Pemphigus Vulgaris of Skin: Cytological Findings and Pitfalls

Abstract

Background: Pemphigus vulgaris (PV) is an autoimmune bullous lesion of the skin and mucous membranes characterized by suprabasal clefting and acantholysis. The responsible autoantibody is desmoglein 3, a protein constituent of the desmosome. The diagnosis of PV is based on histological examination and immunofluorescence study. In addition, cytological smears could also be informative for the initial diagnosis of PV. Cases: Fifteen patients, 7 men and 8 women, with skin bullous disease clinically suspected of being PV were selected for cytological study. The bullae were ruptured and two smears were prepared from the fluid and stained with the Wright-Giemsa and Papanicolaou methods. The smears were taken from both new and old bullae. They showed acantholytic cells (Tzanck cells), some with amoeboid-like cytoplasmic projections, eosinophils, basophils, various forms of typical and atypical lymphocytes with irregular nuclear borders and cerebriform nuclei and dysplastic acantholytic cells with a high nucleo-cytoplasmic ratio and prominent nucleoli. The dysplastic cells were seen only in the old bullae. Histological examination and immunofluorescence study of the lesions confirmed the diagnosis of PV. Conclusion: PV can be diagnosed by cytology. Without a clinical history of PV, the presence of atypical lymphocytes and dysplastic cells may lead to a false diagnosis of malignancy.

Atypical Tzanck smear findings in pemphigus vulgaris

“…Dear Editor, Pemphigus vulgaris (PV) is an autoimmune bullous disease of the skin and mucous membranes characterised by suprabasal clefting and acantholysis. The diagnosis of PV is based on routine histological examination and an immunofluorescence test . A Tzanck smear can also be informative in the initial diagnosis of PV.…”

“…The main characteristic cytological finding of PV is the presence of acantholytic cells, which are large round keratinocytes with a hypertrophic nucleus, perinuclear halo and abundant basophilic cytoplasm . Sometimes, atypical lymphocytes and dysplastic cells mimicking malignancy may be seen in PV , …”

An Uncommon Ocular Manifestation of Pemphigus Vulgaris: Conjunctival Mass

“…8 However, as stated by some authors, diagnosis based on medical history, clinical findings, and histopathology seemed satisfactory in the current case. 9 Usually histopathology is not needed in cases with ocular PV associated with classical presentation, including conjunctivitis, blepharitis, mucous discharge, blisters, and eventually erosions. However, mass lesion on the bulbar or palpebral conjunctiva (with or without corneal involvement) in a patient with PV warrants histopathologic confirmation to differentiate it particularly from conjunctival tumors.…”

Oral pemphigus vulgaris: Liquid‐based cytological findings and pitfalls

“…However, the final diagnosis of PV needs to be confirmed by a histological examination and immunofluorescence study 1, 5, 6. The main characteristic associated with PV cytopathologic findings is the presence of acantholytic cells.…”

“…The main characteristic associated with PV cytopathologic findings is the presence of acantholytic cells. The characteristics of these so called Tzanck cells are well known, as they exhibit strong perinuclear acidophilic staining 5, 6…”