J Cutan Pathol 2015
doi: 10.1111/cup. 12595
John Wiley & Sons. Printed in Singapore
© 2015 John Wiley & Sons A/S.
Published by John Wiley & Sons Ltd
Journal of
Cutaneous Pathology
Letter to the Editor
Spongiotic dermatitis with
Langerhans cell microvesicles
Keywords: epidermal blisters, Langerhans cell microvesicles, spongiotic dermatitis, vasculitis
To the Editor,
The intraepidermal vesiculobullous disorders
include a wide variety of pathogenically heterogeneous disorders that share cleft or bulla
formation within the epidermis. A 68-year-old
male presented to the dermatologist for the
presence of erythematous plaques, papules
and blisters on his abdomen and thighs following intake of multiple medications. Skin
biopsies were taken for hematoxylin and eosin
(H&E) histology and immunohistochemistry
(IHC), as well as for direct immunofluorescence
(DIF) studies. The H&E histology demonstrated
intraepidermal spongiosis and blisters, with
exocytosis of inflammatory cells into the epidermis. Langerhans cell microvesicles (LCM)
were seen in all of the intraepidermal blisters.
By IHC, we determined that these cells were
CD1a positive, and also present around the
blister. Galectin 3 and CD56/NCAM (neural
cell adhesion molecule) were positive around
all of the epidermal blisters. Desmoplakins I
and II (DPI-II) and armadillo repeat protein
deleted in velo-cardio-facial syndrome (ARVCF)
antibodies showed a strong IHC positivity in
the epidermis and skin appendageal structures,
along with cyclooxygenase 2 (COX-2). LCM
are often found in spongiotic dermatitides and
are a common cause of intraepidermal blistering. Langerhans cells seem to be playing an
antigen-presenting cell role in LCM, and also
seem to directly contribute to the pathologic
tissue damage and blister formation.
The classification of the blistering disorders
has been historically accomplished by (1) shared
clinical features (i.e. vesicles, bullae), (2) etiologic factors (i.e. infectious, immunologic)
and/or (3) histologic features (i.e. intraepidermal and subepidermal).1 A spongiotic
dermatitis may be associated with a variety
of causative conditions.2 Spongiotic dermatitis
can be divided into three phases: acute, subacute and chronic; finally, drug eruptions are
also a cause of spongiotic dermatitides.2 The
development of LCMs has been described in
subacute dermatitis, as well as in allergic contact
dermatitis.3
The 68-year-old Caucasian male complaining of a sudden appearance of erythematous
papules, plaques and few blisters on the
abdomen, back, arms and thighs. Physical
examination confirmed these findings. Some
of the lesions were violaceous. The patient was
taking Lisinopril, glibenclamide (Micronase,
USA) and metformin. After the diagnosis and a
review of medications, the patient was treated
with 0.1% Tacrolimus cream and showed extensive improvement. Skin biopsy processing for
histologic studies, IHC and DIF was performed
as previously described.4
Examination of the H&E tissue sections
demonstrated diffuse, florid epidermal spongiosis. Spongiotic microvesicles were seen, and
LCM were also noted. The dermis displayed
a moderately florid, superficial, perivascular infiltrate of lymphocytes, histiocytes and
eosinophils; neutrophils were rare (see Fig. 1).
DIF displayed the following results: IgG (+,
scattered dermal perivascular, perieccrine and
perineural); IgA (−); IgM (+, dermal perieccrine and perineural); IgD (+, epidermal
punctate keratinocytes and dermal perieccrine);
IgE (−); complement/C1q (+, dermal perineural); complement/C3 (+, dermal perineural);
complement/C4(−); kappa light chains (+,
focal superficial dermal perineural); lambda
light chains (+, focal superficial dermal perineural); albumin (+++, epidermal stratum
1
Letter to the Editor
corneum) and fibrinogen (+++, dermal perivascular and perieccrine). Of interest, we noted
the excretion of a material staining positive with
fluorescein Isothiocyanate (FITC)-conjugated
IgG through the sweat ducts in the epidermal
corneal layer (see Figs. 1–3). By DIF, DP I-II and
ARVCF were expressed in the epidermis, hair
follicles, eccrine sweat glands and on dermal
blood vessels and some nerves.
IHC results showed mast cell tryptase positive
staining around dermal eccrine sweat glands
and ducts. Factor XIIIa was positive on dermal
dendrocytes, close to dermal neurovascular
structures. CD3 was positive under the basement membrane zone (BMZ). CD8 was positive
around upper dermal blood vessels, and also
around eccrine sweat gland ducts. Bcl-2 was
positive at the BMZ, as well as in the upper
dermal inflammatory infiltrate and around dermal eccrine sweat glands. COX-2 was positive
around dermal eccrine sweat glands. HLA-DP,
DQ, DR antigen stained positive on several cells
in the epidermis, as well as around blood vessels
supplying hair follicular units, the upper dermal
vascular plexus and around dermal eccrine
gland blood vessels. Several cells of dendritic
cell shape in the epidermis were also positive for
this marker. CD45 stained positive around some
blood vessels in the subcutaneous adipose tissue,
around dermal blood vessels and eccrine sweat
glands and on several individual cells within the
epidermis. CD4 and CD20 were negative. Ki-67
was positive around several dermal blood vessels,
around some parts of the dermal eccrine glands,
in the hair follicles and at the epidermal BMZ
and stratum spinosum of the epidermis. Factor
XIIIa was positive in cells around dermal blood
vessels. The most dramatically positive staining
was seen with CD1a, in selected cells within
the epidermis, inside epidermal blisters, at the
epidermal BMZ, around upper dermal blood
vessels and within all hair follicular units (Fig. 1).
Positive staining with Galectin 3, CD56/NCAM
and matrix metallopeptidase 9 (MMP9) was seen
inside the epidermal blisters and on adjacent epidermis. Tissue inhibitor of metalloproteinases 1
was positive in the hair follicles.
The most common cause of spongiotic dermatitis is an eczematous dermatitis; this process
often demonstrates the presence of serum scale
crust, sometimes psoriasiform epidermal hyperplasia, lymphocytic exocytosis and intraepidermal vesiculation with formation of LCM.1 – 4
We found other dermal dendritic cells within
the immunologic response (dermal dendrocytes), highlighted by Factor XIIIa. The dermal
2
dendrocytes were primarily noted surrounding perivascular inflammatory cells in the
upper dermal vascular plexus. These findings
are indicative of an active antigen processing/presenting process. We also noted that the
CD1a-positive cells seemed to be focally ‘damaging the tissue’; indeed, recent studies have
shown via zymographic studies the presence
of gelatinase in CD1a-positive cells.5 The same
authors also showed that tissue inhibitor of
metalloproteinase 3 was significantly increased
in mature dendritic cells (DCs), and this enzyme
may participate in blister formation.5
Increasing evidence indicates an important
role of T lymphocytes in drug-induced skin conditions and the drugs may be recognized by
alpha/beta T cell receptors, and/or bound covalently to peptides, and also if the drug binds in a
labile way to the presenting major histocompatibility complex (MHC)-peptide. In our case, we
found colocalization of CD8 as well as HLA-DP,
DQ, DR antigen within the dermal perivascular
inflammation, but we did not find significant evidence of CD4 involvement as has been previously
reported. Bcl-2 was very positive in the majority
of the inflammatory cells around the epidermal
blisters and the dermal perivascular inflammatory infiltrate. Bcl-2 has a potential role of Bcl-2
gene family members as regulators of cellular
antioxidant status via immune modulation have
been described.
Our DIF and IHC data indicate a complex
immune response which includes T lymphocytes,
B lymphocytes, MHC molecules, antibodies,
antigen-presenting cells and cell junctions. The
CD1a-positive cells seem to migrate through
the extracellular matrix to sample the local
‘antigenic’ environment; this process requires
chemoattractants, cell adhesion and cell junction molecules (in our case, likely including
DPI-II and ARVCF). The overall process results
in edema and vasodilation; the process also
requires proteinases to open the tissue. We noted
that fibrinogen, complement/C3c, albumin and
to a lesser extent IgG and other immunoglobulins congregated around blood vessels in the
upper dermal vascular plexus, as well as around
dermal nerves, eccrine glands and hair follicular
units. In addition, other inflammatory markers including mast cell tryptase, Bcl-2, COX-2
and Galectin 3 may be involved in increasing
edema, and thus allowing increased migration
of cytokines and pertinent cells. Our findings
suggest that several skin appendageal structures
may also play a role in the eczematous process.
Letter to the Editor
Fig. 1. A) Langerhans cell microvesicles and other markers. A) Hematoxylin and eosin (H&E) (×200) displays a spongiotic
epidermis with Langerhans cell microvesicles (LCM) present (black arrows). A lymphohistiocytic infiltrate is also seen around
upper dermal blood vessels. B) Immunohistochemistry (IHC) with CD1a shows positive staining for Langerhans cells within a
microabscess (brown staining; red arrow). C) IHC staining with metallopeptidase inhibitor 1 (TIMP1), showing positivity on cells
within an epidermal blister (red staining; black arrow). D) Direct immunofluorescence (DIF), showing armadillo repeat protein
deleted in velo-cardio-facial syndrome (ARVCF) staining a large dermal blood vessel (orange staining; white arrow), and fibrinogen
deposits around the blood vessel (green staining; white arrow). E) DIF, showing positive stain with ARVCF to a hair follicle (red
staining; white arrow); blood vessels in the vicinity are surrounded by FITC-conjugated fibrinogen deposits (green staining). Of
importance, LCs and spongiosis were found in the hair follicles. F) IHC-positive staining with galectin 3 inside an epidermal blister
(red staining; black arrow).
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Letter to the Editor
Fig. 2. Direct immunofluorescence (DIF) and immunohistochemistry (IHC) stains. A–D) DIF. A and B) DIF using fluorescein
Isothiocyanate (FITC)-conjugated fibrinogen and Texas red-conjugated armadillo repeat protein deleted in velo-cardio-facial
syndrome (ARVCF), showing positive staining in (A) on fibroblastoid cells in the intermediate dermis (yellow staining; white arrow)
and the same cells in (B) (light red staining; white arrow). C) Positive staining with FITC-conjugated fibrinogen in the epidermal
corneal layer (white staining; white arrow), and around upper dermal blood vessels (white staining; red arrow). Additional, adjacent,
likely extruded material is noted in light green (which could represent additional fibrinogen, or a different material). D) Positive
staining for ARVCF in the upper epidermis (red staining; white arrow). E and F) IHC. E) Positive staining for CD3 on inflammatory
cells around upper dermal blood vessels (brown staining; red arrow). F) Positive staining with Bcl-2 at the epidermal basement
membrane zone (BMZ) (brown staining; black arrow) and around upper dermal blood vessels (brown staining; red arrow).
Moreover, ARVCF stained positive in the epidermis and in several skin appendices along with
DP I-II. These molecules represent components
of cell junctions, which may be altered in the
4
overall inflammatory process. We do not know
the precise significance of these findings; we
speculate that these components could be
altered as a response to the initial immune
Letter to the Editor
Fig. 3. A) Direct immunofluorescence (DIF) and double immunohistochemistry (IHC) stains. IHC double staining, with
anti-HLA-DP, DQ, DR antigen positive around dermal blood vessels, as well as on several cells in the epidermis (brown staining).
In addition, positive staining for Factor XIIIa is focally noted in the dermis (red staining; red arrow). B) IHC, showing positive
staining with Factor XIIIa in cells around dermal blood vessels (brown staining; red arrow) and in the same areas with CD68
(red staining; black arrow). C) DIF, showing positive staining with fluorescein Isothiocyanate (FITC)-conjugated anti-human IgG,
extruding material from a sweat gland (green staining; white arrow). The nuclei of epidermal keratinocytes were counterstained
with 4’,6-diamidino-2-phenylindole (DAPI) (blue). D) DIF, showing positivity around dermal blood vessels using FITC-conjugated
fibrinogen (green staining; white arrow), and Texas red-conjugated armadillo repeat protein deleted in velo-cardio-facial syndrome
(ARVCF) showing positivity in the vessels (red staining; white arrow). The nuclei of vascular endothelial cells were counterstained
with DAPI (blue). E) Same antibodies as in (D), showing positive band-like staining at the epidermal basement membrane zone
(BMZ) using FITC-conjugated fibrinogen (light green staining; white arrow). Please note additional punctate positivity in the
epidermis with Texas red-conjugated ARVCF (yellow dot-like staining). F) IHC, showing positive staining with CD3 of cells below
the epidermal BMZ (brown staining; red arrows), and around upper dermal vessels (brown staining; black arrow).
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Letter to the Editor
process, subsequently altering the respective
cell junctions and contributing to surrounding
edema.
In summary, we noted the involvement and
importance of many cells and molecules (including keratinocytes, mast cells, LCs, T lymphocytes
and blood vessel endothelial cells) in a complex drug reaction response featuring epidermal spongiosis and LCM. We also suggest that
given our data, positive staining markers for cell
junction molecules such as DP I-II and ARVCF
may indicate a direct role of these structures in
edema formation, thus allowing the migration of
other pertinent molecules and cells in the overall
inflammatory process. Larger studies are needed
to address these questions.
the histology slides, contributed essential reagents and tools
and reviewed the final version. Dr Abreu Velez performed
the research, designed the study, correlated the IHC and DIF
findings, analyzed the data and wrote the article. Many thanks
to Jonathan S. Jones, HT (ASCP) at Georgia Dermatopathology
Associates, who provided excellent technical assistance. This
work was supported by Georgia Dermatopathology Associates,
Atlanta, Georgia, USA.
Ana Maria Abreu Velez, MD, PhD1
Michael S. Howard, MD1
Vickie M. Brown, MD2
1
Georgia Dermatopathology Associates,
Atlanta, GA, USA
2
Department of Dermatology,
Dermatology LLC,
Milledgeville, GA, USA
e-mail: abreuvelez@yahoo.com
Acknowledgements
Dr Brown evaluated the patient, took the biopsies, reviewed
the draft and approved the final version. Dr Howard read
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