PEMPHIGUS?
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From: MHKAY1@aol.com
 
Lately I am seeing quite a few interesting cases!
This has not been typical in my suburban practice.
A 27 year old man came in smelling horrid. He reported 3 months of difficulty
eating and had lost 30 pounds. It started as a mild sore throat and he went
thru many courses of various antibiotics. When the condition progressed to
full denution of his oral mucosa and lips he was put on high doses of
acyclovir. By this time he had developed erosion and loss of most of his
fingernails and paronychial skin. He also had a very large area in the
suprapubic region which was verrucous in appearance. Rest of exam was
unremarkable. No history of other medication use. No history of aids etc. Due
to his lack of insurance and financial position I only performed a skin
biopsy and started him on 60 mg Prednisone qd. I ordered all his recent lab
tests including ones done in the ER.
The  H&E path came back very interesting. As I had picked a small, new lesion
there  was intact epidermis. However, above the epidermis was a crusted
bullae filled with eosonophils. The dermis was filled with an eosinophilic
vasculitis. Ther was no sign of epidermal breakdown except at the very
superficial part.
Although I have never seen Pemphigus Vegetans before the clinical suggests
Pemphigus to me and a lot of it is clearly verrucous. The path seems
consistent.
After 6 days he is 50% better and eating voraciously. I have ordered serum
antibodies . Does this sound familiar to anyone? Am I on the right track? If
I have the energy and the photos come out well I might submit it.

Martin Kay
L.A.
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From: Winkelman@medcor.mcgill.ca
 

Yes I think you are on the right track in your diagnosis.  Eosinophilic 
spongiosis and eosinophilic "vasculitis" may very well be the early signs of 
pemphigus, of any subtype.  We have a case very similar to this in our 
teaching slide set at McGill University that is a favorite exam question for 
our chief to ask senior residents.

WJ Winkelman
Immunodermatology Clinic
McGill University>

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