Indian Journal of Pathology and Microbiology

BRIEF COMMUNICATION
Year
: 2015  |  Volume : 58  |  Issue : 4  |  Page : 479--482

Immunofluorescence profile of discoid lupus erythematosus


Shreekant Bharti1, Sunil Dogra2, Biman Saikia1, Ranjana Minz Walker1, Seema Chhabra1, Uma Nahar Saikia3,  
1 Department of Immunopathology, PGIMER, Chandigarh, India
2 Department of Dermatology, PGIMER, Chandigarh, India
3 Department of Histopathology, PGIMER, Chandigarh, India

Correspondence Address:
Dr. Seema Chhabra
Department of Immunopathology, PGIMER, Sector-12, Chandigarh
India

Abstract

The direct immunofluorescence (DIF) of skin in conjunction with histopathology gives the best diagnostic yield. It is invaluable in confirming the diagnosis of small vessel vasculitides and bullous lesions of the skin and can be used as an additional tool to pinpoint the diagnosis of systemic and localized autoimmune diseases involving the skin. This study was undertaken to analyze the strength of DIF vis-à -vis histopathology in the diagnosis of discoid lupus erythematosus (DLE) and at the same time to elaborate the specific immunofluorescence findings in the lesions of DLE. The clinical profile and cutaneous lesions of 75 patients with DLE are described. DIF was positive in 68% and histopathology in 60% of cases. The most common immunoreactant was IgG at the dermoepidermal junction, followed by IgM and IgA. A conclusive diagnosis of DLE could be achieved satisfactorily in 64 cases (85%) by a combination of the two techniques.



How to cite this article:
Bharti S, Dogra S, Saikia B, Walker RM, Chhabra S, Saikia UN. Immunofluorescence profile of discoid lupus erythematosus.Indian J Pathol Microbiol 2015;58:479-482


How to cite this URL:
Bharti S, Dogra S, Saikia B, Walker RM, Chhabra S, Saikia UN. Immunofluorescence profile of discoid lupus erythematosus. Indian J Pathol Microbiol [serial online] 2015 [cited 2019 Dec 9 ];58:479-482
Available from: http://www.ijpmonline.org/text.asp?2015/58/4/479/168850


Full Text

 Introduction



Discoid lupus erythematosus (DLE) comprises 85% cases of cutaneous lupus erythematosus. The classical clinical presentation is a plaque with central depigmentation, surrounding hyperpigmentation with adherent scales, (which on removal show "carpet tack" appearance) with telangiectasia and scarring alopecia.[1] Although the diagnosis of classical DLE is generally clinical, histopathological study of skin biopsy is helpful to confirm the diagnosis in early or atypical DLE lesions and in DLE variants. The histopathological findings in DLE are well described, and there is a paucity of large studies on its direct immunofluorescence (DIF) findings.[2],[3] This retrospective study was undertaken to analyze the role of DIF in the diagnoses of DLE vis-à-vis histopathology examination (HPE) [Table 1].{Table 1}

 Subjects and Methods



Skin biopsies received from dermatology outpatient clinic over a 4-year period with a clinical diagnosis of DLE were included in the study. These biopsies consisted of patients where the clinical presentation of DLE was not classical, such as early DLE lesions, DLE variants, lichen planus (LP) like lesions, and sites involved such as scalp and mucous membranes. Lesional biopsies from all these patients were subjected to routine histopathological and DIF examination. The clinical data were collected from the files of the Department of Dermatology.

The biopsies for histological examination were fixed in 10% buffered formalin and routinely processed for hematoxylin and eosin stain. DIF was done on frozen sections. For DIF study, all the biopsies were obtained in holding fluid (Michel's medium) and stored at 4°C until cut. For the frozen section, the tissue was embedded in optimal cutting temperature medium, and 4–5 µm sections were cut. Two sections were layered on each slide, and the slides were stored at −20°C until they were stained. Optimally, diluted fluorescein isothiocyanate-labeled monospecific immunoglobulins (IgG, IgA, IgM, C3) were layered onto sections. Slides were mounted in buffered glycerin and finally viewed under a Nikon, ultraviolet microscope. DIF patterns were interpreted according to the standard guidelines. The intensity and location of the positive immunoreactants were recorded along with other microscopic findings and then compared with the diagnoses, both clinical and histopathological. The intensity was graded in three levels (+, ++, and +++).

 Results



Clinical details of patients

The ages of onset of disease were 6–65 years (mean, 35.5) and there was a predominance of women in the study population (men: women, 2:3). Clinically, most of the patients presented with erythematous "discoid" plaques. Disseminated lesions were present in 12% of patients without fulfilling criteria for SLE. In a majority of patients (52 out of 75), the site of biopsy was the head-and-neck region and in remaining was upper extremity (9 cases), scalp (8 cases), trunk (5 cases), and lower extremity (1 case). Duration of lesions varied from 2 months to 5 years. Antinuclear antibody (ANA) testing was done in 11 cases only, where it was negative in 8 cases and positive in 3 cases (2 cases with diffuse and one with the mixed pattern on IIF) only.

Direct immunofluorescence results of biopsies

Of total 75 skin biopsy received over this period, DIF was positive in 51 (68%) cases including 3 cases in which a distinction from LP was not possible, neither clinically nor histopathologically. The granular deposits of immunoreactants at the dermoepidermal junction (DEJ), that is, lupus band test (LBT), were noted in 80% (41/51) of cases showing positivity on DIF [Figure 1] and [Figure 2]. Immunofluorescence positivity at civatte bodies (CBs) [Figure 3] was noted in 8 cases (CBs alone in 3 cases, while in 5 cases seen in combination with other patterns) and in all these cases CBs were few in number and were seen in the papillary dermis only with an immunofluorescence intensity of + to ++ with no clustering. Immunofluorescence positivity at superficial blood vessels was noted in 9 cases, but isolated positivity at superficial blood vessels was observed in 4 cases [Table 2]. Epidermal nuclear staining or ANA in vivo [Figure 4] was seen in 5 cases. In patients having positive LBT, the most common immunoreactant at DEJ was IgG, seen in 75% cases, either with other immunoglobulins or complement or alone followed by IgM (70%). Complement C3 and IgA were always found in association with one or other antibodies as shown in [Table 3]. Brightest intensity (+++) was noted for immunoreactant IgG. Combinations of various types of immunoreactants at DEJ were seen in 26 of 41 (63%) cases. LBT involving more than 3 immunoreactants was noted in 17/41 (41%) cases. DIF was clearly negative in 24 cases (32%).{Figure 1}{Figure 2}{Figure 3}{Table 2}{Figure 4}{Table 3}

Histopathological examination results of biopsies

HPE showed characteristic features of DLE in 45 cases (60%). Epidermal changes included hyperkeratosis with follicular plugging (80%), basal cell vacuolization (89%), basement membrane thickening (32%), and thinning and flattening of stratum malpighii (19%). The dermis showed moderate-to-dense periappendigeal and perivascular lymphocytic inflammatory cell infiltrates in all cases. Histopathology showed features other than DLE in 30 cases [Table 1].

Comparison of direct immunofluorescence results with histopathological findings

Diagnostic specificity and a positive predictive value of both methods were maximal (100%), but DIF showed greater diagnostic sensitivity compared to HPE (79.68% vs. 70.31%) with a negative predictive value being 45.8% for DIF and 36.66% for HPE.

 Discussion



The age of onset of DLE in our series was similar to the ones in reports compiled by others.[4],[5],[6] The female preponderance seen in this study is consistent with other studies [5],[6] but some of the studies have shown male predominance in their study cohort.[4] Hormonal factors such as estrogen are considered additional risk factors in females.

DIF positivity was observed in 68% cases in our cohort. The reasons for the biopsies to be negative on DIF may be several, including duration and type of lesions, their anatomic distribution (sun exposed or unexposed or truncal) and previous treatment.[3] In the present retrospective study, these factors could not be analyzed. Moreover, in some of the cases, the clinical diagnosis of DLE was not certain.

The DIF and HPE results of our study are in accordance with other studies.[4],[5],[6],[7],[8] The initial studies by Tuffanelli [5] showed DIF positivity in more than 90% of cases; however, the most recent studies have shown lower frequencies of positive results ranging from 58% to 79%.[4],[6],[7],[8]

IgG was found to be the most commonly deposited immunoreactant (77% cases) as noted by George et al.[4] (80% of cases) and Al-Suwaid et al. (77.8% of cases).[6] The frequency of different immunoreactants and the morphological patterns observed in our study are in accordance with the observations made by others.[6]

The comparison of the two diagnostic techniques showed that the sensitivity of DIF alone was significantly greater than that of histopathology alone as shown above. And a conclusive diagnosis of DLE could be achieved satisfactorily in 64 cases (85%) by a combination of the two techniques (with one or both methods giving characteristic findings). Thus, the yield of combined sensitivity of both techniques together was greater than either of the two techniques separately. George et al.[4] demonstrated that the combination of the results of DIF and HPE correctly diagnosed DLE in 83% of cases and Naqqash et al. showed the same finding in 85% of cases.[8] This justifies the adjunctive role of DIF in skin biopsy of DLE to HPE. So, we concur with the view that DIF should always be performed in conjunction with conventional histology to boost sensitivity and specificity of diagnosis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Prystowsky SD, Gilliam JN. Discoid lupus erythematosus as part of a larger disease spectrum. Correlation of clinical features with laboratory findings in lupus erythematosus. Arch Dermatol 1975;111:1448-52.
2Crowson AN, Magro C. The cutaneous pathology of lupus erythematosus: a review. J Cutan Pathol 2001;28:1-23.
3Sampaio MC, de Oliveira ZN, Machado MC, dos Reis VM, Vilela MA. Discoid lupus erythematosus in children – A retrospective study of 34 patients. Pediatr Dermatol 2008;25:163-7.
4George R, Mathai R, Kurian S. Cutaneous lupus erythematosus in India: immunofluorescence profile. Int J Dermatol 1992;31:265-9.
5Tuffanelli DL. Cutaneous immunopathology: recent observations. J Invest Dermatol 1975;65:143-53.
6Al-Suwaid AR, Venkataram MN, Bhushnurmath SR. Cutaneous lupus erythematosus: comparison of direct immunofluorescence findings with histopathology. Int J Dermatol 1995;34:480-2.
7Nieboer C. The reliability of immunofluorescence and histopathology in the diagnosis of discoid lupus erythematosus and lichen planus. Br J Dermatol 1987;116:189-98.
8Naqqash S, Asad F, Pal SS. Direct immunofluorescence and histopathology in chronic discoid lupus erythematosus. J Pak Assoc Dermatologists 2011;21:98-101.