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Development of oral lesions in erythema multiforme exudativum
Development of oral lesions in erythema multiforme exudativum
I PATIENT 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22
TISSUE INVOLVED
) ORAL ii++ ii ++ +++ ++++ ++++ ++++ ++++ ++++ +++ +++ ++ +++ ++++ +++ ++ ++++ ii+ +++ ++++ +++ ++
OCULAR
NASAL
GENITAL
ii 0 + ++ ++ ++ ii ++ ++ + 0 0 + ++ + + + + ii+ + + 0
+ 0 0 0 0 + + 0 + + 00 0 0 + 0 + +
+ ii ++ ++ +++ ++ ++++ +++ + + 0 0 0 ++ ++ ++ ii 0 0 0 0 0
;: 0 + 0
COURSE
I
ANAL 0 0 0 I0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
CUTANEOUS
JOINT
j SEVERE
+ ++ ++++ ++ ++ ++ 0 0 ++ 0 + ++++ + 0 0 0 0 0 0 0 0 0
0 + 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
++ +
MILD
+ ++ +++ +++ +++ +++ ++ + + + ++ +++ ++ + +++ ++ ++ ++ ++ +
The fiwt, 01’ n~tr~/nt~, stagtl is r*ar~ll~-s(‘~rr I)(‘cir\rsc ol’ its early appearance ant1 its short dnr;rtion. Xost, oi’tcn the macular stage has hcer~ cwnplctcd 1wI’ow tlro patient seeks treatment. \\‘hcn sren, the initial lesion is an isoliltd, small ( 1 to :3 mm.), noniirduratctl red maculc. It. may progrws slightly in size and clcrelop ii whitish ctwtcr that r~wmbl~~s the typical cntancwus target lesion and can be slightly raised. (Fig. 2, .I). This Stage IilStS Ollly il l’CW hOlll.Y, as it Elpitll? prug~~~ssrs to a bnllons formation. The microscopic findings (Fig. 3 ) arca those of beginning infiltration of miucd leukocytes and significant, rngorgement of the SIlh,jiI?cIlt blood \-essels. Most, important aYe the changes within the epitlielium. Considerable intracellular hydropic drgeneration is noted resulting in ballooning oI’ thv c~ells involved. in some areas the balloonrd c~clls have coalwced to form trriwocysts. (~onwivat)l,v this could 1w seen as tlrc p~~~~nrw~ of the bullons stage which results from prvgwssion of the lr~dropic deg::crl(~l2tiorl to inicwwyst and rvrntilally to drvc~lopctl hllons lcsioris.
Piy. 3. The histologic appearance of the macular stage illustrates the hydropic degeneration and microcyst formation in the epithelium and vascular engorgemcnt of lamina propria. Some inflammatory infiltrate is noted, hut it is not yet sevcrc. Fiq. 4. The bulla is seen histologically to contain considerable hemorrhagic elements. The epithehum separated by the hulla is thwned, resu1tin.g from loss of the basal and lower germinal layers of cells. Note the formation of many mlcrocystw in tbc cpithelium. Prripheral to the bulla, basal-cell degeneration is seen and resulting separation of epithelium ant1 lamina propria is not,ed. Inflammatory infiltration is much more marked at this time.
frown tile lamina propria. This appearance gives histologic support to the clinical propensity of the epithelium to slough in sheetlike proportions without the necessity for prior bullous formation under all areas involved. Because of the rapid progression of the macular and bullous stages, the .slo*tighing stage is frequently the first stage seen by the examiner. It is due to the devitalization of the epithelium caused by separation from its nourishment cpithelium
Pip.
P
ot’ the devitalized mucosal c~l)ithclium. the drnndctl I issur exudes il tiltrirlolls exudate saturated with IcukocTy& which (~ovcrs and protects the tissw until Nepithclization occurs, a process that normally takes 5 to X days (Fig. 7 1. ‘l’h(~ PSIIdate may be almost transparcwt, or it nlav be white and opaque. If whittl. it tends to he mottled with areas of henlorrhagc or minor ulcera.tions (Fig. S,I. I)uring this st,agc the: pseudomembrane 11I’ prottvtiw exudate Can be wiped off, leaving thv denuded tissue exposed. It nl;~y I)(~ quite hemorrhagic*, depending upon lesiotl I,>rlepth and the stage of rc-epit llclization. TVpon 10s~ of’ thy pSelxcioJll(~JnhriJ?l(~ either artificial or natural IIIC’~~S, ;I IICW one is recreated in the sanle n1anIl(‘r ;Is the origina. if prot,eetion is sl ill newswry. After suficic>nt, epithclium has formrcl under this protect,iw cowr. 1 tit’ Illcl~lbJ~arlc~ Will rlOt rr-farrrl. ‘~‘his stage is seen microscopically to be ~w\~~~IYYI with a \~ariablt~ thickness of lvllkocytt~-inpregnatetl fibrinous exudate nntlvr \vhicJh cndothclial proliferation arrcl pro~~~~sses of tissue repair are a&w. A clc~riw infiltration of chronir inflammatory c*ells is still noted. kLlthOUg’:‘iJ JlOt illlIst I’ittPcl 11~1’~. (~pith(~~iz~It iofl is ilJI iJltc’gJ’;li [)iII’t 01 this stage (Fig. Cj1.
Fig. 9. The fibrinous leukwytic exudate that clinically covers this tissue is seersas an avascular zone containing many polymorphonuclear leukocytes enmeshed in a fibrinous matrix. Jn the lamina propria, endothelial proliferation and the processes of repair aw seen to bc active.
are more advanced in forming pvotectirc epithrlium while the more. erythemat,ous areas are still building their epithelial covering (Fig. 10). Evenball?, the mucous membrane will achier-e a homogenous appearance and resume its original texture (Fig. 11). Scarring occurs occasionally Iwt is not predominant. Microscopically, several different stages of rpithelixation can lx identified (Fig. I“- 1. DISCUSSION
I
Fiy. healing and red lesion. Pig. achieved
Pig.
10
Piu.
11
10. The healing stage shows a mottled geographic appcaranw of varying degrees of and rc-epithelization. Awas of white epit,hclial tissw are swn to contrast ag-ainst pink areas of lesser healing. The photograph was taken 15 days after eruption of the fiwt lf. Tw(lnty-four days after appearnnre a normal homogenous murosa.
of tlrc initial
1~5ions, this patiwt’s
mouth hat1
SUMMARY
REFERENCES
I PATIENT 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22
TISSUE INVOLVED
) ORAL ii++ ii ++ +++ ++++ ++++ ++++ ++++ ++++ +++ +++ ++ +++ ++++ +++ ++ ++++ ii+ +++ ++++ +++ ++
OCULAR
NASAL
GENITAL
ii 0 + ++ ++ ++ ii ++ ++ + 0 0 + ++ + + + + ii+ + + 0
+ 0 0 0 0 + + 0 + + 00 0 0 + 0 + +
+ ii ++ ++ +++ ++ ++++ +++ + + 0 0 0 ++ ++ ++ ii 0 0 0 0 0
;: 0 + 0
COURSE
I
ANAL 0 0 0 I0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
CUTANEOUS
JOINT
j SEVERE
+ ++ ++++ ++ ++ ++ 0 0 ++ 0 + ++++ + 0 0 0 0 0 0 0 0 0
0 + 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
++ +
MILD
+ ++ +++ +++ +++ +++ ++ + + + ++ +++ ++ + +++ ++ ++ ++ ++ +
The fiwt, 01’ n~tr~/nt~, stagtl is r*ar~ll~-s(‘~rr I)(‘cir\rsc ol’ its early appearance ant1 its short dnr;rtion. Xost, oi’tcn the macular stage has hcer~ cwnplctcd 1wI’ow tlro patient seeks treatment. \\‘hcn sren, the initial lesion is an isoliltd, small ( 1 to :3 mm.), noniirduratctl red maculc. It. may progrws slightly in size and clcrelop ii whitish ctwtcr that r~wmbl~~s the typical cntancwus target lesion and can be slightly raised. (Fig. 2, .I). This Stage IilStS Ollly il l’CW hOlll.Y, as it Elpitll? prug~~~ssrs to a bnllons formation. The microscopic findings (Fig. 3 ) arca those of beginning infiltration of miucd leukocytes and significant, rngorgement of the SIlh,jiI?cIlt blood \-essels. Most, important aYe the changes within the epitlielium. Considerable intracellular hydropic drgeneration is noted resulting in ballooning oI’ thv c~ells involved. in some areas the balloonrd c~clls have coalwced to form trriwocysts. (~onwivat)l,v this could 1w seen as tlrc p~~~~nrw~ of the bullons stage which results from prvgwssion of the lr~dropic deg::crl(~l2tiorl to inicwwyst and rvrntilally to drvc~lopctl hllons lcsioris.
Piy. 3. The histologic appearance of the macular stage illustrates the hydropic degeneration and microcyst formation in the epithelium and vascular engorgemcnt of lamina propria. Some inflammatory infiltrate is noted, hut it is not yet sevcrc. Fiq. 4. The bulla is seen histologically to contain considerable hemorrhagic elements. The epithehum separated by the hulla is thwned, resu1tin.g from loss of the basal and lower germinal layers of cells. Note the formation of many mlcrocystw in tbc cpithelium. Prripheral to the bulla, basal-cell degeneration is seen and resulting separation of epithelium ant1 lamina propria is not,ed. Inflammatory infiltration is much more marked at this time.
frown tile lamina propria. This appearance gives histologic support to the clinical propensity of the epithelium to slough in sheetlike proportions without the necessity for prior bullous formation under all areas involved. Because of the rapid progression of the macular and bullous stages, the .slo*tighing stage is frequently the first stage seen by the examiner. It is due to the devitalization of the epithelium caused by separation from its nourishment cpithelium
Pip.
P
ot’ the devitalized mucosal c~l)ithclium. the drnndctl I issur exudes il tiltrirlolls exudate saturated with IcukocTy& which (~ovcrs and protects the tissw until Nepithclization occurs, a process that normally takes 5 to X days (Fig. 7 1. ‘l’h(~ PSIIdate may be almost transparcwt, or it nlav be white and opaque. If whittl. it tends to he mottled with areas of henlorrhagc or minor ulcera.tions (Fig. S,I. I)uring this st,agc the: pseudomembrane 11I’ prottvtiw exudate Can be wiped off, leaving thv denuded tissue exposed. It nl;~y I)(~ quite hemorrhagic*, depending upon lesiotl I,>rlepth and the stage of rc-epit llclization. TVpon 10s~ of’ thy pSelxcioJll(~JnhriJ?l(~ either artificial or natural IIIC’~~S, ;I IICW one is recreated in the sanle n1anIl(‘r ;Is the origina. if prot,eetion is sl ill newswry. After suficic>nt, epithclium has formrcl under this protect,iw cowr. 1 tit’ Illcl~lbJ~arlc~ Will rlOt rr-farrrl. ‘~‘his stage is seen microscopically to be ~w\~~~IYYI with a \~ariablt~ thickness of lvllkocytt~-inpregnatetl fibrinous exudate nntlvr \vhicJh cndothclial proliferation arrcl pro~~~~sses of tissue repair are a&w. A clc~riw infiltration of chronir inflammatory c*ells is still noted. kLlthOUg’:‘iJ JlOt illlIst I’ittPcl 11~1’~. (~pith(~~iz~It iofl is ilJI iJltc’gJ’;li [)iII’t 01 this stage (Fig. Cj1.
Fig. 9. The fibrinous leukwytic exudate that clinically covers this tissue is seersas an avascular zone containing many polymorphonuclear leukocytes enmeshed in a fibrinous matrix. Jn the lamina propria, endothelial proliferation and the processes of repair aw seen to bc active.
are more advanced in forming pvotectirc epithrlium while the more. erythemat,ous areas are still building their epithelial covering (Fig. 10). Evenball?, the mucous membrane will achier-e a homogenous appearance and resume its original texture (Fig. 11). Scarring occurs occasionally Iwt is not predominant. Microscopically, several different stages of rpithelixation can lx identified (Fig. I“- 1. DISCUSSION
I
Fiy. healing and red lesion. Pig. achieved
Pig.
10
Piu.
11
10. The healing stage shows a mottled geographic appcaranw of varying degrees of and rc-epithelization. Awas of white epit,hclial tissw are swn to contrast ag-ainst pink areas of lesser healing. The photograph was taken 15 days after eruption of the fiwt lf. Tw(lnty-four days after appearnnre a normal homogenous murosa.
of tlrc initial
1~5ions, this patiwt’s
mouth hat1
SUMMARY
REFERENCES