COM October 2005

This is a 39-year-old white female who first noticed a few nonhealing oral ulcers that started at the end of 2004. They included generalized gingiva (both maxilla and mandible) (Fig 1) and progressively worsened to involve the palate and floor of mouth. The oral ulcerative lesions were associated with severe pain. In early May 2005, she presented to the University of Washington Oral Medicine Clinic for an evaluation at which she was referred to the Department of Oral Surgery for a biopsy, which was submitted for both light H & E histology and direct immunofluorescence studies. She denied any skin changes, swallowing problems, throat soreness, chest pain, chest fullness, or any vaginal or anal lesions. Her last visit to her gynecologist was in April 2005, and the results were normal. Based on the pathology report, she was referred to a dermatologist who placed her on steroid treatment.

Figure 1. This is a clinical view of the lesion at presentation demonstrating generalized ulcerative gingivitis “desquamative gingivitis” on the facial maxillary and mandibular gingiva.

She has a history of genital herpes. Her past medical and family history is otherwise negative for any blistering skin or mucosal diseases and is negative for any known allergies.

The patient exhibited a positive Nikolsky sign where separation of the epithelium from the connective tissue was evident. The ulcerative lesions included generalized gingiva (maxilla and mandible) (Fig 1), floor of mouth and palate. There was no evidence of true vesicles or bullae formation.

Figure 1. This is a clinical view of the lesion at presentation demonstrating generalized ulcerative gingivitis “desquamative gingivitis” on the facial maxillary and mandibular gingiva.

The formalin-fixed and hematoxylin- and eosin-stained sections showed evidence of supra-basilar epithelial separation (Fig 2) with acantholysis (Fig 3) releasing a few Tzanck cells. The immunofluorescence antibody stain revealed positive staining with IgG (Fig 4) and C3 (Fig 5) antibodies in arranged in a fishnet pattern within the spinous layer cells.

Figure 2. Low power (x100) view of a hematoxylin and eosin stained tissue section demonstrating a clear supra basilar epithelial split.

Figure 3. Low power (x100) view of a hematoxylin and eosin stained tissue section demonstrating a supra basilar epithelial split and acantholysis.

Figure 4. Low power (x200) view of a direct Immunoflourescent stain demonstrating positive staining with IgG antibody with a fishnet appearance.

Figure 5. Low power (x100) view of a direct Immunoflourescent stain demonstrating positive staining with C3 antibody with a fishnet appearance.