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The oral lesions of pemphigus vulgaris
Oral pathology American
Academy
of Oral
Pathology
Donald Kerr, Editor
The oral lesions of pemphigus vulgaris Histochemical
observations
Gerald Shkikr, DEPARTMENT
D.D.X., M.X., Boston, Mass. OF
ORAL
PATHOLOGY,
TUFTS
UNIVERSITY
SCHOOL
OF
DENTAL
MEDICINE
T
he microscopic features of pemphigus have been described in a number of excellent recent studies. The works of Rook and Whimster,l Lever,2 and Director3 served to confirm Civatte’# original findings that the major alteration found in lesions of pemphigus was the presence of acantholysis, a sepa,ration of epithelial cells of the epidermis due to dissolution or loss of the intercellular bridges. In the early stages of vesicle formation in pemphigus, there is intercellular edema within the stratum germinativum and lower stratum spinosum. This initial pathologic change is followed by the development of horizontal clefts or separations, usually just above the basal layer. The vesicle forms between the stratum germinativum and the stratum spinosum and contains clear fluid and epidermal cells. The epithelial or “acantholytic” cells within the vesicle show degenerative changes characterized by large, swollen, hyperchromatic nuclei and relatively little cytoplasm. The underlying corium is moderately infiltrated with chronic inflammatory cells as well as scattered eosinophils and polymorphonuclear leukocytes. The inflammatory cells are often seen in varying numbers within the fluid of the vesicle. The oral lesions of pemphigus present a histopathologic pattern entirely similar to that studied in skin lesions. Acantholysis is invariably observed,5s6 and, because of the common occurrence of oral lesions in pemphigus and the easewith which oral mucosal biopsy procedures may be carried out, McCarthy and Shklar? have suggested oral biopsy as a routine diagnostic test for pemphigus vulgaris. The oral lesions often antedate the development of skin lesions, and definitive diagnosis at the onset of the disease is usually desirable (Fig. 1). This Health.
study
was
supported
by
Research
Grant
No.
DE
0186102,
National
Institutes
of
629
630
Nhklnr
O.S., 0.N.L 0.1’. Iltry, 1967
Histochemical studies of t hc dermatologic lesions of pcmphigus vulgaris have yielded little definitive information .b The basement membrane, as revealed by periodic acid-Schiff staining, has been found to be int,a.cP or somewhat thickerredlo in lesions of pemphigus vulgaris. In lesions of mucous membrane pemphigoid, a thinning or even an absence of the basement membrane was reported.ll Few histochemical studies of the oral lesions of pemphigus have been carried out. Shklar and MeyerI reported no significant alterations in mucopolysaccharide distribution and indicated that the periodic acid-Schiff technique revealed little that could not be studied more effectively on routine hematoxylin-esoin sections. Since there have been so few studies of the histochemistry of oral pemphigus lesions, it was thought that the use of a variety of specific staining techniques would be of interest. In addition to polysaceharide distribut~ion as revealed by the periodic acid-Schiff technique, it was decided that metaehromasia, ribonucleic acid distribution, and tyrosine, tryptophan, and sulfhydryl distribution should be studied. The techniques for these substances have been adequately studied, and their reliability is widely accepted. MATERSALS AND
METHODS
Oral biopsy specimens from six oral lesions of pemphigus vulgaris were studied by means of routine hematoxylin and eosin staining and a variety of histochemical techniques. Glycogen and mucopolysaccharides were studied with the periodic acid-Schiff technique. I39I1 Control slides were incubated for one hour in a 1 per cent diastase solution in order to eliminate glycogen. Metachromasia was studied with t,oluidine blue staining,l” and ribonucleic acid distribution was studied with toluidine blue and ribonuclease. Sections were stained with aqueous toluidine blue (0.05 per cent, pH 4.5)) and parallel control sections were incubated for one hour at 37O C. in an unbuffered ribonuclease solution (1 mg. per milliliter) prepared with glass-distilled water.l”B I6
Volume Number
Oral lesions
23 5
of pemphigus vulgaris
631
Tyrosine and tryptophan were demonstrated histochemically according to the methods of Glenner and Lillie,17* l8 and sulfhydryls were demonstrated according IX, the method of Barnett and Se&man. I9 The oral lesions of pemphigus vulgaris consisted of three specimensfrom the hard palate, one specimen from the gingiva, one specimen from the tongue, and one specimen from the buccal mucosa. The ages of the one female and five male patients ranged from 38 to 57 years. MICROSCOPIC Histopathology
OBSERVATIONS
All oral lesions of pemphigus revealed obvious acontholytic alterations. In early lesions, in which the vesicle was small and intact, the horizontal split could be observed directly above the stratum germinatirum (Fig. 2). The upper layers of the stratified squamous epithelium were lifted up, and the vesicle developed between the basal layer and the stratum spinosum. The vesicle contained some mucoid material, many ( ‘ acantholytic ’ ’ epithelial cells with large hyperchromatic nuclei and diminished amounts of cytoplasm, and varying numbers of chronic inflammatory cells with scattered polymorphonuclear leukocytes and eosinophils. Some specimens presented evidence of epithelial hyperplasia, characterized by extension of rete pegs into underlying connective tissue. Lesions of the hard palate showed somedegree of hyperkeratosis. The corium was infiltrated with lymphocytes, plasma cells, and histiocytes. In older and larger lesions the roof of the vesicle or bulla was often lost prior to or during removal of the biopsy specimen. In these instances, only the floor of the bulla remained for study. Histochemistry
Mucopolysaccharides. The periodic acid-Schiff technique revealed a welldemarcated, well-outlined basement membrane (Fig. 3). The epithelium was generally nonreactive for glycogen, except for the stratum corneum in certain cases. The underlying corium was slightly reactive, and the vesicle fluid was moderately reactive for mucopolysaccharides (Fig. 4). Metachromasia. Metachromasia was not observed in the specimens studied (Fig. 5). Ribonucleic acid. A particularly strong reaction for RNA was observed in the cytoplasm of the epithelial cells of the stratum germinativum and in the cytoplasm of the acantholytic cells separating from the epithelium and entering the vesicle (Figs. 6 and 7). Tyrosine. Sections revealed a light to moderate reactivity for tyrosine. The epithelial cells of the vesicle base and the roof were moderately reactive (Fig. 8). In those specimens with hyperkeratosis, there was an increased react,ivity at the stratum corneum. Tryptophan. Sections were nonreactive for tryptophan. Sulfhydryl groups. Sections revealed a reactivity varying from light to moderate in degree. The epithelial cells of the vesicle base and the vesicle’s covering layer were moderately reactive. In those specimens with hyperkeratosis at the epithelial surface, there was an increased staining for sulfhydryl groups in the hyperkeratotic stratum corneum (Fig. 9). Text amtinued on p. 696.
632
Fig.
Shkln,
3
Pig.
1. Biopy specimen of oral lesion of pemphigus vulgaris. Vesicle is seen between germinativum and upper epidermis. Epithelial hyperplasia is evident. (Hematoxylin and eosin stain. Magnification, x 80; reduced IL.) Fig. 3. OraI lesion of pemphigus vulgaris stained for polysaccharides. Basement membrane is clearly demarcated (Periodic acid-Schiff stain. Magnification, x 100; reduced I/.)
stratum
Volume Nuniber
23 5
h-al
lesions
of pentphigus
tndgnris
633
Fig.
Fig. 4. Oral lesion of pemphigus vulgaris stained for polysaccharides. Vesicle fluid ,eacts positively and basement membrane is clearly outlined (arrow). (Periodic acid-Schiff stain. ‘Magnification, x 200; reduced M.) Fig. 5. Palatal lesion of pemphigus vulgaris stained for demonstration of RN A and metaehromasia. Acantholysis and vesicle formation are seen. Hyperkeratosis is noted in this case. (Toluidine blue stain. Magnification, x 200; reduced l/4.)
5
6
Fig.
Fig. 6. Floor of oral bulla in specimeu prepared for demonstzxtion of RNA. @to] )f epithelial cells stains deeply. Acantholytic cells with large hyperchromatic nuclei are ev: /dent. :Toluidine blue stain. Magnification, x 250; reduced 1/.) from Fig. 7. Specimen prepared for demonstration of RNA, RNA ha.3 been removed :ytoplasm of epithelial cells. (Toluidine blue and ribonuclease st,ain. Magnificrttion, x 250 ; ,educed Y4.)
Volume 23 ru’ua.ber 5
Ornl lesions
of pentphigus
vulgcrris
635
E
Fig. 8. Specimen prepared for demonstration of tyrosine. Epithelium is moderately rea Let ,ive. Ma.gnification, x 250; reduced I/.) Fig. 9. Oral bulla of pemphigus prepared for demonstration of sulfhydryl groups. V 'esiicle Epithelium is slightly reactive, with some increased reactivi tY in c ontents are nonreactive. (Magnification, x 200; reduced 1/.) eLratum corneum.
COMMENT The histologic alterations in lesions of pemphig~~s vulgaris arc wc~ll understood.20 Acantholysis is a fundamental change in oral IGons as well as in dcrmatologic lesions. Since the histopatholog)of pemphigus is relat.ivcly unique, it was t.hought that histochemical techniques might shed further light on these interesting changes and possibly reveal some information concerning the etiology and pathogenesis of pemphigus. The basement membrane in lesions of pemphigus was found to be intact and appeared well outlined when studied by the periodic acid-Schiff technique, This is in contrast to ora. lesions of erythema multiforme, where the b’asement membrane is fragmented and irregular or completely absent.21 In erythema multiforme there was also found to be a severe and spectacular liquefactive degeneration in the upper epithelium. Although intraepithelial resicles developed, they res&ted from the liquefact.ive degeneration rather than from acantholysis as in pemphigus lesions. Furthermore, in erythema multiformc, as the degeneration of epithelium continues, the vesicle invariably becomes subepithelial. Thus, the histologic features of oral lesions of pemphigus and erythema multiforme are quite distinct, and mucopolysaccharide staining may be of help in revealing these differences. In mucous membrane pcmphigoid (benign RAUCOUS membrane pemphigus) the separation t,hat eventually results in a vesicle is invariably subepithelial and occurs immedia,tely beneath the epithclium.22 Acant,holpsis is not observed. The strong reaction for RNA was of interest.. This was not observed in other oral mucosal lesions, and the intense reactivity was particularly evident in the separating acantholptic cells. The round acantholyt,ic cells and an absence of intercellular bridges in the area have been well describtxd in rlectron microscopic studics.23 a.nd wlfhydryl groups yielded little inStudies for tyrosine, tryptophan, formation of interest in relation to pemphigus lesions. SUMMARY Oral lesions of pemphigus were studied with a. variety of histochemical techniques. A marked increase in RNA was observed in the cytoplasm of acantholytic cells and epithelial cells at the floor of the vesicle. The basement membrane was not disturbed a,nd was clearly demarcated in all specimens studied. Techniques for tyrosine, tryptophan, a.nd sulfhydryl groups revealed little of interest in relation to pemphigus lesions. REFERENCES
I. Rook, A. J., and Whimster, I. W.: The Histologic Diagnosis of Pemphigus, Brit. J. Dermat. 62: 443, 1950. 2. Lever, W. F.: Pemphigus: A Histopathologic Study, Arch. Dermat. 64: 727, 1951. A Clinieopathologieal Study, Arch. Dermat. 65: 3. Director, W.: Pemphigus Vulgaris: 155, 1952. 4. Civatte, A.: Diagnostic histopathologique de la dermatite polymorphe (IOulOureuse OU maladie de Duhring-Brocq, Ann. dermat. et syph. 3: 1, 1943. Mucous Membrane Pemphigus, New England 5. McCarthy, P. L., and Shklar, G.: Benign J. Med. 258: 726-731, 1958. aum pemphigus vulgaris der mund6. Katzenellenbogen, I., and Sandbank, M.: Beitrag schleimhaut, Hautarzt 10: 363, 1959.
Volume Number
Oral lesions of pemphigus
23 5
vulgaris
637
7. McCarthy, P. L., and Shklar, G.: Diseases of the Oral Mucosa, New York, 1964, McGraw-Hill Book Company, Inc., pp. 169-171. 8. :Lever, W. F.: Pemphigus and Pemphigoid, Springfield, Ill., 1965, Charles C Thomas, Publisher. 9. Braun-Falco, 0.: Histochemical Findings in “Pemphigus with Subepidermal Vesicle Formation” With a Contribution to the Pathogenesis of subepidermal Vesicle Formation, Arch. klin. exper. Dermat. 211: 213, 1960. 10. Steiner, K.: Mucoid Substances and Cutaneous Connective Tissue in Dermatoses. 111. Cutaneous Mucopolysaccharides in Inflammation of the Skin, J. Invest Dermat. 28: 419.424, 1957. 11. Achten, G., and Corbusier-Ledoux, M.: Contribution a l’etude histologique de la membrane basale dans les dermatoses bulleuses, Arch. belges dermat. et 8yph. 14: 290, :l958. 12. ;Shklar, G., and Meyer, I.: The Histopathology and Histochemistry of Dermatologic Lesions .rn the Mouth. ORAL SURG.. ORAL. MED. & ORAL PATH. 14: 1069-1084. 1961. 13. .Lillie, R. D. : ‘Reticulum Staining With Schiff Reagent After Oxidation by Acidified Sodium Periodate, J. Lab. & Clin. Med. 32: 910-912, 1947. 14. McManus, J. F. A.: Histological Demonstration of Mucin After Periodic Acid, Nature 158:
202.
--
I
1946. ----.
15. Pearse, E. A. G.: Histochemistry: Theoretical and Applied, Boston, 1960, Little, Brown & Company, p. 205. 16. Kronman, J. H:, and Chauncey, H. H.: Testosterone-Induced Changes in Salivary Gland Histochemistry m the Female Golden Hamster, J. Oral Therap. & Pharmacol. 1: 392, 1965. 17. Glenner, G. G:, and Lillie, R. D.: Observations of the Diazotization-Coupling Reaction for the Histochemmal Demonstration of Tyrosine: Metal Chelation and Formazan Variants, J. Histochem. 4: 407, 1956. 18. Glenner, G. G., and Lillie, R. D.: The Histochemical Demonstration of Indole Derivative8 by the Post-Coupled p-Dimethylaminobenzylidene Reaction, J. Histochem. 5: 416, 1957. 19. Bamett, R. J., and Seligman, A. M.: Histochemical Demonstration of Protein-Bound Sulfhydryl Groups, Science 116: 323, 1952. 2Q. Lever, W. F.: Pemphigus, Medicine 32: l-123, 1953. 21. Shklar, G.: Oral Lesions of Erythema Multiforme: Histologic and Histochemical Observations, Arch Dermat. 92: 495-500, 1965. 22. Shklar,. G., and McCarthy, P. L.: The Oral Manifestations of Benign Mucous Membrane Pemphlgus (Mucous Membrane Pemphigoid), ORAL SURG., ORAL MED. & ORAL PATH. 12:
950-966, 1959.
23. Wilgram, Acantholysis
G. F., Caulfield, in Pemphigus
J. B., and Lever, WV. F.: An Electron Microscopic Vulgaris, J. Invest. Dermat. 36: 373, 1961.
Study
of
Academy
of Oral
Pathology
Donald Kerr, Editor
The oral lesions of pemphigus vulgaris Histochemical
observations
Gerald Shkikr, DEPARTMENT
D.D.X., M.X., Boston, Mass. OF
ORAL
PATHOLOGY,
TUFTS
UNIVERSITY
SCHOOL
OF
DENTAL
MEDICINE
T
he microscopic features of pemphigus have been described in a number of excellent recent studies. The works of Rook and Whimster,l Lever,2 and Director3 served to confirm Civatte’# original findings that the major alteration found in lesions of pemphigus was the presence of acantholysis, a sepa,ration of epithelial cells of the epidermis due to dissolution or loss of the intercellular bridges. In the early stages of vesicle formation in pemphigus, there is intercellular edema within the stratum germinativum and lower stratum spinosum. This initial pathologic change is followed by the development of horizontal clefts or separations, usually just above the basal layer. The vesicle forms between the stratum germinativum and the stratum spinosum and contains clear fluid and epidermal cells. The epithelial or “acantholytic” cells within the vesicle show degenerative changes characterized by large, swollen, hyperchromatic nuclei and relatively little cytoplasm. The underlying corium is moderately infiltrated with chronic inflammatory cells as well as scattered eosinophils and polymorphonuclear leukocytes. The inflammatory cells are often seen in varying numbers within the fluid of the vesicle. The oral lesions of pemphigus present a histopathologic pattern entirely similar to that studied in skin lesions. Acantholysis is invariably observed,5s6 and, because of the common occurrence of oral lesions in pemphigus and the easewith which oral mucosal biopsy procedures may be carried out, McCarthy and Shklar? have suggested oral biopsy as a routine diagnostic test for pemphigus vulgaris. The oral lesions often antedate the development of skin lesions, and definitive diagnosis at the onset of the disease is usually desirable (Fig. 1). This Health.
study
was
supported
by
Research
Grant
No.
DE
0186102,
National
Institutes
of
629
630
Nhklnr
O.S., 0.N.L 0.1’. Iltry, 1967
Histochemical studies of t hc dermatologic lesions of pcmphigus vulgaris have yielded little definitive information .b The basement membrane, as revealed by periodic acid-Schiff staining, has been found to be int,a.cP or somewhat thickerredlo in lesions of pemphigus vulgaris. In lesions of mucous membrane pemphigoid, a thinning or even an absence of the basement membrane was reported.ll Few histochemical studies of the oral lesions of pemphigus have been carried out. Shklar and MeyerI reported no significant alterations in mucopolysaccharide distribution and indicated that the periodic acid-Schiff technique revealed little that could not be studied more effectively on routine hematoxylin-esoin sections. Since there have been so few studies of the histochemistry of oral pemphigus lesions, it was thought that the use of a variety of specific staining techniques would be of interest. In addition to polysaceharide distribut~ion as revealed by the periodic acid-Schiff technique, it was decided that metaehromasia, ribonucleic acid distribution, and tyrosine, tryptophan, and sulfhydryl distribution should be studied. The techniques for these substances have been adequately studied, and their reliability is widely accepted. MATERSALS AND
METHODS
Oral biopsy specimens from six oral lesions of pemphigus vulgaris were studied by means of routine hematoxylin and eosin staining and a variety of histochemical techniques. Glycogen and mucopolysaccharides were studied with the periodic acid-Schiff technique. I39I1 Control slides were incubated for one hour in a 1 per cent diastase solution in order to eliminate glycogen. Metachromasia was studied with t,oluidine blue staining,l” and ribonucleic acid distribution was studied with toluidine blue and ribonuclease. Sections were stained with aqueous toluidine blue (0.05 per cent, pH 4.5)) and parallel control sections were incubated for one hour at 37O C. in an unbuffered ribonuclease solution (1 mg. per milliliter) prepared with glass-distilled water.l”B I6
Volume Number
Oral lesions
23 5
of pemphigus vulgaris
631
Tyrosine and tryptophan were demonstrated histochemically according to the methods of Glenner and Lillie,17* l8 and sulfhydryls were demonstrated according IX, the method of Barnett and Se&man. I9 The oral lesions of pemphigus vulgaris consisted of three specimensfrom the hard palate, one specimen from the gingiva, one specimen from the tongue, and one specimen from the buccal mucosa. The ages of the one female and five male patients ranged from 38 to 57 years. MICROSCOPIC Histopathology
OBSERVATIONS
All oral lesions of pemphigus revealed obvious acontholytic alterations. In early lesions, in which the vesicle was small and intact, the horizontal split could be observed directly above the stratum germinatirum (Fig. 2). The upper layers of the stratified squamous epithelium were lifted up, and the vesicle developed between the basal layer and the stratum spinosum. The vesicle contained some mucoid material, many ( ‘ acantholytic ’ ’ epithelial cells with large hyperchromatic nuclei and diminished amounts of cytoplasm, and varying numbers of chronic inflammatory cells with scattered polymorphonuclear leukocytes and eosinophils. Some specimens presented evidence of epithelial hyperplasia, characterized by extension of rete pegs into underlying connective tissue. Lesions of the hard palate showed somedegree of hyperkeratosis. The corium was infiltrated with lymphocytes, plasma cells, and histiocytes. In older and larger lesions the roof of the vesicle or bulla was often lost prior to or during removal of the biopsy specimen. In these instances, only the floor of the bulla remained for study. Histochemistry
Mucopolysaccharides. The periodic acid-Schiff technique revealed a welldemarcated, well-outlined basement membrane (Fig. 3). The epithelium was generally nonreactive for glycogen, except for the stratum corneum in certain cases. The underlying corium was slightly reactive, and the vesicle fluid was moderately reactive for mucopolysaccharides (Fig. 4). Metachromasia. Metachromasia was not observed in the specimens studied (Fig. 5). Ribonucleic acid. A particularly strong reaction for RNA was observed in the cytoplasm of the epithelial cells of the stratum germinativum and in the cytoplasm of the acantholytic cells separating from the epithelium and entering the vesicle (Figs. 6 and 7). Tyrosine. Sections revealed a light to moderate reactivity for tyrosine. The epithelial cells of the vesicle base and the roof were moderately reactive (Fig. 8). In those specimens with hyperkeratosis, there was an increased react,ivity at the stratum corneum. Tryptophan. Sections were nonreactive for tryptophan. Sulfhydryl groups. Sections revealed a reactivity varying from light to moderate in degree. The epithelial cells of the vesicle base and the vesicle’s covering layer were moderately reactive. In those specimens with hyperkeratosis at the epithelial surface, there was an increased staining for sulfhydryl groups in the hyperkeratotic stratum corneum (Fig. 9). Text amtinued on p. 696.
632
Fig.
Shkln,
3
Pig.
1. Biopy specimen of oral lesion of pemphigus vulgaris. Vesicle is seen between germinativum and upper epidermis. Epithelial hyperplasia is evident. (Hematoxylin and eosin stain. Magnification, x 80; reduced IL.) Fig. 3. OraI lesion of pemphigus vulgaris stained for polysaccharides. Basement membrane is clearly demarcated (Periodic acid-Schiff stain. Magnification, x 100; reduced I/.)
stratum
Volume Nuniber
23 5
h-al
lesions
of pentphigus
tndgnris
633
Fig.
Fig. 4. Oral lesion of pemphigus vulgaris stained for polysaccharides. Vesicle fluid ,eacts positively and basement membrane is clearly outlined (arrow). (Periodic acid-Schiff stain. ‘Magnification, x 200; reduced M.) Fig. 5. Palatal lesion of pemphigus vulgaris stained for demonstration of RN A and metaehromasia. Acantholysis and vesicle formation are seen. Hyperkeratosis is noted in this case. (Toluidine blue stain. Magnification, x 200; reduced l/4.)
5
6
Fig.
Fig. 6. Floor of oral bulla in specimeu prepared for demonstzxtion of RNA. @to] )f epithelial cells stains deeply. Acantholytic cells with large hyperchromatic nuclei are ev: /dent. :Toluidine blue stain. Magnification, x 250; reduced 1/.) from Fig. 7. Specimen prepared for demonstration of RNA, RNA ha.3 been removed :ytoplasm of epithelial cells. (Toluidine blue and ribonuclease st,ain. Magnificrttion, x 250 ; ,educed Y4.)
Volume 23 ru’ua.ber 5
Ornl lesions
of pentphigus
vulgcrris
635
E
Fig. 8. Specimen prepared for demonstration of tyrosine. Epithelium is moderately rea Let ,ive. Ma.gnification, x 250; reduced I/.) Fig. 9. Oral bulla of pemphigus prepared for demonstration of sulfhydryl groups. V 'esiicle Epithelium is slightly reactive, with some increased reactivi tY in c ontents are nonreactive. (Magnification, x 200; reduced 1/.) eLratum corneum.
COMMENT The histologic alterations in lesions of pemphig~~s vulgaris arc wc~ll understood.20 Acantholysis is a fundamental change in oral IGons as well as in dcrmatologic lesions. Since the histopatholog)of pemphigus is relat.ivcly unique, it was t.hought that histochemical techniques might shed further light on these interesting changes and possibly reveal some information concerning the etiology and pathogenesis of pemphigus. The basement membrane in lesions of pemphigus was found to be intact and appeared well outlined when studied by the periodic acid-Schiff technique, This is in contrast to ora. lesions of erythema multiforme, where the b’asement membrane is fragmented and irregular or completely absent.21 In erythema multiforme there was also found to be a severe and spectacular liquefactive degeneration in the upper epithelium. Although intraepithelial resicles developed, they res&ted from the liquefact.ive degeneration rather than from acantholysis as in pemphigus lesions. Furthermore, in erythema multiformc, as the degeneration of epithelium continues, the vesicle invariably becomes subepithelial. Thus, the histologic features of oral lesions of pemphigus and erythema multiforme are quite distinct, and mucopolysaccharide staining may be of help in revealing these differences. In mucous membrane pcmphigoid (benign RAUCOUS membrane pemphigus) the separation t,hat eventually results in a vesicle is invariably subepithelial and occurs immedia,tely beneath the epithclium.22 Acant,holpsis is not observed. The strong reaction for RNA was of interest.. This was not observed in other oral mucosal lesions, and the intense reactivity was particularly evident in the separating acantholptic cells. The round acantholyt,ic cells and an absence of intercellular bridges in the area have been well describtxd in rlectron microscopic studics.23 a.nd wlfhydryl groups yielded little inStudies for tyrosine, tryptophan, formation of interest in relation to pemphigus lesions. SUMMARY Oral lesions of pemphigus were studied with a. variety of histochemical techniques. A marked increase in RNA was observed in the cytoplasm of acantholytic cells and epithelial cells at the floor of the vesicle. The basement membrane was not disturbed a,nd was clearly demarcated in all specimens studied. Techniques for tyrosine, tryptophan, a.nd sulfhydryl groups revealed little of interest in relation to pemphigus lesions. REFERENCES
I. Rook, A. J., and Whimster, I. W.: The Histologic Diagnosis of Pemphigus, Brit. J. Dermat. 62: 443, 1950. 2. Lever, W. F.: Pemphigus: A Histopathologic Study, Arch. Dermat. 64: 727, 1951. A Clinieopathologieal Study, Arch. Dermat. 65: 3. Director, W.: Pemphigus Vulgaris: 155, 1952. 4. Civatte, A.: Diagnostic histopathologique de la dermatite polymorphe (IOulOureuse OU maladie de Duhring-Brocq, Ann. dermat. et syph. 3: 1, 1943. Mucous Membrane Pemphigus, New England 5. McCarthy, P. L., and Shklar, G.: Benign J. Med. 258: 726-731, 1958. aum pemphigus vulgaris der mund6. Katzenellenbogen, I., and Sandbank, M.: Beitrag schleimhaut, Hautarzt 10: 363, 1959.
Volume Number
Oral lesions of pemphigus
23 5
vulgaris
637
7. McCarthy, P. L., and Shklar, G.: Diseases of the Oral Mucosa, New York, 1964, McGraw-Hill Book Company, Inc., pp. 169-171. 8. :Lever, W. F.: Pemphigus and Pemphigoid, Springfield, Ill., 1965, Charles C Thomas, Publisher. 9. Braun-Falco, 0.: Histochemical Findings in “Pemphigus with Subepidermal Vesicle Formation” With a Contribution to the Pathogenesis of subepidermal Vesicle Formation, Arch. klin. exper. Dermat. 211: 213, 1960. 10. Steiner, K.: Mucoid Substances and Cutaneous Connective Tissue in Dermatoses. 111. Cutaneous Mucopolysaccharides in Inflammation of the Skin, J. Invest Dermat. 28: 419.424, 1957. 11. Achten, G., and Corbusier-Ledoux, M.: Contribution a l’etude histologique de la membrane basale dans les dermatoses bulleuses, Arch. belges dermat. et 8yph. 14: 290, :l958. 12. ;Shklar, G., and Meyer, I.: The Histopathology and Histochemistry of Dermatologic Lesions .rn the Mouth. ORAL SURG.. ORAL. MED. & ORAL PATH. 14: 1069-1084. 1961. 13. .Lillie, R. D. : ‘Reticulum Staining With Schiff Reagent After Oxidation by Acidified Sodium Periodate, J. Lab. & Clin. Med. 32: 910-912, 1947. 14. McManus, J. F. A.: Histological Demonstration of Mucin After Periodic Acid, Nature 158:
202.
--
I
1946. ----.
15. Pearse, E. A. G.: Histochemistry: Theoretical and Applied, Boston, 1960, Little, Brown & Company, p. 205. 16. Kronman, J. H:, and Chauncey, H. H.: Testosterone-Induced Changes in Salivary Gland Histochemistry m the Female Golden Hamster, J. Oral Therap. & Pharmacol. 1: 392, 1965. 17. Glenner, G. G:, and Lillie, R. D.: Observations of the Diazotization-Coupling Reaction for the Histochemmal Demonstration of Tyrosine: Metal Chelation and Formazan Variants, J. Histochem. 4: 407, 1956. 18. Glenner, G. G., and Lillie, R. D.: The Histochemical Demonstration of Indole Derivative8 by the Post-Coupled p-Dimethylaminobenzylidene Reaction, J. Histochem. 5: 416, 1957. 19. Bamett, R. J., and Seligman, A. M.: Histochemical Demonstration of Protein-Bound Sulfhydryl Groups, Science 116: 323, 1952. 2Q. Lever, W. F.: Pemphigus, Medicine 32: l-123, 1953. 21. Shklar, G.: Oral Lesions of Erythema Multiforme: Histologic and Histochemical Observations, Arch Dermat. 92: 495-500, 1965. 22. Shklar,. G., and McCarthy, P. L.: The Oral Manifestations of Benign Mucous Membrane Pemphlgus (Mucous Membrane Pemphigoid), ORAL SURG., ORAL MED. & ORAL PATH. 12:
950-966, 1959.
23. Wilgram, Acantholysis
G. F., Caulfield, in Pemphigus
J. B., and Lever, WV. F.: An Electron Microscopic Vulgaris, J. Invest. Dermat. 36: 373, 1961.
Study
of