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Langerhans cells with monoclonal antibody Lag
Volume 20 Number 4 April 1989
Correspondence
securely receive the metal hub of a disposable hypodermic needle.
Jack E. Sebben, AID University of California at Davis Davis, CA 95616
pmritic urticarial papules and plaques of pregnancy only when the results of direct immunofluorescence are negative.: It might be preferable to spend money if this contributes to the proper diagnosis and proper care for only a few cases. I am confident that Dr. Goodall has automobile insurance but still does not have a crash every week--is that a waste of money?
Immunofluorescence biopsy for pruritic urticarial papules and plaques of pregnancy To the Editor." Goodall suggested that performing immunofluorescence biopsy for clinically typical pruritic urticarial papules and plaques of pregnancy to rule out the slight possibility of herpes gestationis is a waste of money (J AM ACAD DERMXTOL 1988;18:1146). This was appropriately challenged by J. K. Shomick in his reply. I share the opinion of Dr. Shomiek, which has recently been supported in my department by an incident that occurred before the letter was published in the JOUP.NAL;thus Dr. Goodall cannot be considered responsible. We have been routinely using direct immunofluorescence assays in all cases of putative pruritie urticarial papules and plaques of pregnancy for many years, and of more than 100 we have picked up two cases of herpes gestationis. Recently, a resident whose beliefs were presumably similar to those of Goodall decided not to comply with departmental policy when he saw a young primiparous woman with what he interpreted as pruritic urticarial papules and plaques of pregnancy. He prescribed topical steroids and did not perform direct immunofluorescence assays, nor did he draw blood for herpes gestationis factor. The delivery was normal, as was the baby. When the child was 3 months old a widespread buUous eruption developed that fulfilled the clinical, histologic, and direct and indirect immunofluorescence criteria for bullous pemphigoid. Western blot analysis showed antibodies to a 180-kilodalton protein in the child's serum, whereas the mother's serum was negative for this test, as well as for indirect immunofluorescence. The child's bullous disease responded to sulfapyridine and did not recur after the drug was stopped and at 1-year follow-up. The question we are facing now is whether the child had transmitted herpes gestationis or de novo bullous pemphigoid because the buUous disease began at 3 months, not at birth; this is discussed elsewhere. I If the resident had performed direct immunofluorescence assays during pregnancy, we would now be more comfortable advising the mother about a future pregnancy. We are hoping that such a pregnancy will result from the same father so that we may have the answer. I think this case strongly supports Dr. Shornick's statement that direct immunofluorescence confirmation of pruritic urticarial papules and plaques of pregnancy should always be obtained. I make the diagnosis of
711
J.-H. Saurat, MD Hbpital Cantonal Universitaire, 1211 Geneva 4, Switzerland
REFERENCES 1. Abba Z, Harms M, Didierjean L, Saurat JH. PemphigoYde bulleuse chez un enfant de 3 mois.Ann Dermatol Venereol [In press]. 2. Saurat JH. Les dermatoses prurigineusesde la grossesse:la "PUPPP" existe-t-elle? Ann Dermatol Venereol 1982; 109:691-3.
Langerhans cells with monoclonal antibody Lag To the Editor." ] read with interest the study of Langerhans cell histiocytosis with the monoclonal antibody Lag, which reacts to an antigen localized in the membrane of Birbeck granules and related structures (J AM ACAD DERMATOL1988;18:646-54). I was not surprised to learn that Lag stained almost all T6-positive cells in skin lesions but only 70% of those in diseased lymph nodes. It is well recognized, although not welldocumented, that the presence of Birbeck granules in Langerhans ceil histiocytosis cells depends on the site of the lesion. Birbeck granules are seen in lymph node lesions but are not found as readily as in skin lesions. Birbeck granules are extremely rare in T6-positive Langerhans cell histioeytosis ceils in liver or spleen, even in those patients with otherwise identical cells that contain granules at other sites. 1 It would be interesting to confirm that Langerhans cell hisfiocytosis cells in liver and spleen fail to stain with the Lag antibody. It seems likely that the presence or absence of Birbeck granules in Langerhans cell histiocytosis cells is related to local factors at the site of the lesion rather than being evidence of two different cell populations, as was suggested in the article. Janet McLelland, MRCP The Royal Victoria Infirmary Newcastle upon Tyne NE1 4LP United Kingdom
REFERENCES 1. Favara BE, Jaffe R. Pathology of Langerhans cell histiocytosis. In: Oshand ME, Pochedly C, eds. HistiocytosisX. Philadelphia: WB Saunders, 1987;75-98.
Correspondence
securely receive the metal hub of a disposable hypodermic needle.
Jack E. Sebben, AID University of California at Davis Davis, CA 95616
pmritic urticarial papules and plaques of pregnancy only when the results of direct immunofluorescence are negative.: It might be preferable to spend money if this contributes to the proper diagnosis and proper care for only a few cases. I am confident that Dr. Goodall has automobile insurance but still does not have a crash every week--is that a waste of money?
Immunofluorescence biopsy for pruritic urticarial papules and plaques of pregnancy To the Editor." Goodall suggested that performing immunofluorescence biopsy for clinically typical pruritic urticarial papules and plaques of pregnancy to rule out the slight possibility of herpes gestationis is a waste of money (J AM ACAD DERMXTOL 1988;18:1146). This was appropriately challenged by J. K. Shomick in his reply. I share the opinion of Dr. Shomiek, which has recently been supported in my department by an incident that occurred before the letter was published in the JOUP.NAL;thus Dr. Goodall cannot be considered responsible. We have been routinely using direct immunofluorescence assays in all cases of putative pruritie urticarial papules and plaques of pregnancy for many years, and of more than 100 we have picked up two cases of herpes gestationis. Recently, a resident whose beliefs were presumably similar to those of Goodall decided not to comply with departmental policy when he saw a young primiparous woman with what he interpreted as pruritic urticarial papules and plaques of pregnancy. He prescribed topical steroids and did not perform direct immunofluorescence assays, nor did he draw blood for herpes gestationis factor. The delivery was normal, as was the baby. When the child was 3 months old a widespread buUous eruption developed that fulfilled the clinical, histologic, and direct and indirect immunofluorescence criteria for bullous pemphigoid. Western blot analysis showed antibodies to a 180-kilodalton protein in the child's serum, whereas the mother's serum was negative for this test, as well as for indirect immunofluorescence. The child's bullous disease responded to sulfapyridine and did not recur after the drug was stopped and at 1-year follow-up. The question we are facing now is whether the child had transmitted herpes gestationis or de novo bullous pemphigoid because the buUous disease began at 3 months, not at birth; this is discussed elsewhere. I If the resident had performed direct immunofluorescence assays during pregnancy, we would now be more comfortable advising the mother about a future pregnancy. We are hoping that such a pregnancy will result from the same father so that we may have the answer. I think this case strongly supports Dr. Shornick's statement that direct immunofluorescence confirmation of pruritic urticarial papules and plaques of pregnancy should always be obtained. I make the diagnosis of
711
J.-H. Saurat, MD Hbpital Cantonal Universitaire, 1211 Geneva 4, Switzerland
REFERENCES 1. Abba Z, Harms M, Didierjean L, Saurat JH. PemphigoYde bulleuse chez un enfant de 3 mois.Ann Dermatol Venereol [In press]. 2. Saurat JH. Les dermatoses prurigineusesde la grossesse:la "PUPPP" existe-t-elle? Ann Dermatol Venereol 1982; 109:691-3.
Langerhans cells with monoclonal antibody Lag To the Editor." ] read with interest the study of Langerhans cell histiocytosis with the monoclonal antibody Lag, which reacts to an antigen localized in the membrane of Birbeck granules and related structures (J AM ACAD DERMATOL1988;18:646-54). I was not surprised to learn that Lag stained almost all T6-positive cells in skin lesions but only 70% of those in diseased lymph nodes. It is well recognized, although not welldocumented, that the presence of Birbeck granules in Langerhans ceil histiocytosis cells depends on the site of the lesion. Birbeck granules are seen in lymph node lesions but are not found as readily as in skin lesions. Birbeck granules are extremely rare in T6-positive Langerhans cell histioeytosis ceils in liver or spleen, even in those patients with otherwise identical cells that contain granules at other sites. 1 It would be interesting to confirm that Langerhans cell hisfiocytosis cells in liver and spleen fail to stain with the Lag antibody. It seems likely that the presence or absence of Birbeck granules in Langerhans cell histiocytosis cells is related to local factors at the site of the lesion rather than being evidence of two different cell populations, as was suggested in the article. Janet McLelland, MRCP The Royal Victoria Infirmary Newcastle upon Tyne NE1 4LP United Kingdom
REFERENCES 1. Favara BE, Jaffe R. Pathology of Langerhans cell histiocytosis. In: Oshand ME, Pochedly C, eds. HistiocytosisX. Philadelphia: WB Saunders, 1987;75-98.