICHEN PLANUS

Definition: The Auspitz sign is simply bleeding that occurs after psoriasis scales have been removed. It occurs because the capillaries run very close to the surface of the skin under a psoriasis lesion, and removing the scale essentially pulls the tops off the capillaries, causing bleeding. also found in Darier's disease and actinic keratos

 Auspitz’ Sign can be used as a diagnostic tool for

psoriasis.  The combination of inflamed, thickened skin with silvery scales and Auspitz’ Sign, however, appears to be unique to psoriasis.

SAME PATIENT WITH AUSPITZ SIGN ON HAND

Autoimmune skin disorders sometimes are characterized by acantholysis , or loss of the normal epithelial cell-to-cell adhesion within the skin. Clinically, these disorders present with blistering of the skin and include the pemphigus and pemphigoid groups of disorders. On visual inspection only, these skin conditions are difficult to diagnose and may be confused with other types of skin disorder.

Nikolsky’s sign is a well-described clinical sign that can be helpful in differentiating the autoimmune skin disorders and determining their prognosis.

ELICITATION  Positive Nikolsky’s sign included the ability to

dislodge both affected skin (i.e , skin within or immediately adjacent to pemphigus lesions) and normal skin.  It helps to differentiate as it occurs in pemphigus foliaceus and not pemphigus vulgaris because, in the latter disorder, unaffected normal skin could not be removed by lateral pressure.

NIKOLSKY’S SIGN IN PEMPHIGUS Elicitation: Apply pressure to the affected skin (eg , where a blister is located), perilesional skin, or normal skin in patients with suspected pemphigus. Positive Response: There is extension of the blister and/or removal of epidermis in the area immediately surrounding the blister.

Elicitation of Nikolsky’s sign.

PATHOPHYSIOLOGY: Primary histologic finding in patients with pemphigus is acantholysis with the occurrence of suprabasal epidermal / intraepidermal splits . These events presumably contribute to the epidermal separation , characteristic of a positive Nikolsky’s sign.

CLINICAL SIGNIFICANCE OF NIKOLSKY’S SIGN  In general, Nikolsky’s sign has been considered very

useful in differentiating the bullous skin diseases.  Specifically, elicitation of the sign can help distinguish pemphigus vulgaris, which is strongly associated with the sign, from bullous pemphigoid, in which the sign is usually absent.

 There are a number of other diseases associated

with a positive Nikolsky’s sign.  toxic epidermal necrolysis,  staphylococcal scalded skin syndrome,  bullous impetigo, and  epidermolysis bullosa all, can exhibit the sign.

LE CELL: These are cell , which appears i n blood of patients with Systemic Lupus Erythematous

(SLE). The LE cell is a result of an immunological mechanism where nucleoprotein or part (but not DNA) can be regarded as the Ag and LE cell factor as an Ab.

PRINCIPLE:  The test is based on the principle that ANA’s (Anti

Nuclear Antibodies) can’t penetrate the intact cells & thus cell nuclei s/b exposed to bind them with the ANA’s . The binding of exposed nucleus with ANA’s result in homogenous mass of nuclear chromatin material which is c/d LE body or haematoxylin body.

Procedure  Blood from SLE suspected patient is withdrawn  It is centrifuged to separate serum  This serum is added to buffy coat of blood from

normal person  Observed under microscope  Positive reaction consists of rosettes of neutrophils surrounding the nuclear material from a lymphocytes

Morphology and histo-chemical studies  Blood is drawn from patient of SLE and allowed to stand for a matter of minutes.  LE cells began to appear ( LE cell phenomenon ).

 It results from the action upon leukocytes of a substance in patient’s serum which migrates on electrophoresis .  This results in binding of denatured & damaged nucleus with ANA’S.

 The ANA-coated denatured nucleus is chemotactic for phagocytic cells. If this mass is engulfed by a neutrophil , displacing the nuclei of neutrophil to the rim of the cell, it is c/d LE cell. If the mass , more often an intact lymphocyte is phagocytosed by a monocyte, it is c/d TART cell.

 These altered nuclei then extruded from the cell and are phagocytized by other viable leukocytes.  The altered nuclei in their cytoplasm, are the LE cells.

CLINICAL FEATURES:  LE cell is +ve in 70% cases of SLE. While newer &

more sensitive immunoflourescence tests for AutoAb Are +ve in almost 100% of cases of SLE.  Other conditions showing +ve LE test Rheumatoid arthritis Lupoid hepatitis Penicillin sensitivity