This document describes a biopsy of an 80-year-old female with a clinical diagnosis of bullous pemphigoid. Microscopic examination showed a subepidermal bulla filled with plasma, neutrophils, and eosinophils. The dermis beneath showed a dense perivascular infiltrate of lymphocytes, eosinophils, and plasma cells. These features are consistent with bullous pemphigoid. Bullous pemphigoid is an autoimmune blistering disease that typically affects the elderly and presents as large, tense bullae on the trunk and extremities. Histologically, it shows a subepidermal blister often containing eosinophils and a superficial perivascular mixed inflammatory infiltrate

1. • Age/Sex : 80/Female
• Hospital OP/ IP No: A18009538
• Biopsy No: 349/18
• Date Of Receiving Specimen : 10/02/2018
• Clinical Diagnosis : Bullous pemphigoid.
• Nature of Specimen : A 6mm punch biopsy
including a vessel from abdomen.
.

2. Gross Examination
Received a single skin covered punch biopsy specimen
measuring 0.5x0.5cm. All embedded in one block.

3. Microscopy
4x

4. Microscopy
10 x

5. Microscopy
40 x

6. Microscopy
10 x

7. Microscopy
40 x

8. Microscopy
Section studied shows epidermis with subepidermal bulla.
Bullous cavity is filled with plasma, moderate infiltration of
neutrophils and eosinophils along with nuclear debris.
Adjacent epidermis shows basal cell vacuolation and mild
spongiosis. Dermis beneath the bulla shows dense
perivascular infiltrate composed of lymphocytes, eosinophils,
few plasma cells and melanophages.

9. Impression
Features are consistent with Bullous pemphigoid.

10. DISCUSSION

11. Bullous pemphigoid
• Common subepidermal, blistering, autoimmune disease of skin due to IgG
antibodies to the hemidesmosomal antigens Bullous pemphigoid antigen
1 and 2.
• Affects elderly patients and presents as large, tense bullae involving trunk,
extremities, and intertriginous areas.
• Nikolsky sign is negative.
• Oral lesions are present in about one third of the patients.

12. Histopathology
• Subepidermal vesicle often filled
with eosinophils.
• Superficial perivascular mixed
inflammatory cell infiltrate rich in
eosinophils.
• In the cell-poor variant, only scant
inflammatory cell infiltrate is
present.
• Early lesions may present with
spongiosis and infiltrate of
eosinophils (eosinophilic
spongiosis)
Histologic section shows subepidermal
blister containing eosinophils and some
neutrophils.

13. Techniques for Diagnosis
• Direct immunofluorescence studies
- a linear deposition of C3 and IgG at
the dermoepidermal junction.
• Salt-split skin immunofluorescence
shows that the pemphigoid
antibodies are localized to the roof
of the blister in most cases

14. Differential Diagnosis

15. Differential Diagnosis
Herpes gestationis
• Presents as intensely pruritic lesions
on the abdomen and extremities of
pregnant women in second and third
trimesters.
• Perivascular infiltrate composed of
lymphocytes and eosinophils in zones
of erythema and edema.
• There is marked papillary dermal
edema and eosinophilic spongiosis
• Focal necrosis of the basal
keratinocytes leading to the
subpeidermal blister.

16. Epidermolysis bullosa acquisita
• Presents as blisters developing on acral
areas that heal with scarring.
• Histologic and immunofluorescence
changes may be identical to that of
bullous pemphigoid.
• Eosinophils are fewer in number, and
lymphocytes and neutrophils may
predominate.
• Immunofluorescence of salt-split skin
shows the localization of IgG
antibodies to the floor of the blister

17. Porphyria cutanea tarda
• Subepidermal blister with minimal
inflammatory cell infiltrate.
• The dermal papillae extend into the
blister cavity with a festooning
appearance.
• PAS-positive eosinophilic deposits
around the blood vessels of the
papillary dermis are characteristic.