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FEATURES OF CYTOLOGICAL PICTURE AT MULTIFORME EXUDATIVE ERYTHEMA IN ORAL CAVITY

FEATURES OF CYTOLOGICAL PICTURE AT MULTIFORME EXUDATIVE ERYTHEMA IN ORAL CAVITY
Lakhtin Yuriy, professor, doctor of medicine, associate professor

Pavel Moskalenko , assistant, candidate of medicine

Sumy State University, Ukraine

Lidiya Karpez , assistant, candidate of medicine

Kharkiv Medical Academy of Post-graduate Education, Ukraine

Championship participant: the National Research Analytics Championship - "Ukraine";

the Open European-Asian Research Analytics Championship;

It was studied the cytological picture of the erosions contents in patients with toxic-allergic form of multiforme exudative erythema in oral cavity. It was found that the composition of cellular elements is specific for the exudate of nonspecific inflammation. Hematogenous and histiogenous cells are mostly not destroyed. There is a large number of the cell of mononuclear type, polyblasts, eosinophils and epithelium frequent present in the state of hydropic degeneration.

Keywords: multiforme exudative erythema, toxic-allergic reaction, cytology, eosinophils, polyblasts, mononuclear cells.

 

Introduction. Multiforme exudative erythema (MEE) is an acute polymorphic dermatosis, which occurs in the form of a bluish-red color rash on the skin of the extremities, mucous membranes, sometimes in the genital area [1].

The etiology of MEE is not fully understood, so the causes of the disease are varied, but in patients with this disease there is some trigger factor which triggers the mechanism of the immune reaction of hypersensitivity. One of them is the infectious diseases caused by the herpes simplex virus [10], Chlamydia [8] and mycoplasma pneumonia [13]. Another factor is the allergens of medicated nature [2, 5-7].

In this regard, many local authors identify infectious-allergic (idiopathic) and toxic-allergic (symptomatic) forms of MEE. In the development of idiopathic form the main trigger factors are infections. In toxic-allergic form it is revealed the hypersensitivity to different medications [3]. Toxic-allergic form is characterized by vivid hyperemia, a tendency to lesions merge, frequent lesions of the mucous membranes, including genital, expressed epidermolytic component (vesicles), isomorphic reaction. Infectious-allergic form is often present in the form of small elements of the "stagnant" shade that do not have a tendency to merge, preferentially localized on the extremities and less frequently on the mucous membranes [2].

In the clinic, the foreign experts often distinguish two forms of MEE - big and small. Both are characterized by the same type of primary lesions, but differ in the presence or absence of mucosal lesions and general symptoms [14].

According to the International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) -WHO Version for (2016) the following forms of MEEt (L51 Erythema multiforme) are distinguished: L51.0 Nonbullous erythema multiforme, L51.1 Bullous erythema multiforme, Stevens- Johnson syndrome, L51.2 Toxic epidermal necrolysis [Lyell], L51.8 Other erythema multiforme, L51.9 Erythema multiforme, unspecified [9].

As the disease develops acutely, it demands to start the treatment at an early stage. However, cystic syndrome in the oral cavity appears at a number of dermatoses (Lyell's syndrome, acantholytic and nonacantholytic pemphigus, bullous pemphigoid, Duhring’s disease, bullous form of lichen ruber planus, vesico-vascular syndrome, acute herpetic stomatitis), which requires timely differential diagnosis of this condition. One of the methods of diagnosis of MEE is cytology. It is relatively informative, non-invasive, it takes little time and acceptable to patients.

The aimof the study was to investigate the features of the cytological picture under toxic-allergic form of multiforme exudative erythema in oral cavity.

Materials and methods. The study included 15 patients with MEE (6 men and 9 women), aged 26-57 years, directed to the department for consultation. We adhered to the domestic interpretation of the diagnosis formulation and considered the type of MEE in patients as a toxic-allergic, which corresponds to the code L51.1 Bullous erythema multiforme, Stevens-Johnson syndrome ICD-10. All patients, after removing the pellicle, underwent the sampling of the contents of erosion by scraping. The material was fixed in a solution of methanol, stained by Romanovsky-Giemsa method. In cytological preparations it was studied the qualitative and quantitative composition of hematogenous and histiogenouscellular elements.

Results. All patients reported rapid development of the disease, usually within 1-2 days. There was a sharp pain in the oral cavity even at rest, worse when speaking, tongue movements, eating. From the medical history we found that before the development of stomatitis the patients were treated, for various reasons, with medications (antibiotics, sulfonamides, nonsteroidal anti-inflammatory drugs, tranquilizers). It should be noted that here we indicate only groups of drugs, which, according to the literature, most common cause the toxic and allergic reactions. However, patients took, on their own or prescribed by a doctor, not only these drugs, but others (vitamins, desensitization, expectorants, antacid, etc.). Therefore, it is difficult to indicate the specific source of the drug allergic reactions.

On examination of the oral cavity there was observed diffuse or limited erythema and swelling of the mucous membranes of the lips, cheeks, floor of the mouth, tongue, soft palate. In some patients under this background, there were sharply painful large erosions, while others had multiple gray or white fibrinous pellicles, which were pulled off difficultly, at the same time exposing the bleeding erosion. Gingiva was intact. The patients had no skin lesions (Fig. 1).

Fig. 1. Patient S., 53 years old. Multiforme exudative erythema of the oral cavity

 

In preparations the cytologic picture is consistent with acute nonspecific inflammatory process: the accumulation of white blood cells, red blood cells, epithelial cells, microflora. Noteworthy is the presence in cytological preparations of all patients the unbroken eosinophils nearly in every field of view. A large number of unaltered neutrophils and their clusters with vacuolated cytoplasm are found (Fig. 2).

Fig. 2. The cellular structure of the contents of erosion at MEE. Staining by Romanovsky-Giemsa method. 700 × 1 - neutrophils, 2 - eosinophil, 3 - lymphocyte, 4 - erythrocyte

 

Almost in every field of view monocytes and lymphocytes are identified. Most often they also have vacuolated cytoplasm (Fig. 3).

Fig. 3. The cellular structure of the contents of erosion at MEE. Staining by Romanovsky-Giemsa method.×700: 1 – lymphocyte, 2 – monocyte, 3 - epithelium

 

In addition to monocytes of vasogenic origin, the tissular monocytes (histiocytes) are seen. They were found most often in the transformed form as polyblasts and macrophages, but the phagocytic reaction was weakly expressed. They had different sizes and shapes (Fig. 4).

Fig. 4. The cellular structure of the contents of erosion at MEE. Staining by Romanovsky-Giemsa method. ×700: 1 – polyblasts,2 - macrophage

 

It was observed the sporadic epithelial cells in the state of hydropic degeneration or their layers (Fig. 5). Microbial background was represented scantily, mainly with coccal flora.

Fig. 5. The cellular structure of the contents of erosion at MEE. Staining by Romanovsky-Giemsa method. ×280: epithelial cells in the state of hydropic degeneration

 

The role of many cells in the wound fluid is studied well enough. The presence of eosinophils, in most cases, evidences of allergic reactions. Their detection in the content of erosions should set up a specialist on an appropriate genesis of a pathological condition. Lymphocytes and other mononuclear cells constitute the majority of wound exudate cells, they play a key role in the immune response, taking part in the processes aimed at maintaining homeostasis, the regulation of the inflammation intensity. Monocytes actively phage and digest microbes, erythrocytes and other cells. Circulating monocytes migrate into the inflammatory focus and differentiate into exudate macrophages. These cells, often with T-lymphocytes, constitute an inflammatory exudate. It is believed that polyblasts are formed partially from the lymphocytes by hypertrophy of the nucleus and protoplasm, partially from to tissue histiocytes. Polyblasts role in wound focus is enormous, they produce immune bodies, and in other words, they are involved in the development of tissue immunity, in cleaning wounds from bacteria and dead cells and in regenerative processes [4, 12].

Conclusions. Thus, in a material of erosion at multiforme exudative erythema the morphological structure is typical for nonspecific inflammation. Gistiogenous and hematogenous elements are preferentially undestroyed with vacuolated cytoplasm. Cells are represented by eosinophils, lymphocytes, monocytes with transformation into polyblasts and macrophages.

 

References:

  • 1. Григорьев Д.В. Многоформная экссудативная эритема, синдром Стивенса–Джонсона и синдром Лайелла – современная трактовка проблемы // РМЖ. - 2013. - №22. - С. 1073.
  • 2. Иванов О.Л., Халдина М.В. Многоформная экссудативная эритема, клинические, иммунологические и терапевтические особенности // Лечащий врач. - 2003. - №9. - C. 4-9.
  • 3. Клинический случай развития многоформной экссудативной эритемы, токсико-аллергического типа / Якубович А.И., Цыренова С.А., Осипова Е.А. // Сибирский медицинский журнал (Иркутск). -  2015. - № 1. - С. 113-115.
  • 4. Эозинофилы в отпечатках раны. Лимфоциты в цитологии раны [Электронный ресурс]. – Режим доступа: http://meduniver.com/Medical/Biology/423.html
  • 5. A importância das provas epicutâneas de contacto no diagnóstico diferencial de reações a medicamentos / Ana Rita Travassos, David Pacheco, Joana Antunes [et al.] // Anais Brasileiros de Dermatologia. – 2011. – Vol. 86(4, Suppl. 1). – P. 21-23.
  • 6. Bassi A., D'Erme A. M., Gola M. Erythema multiforme-like irritant contact dermatitis after application of an antiscabies treatment // International journal of immunopathology and pharmacology. – 2011. – Vol. 24(2). – P. 545-547.
  • 7. Exudative Erythema Multiforme Due to Cyclobenzaprine / Gómez Torrijos E., García Arpa M., García Rodríguez C. [et al.] // J Investig Allergol Clin Immunol. – 2016. – Vol. 26(4). – P. 265-266.
  • 8. Imashuku S., Kudo N. Chlamydia Pneumoniae Infection-Associated Erythema Multiforme // Pediatric Reports. – 2013. – Vol. 5(2). – P. 35-37.
  • 9. International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10)-WHO Version for; 2016. http://apps.who.int/classifications/icd10/browse/2016/en#/L50-L54
  • 10. Kamala K.A., Ashok L., Annigeri R.G. Herpes associated erythema multiforme // Contemp Clin Dent. – 2011. –Vol, 2. – P. 372-375
  • 11. Llamazares A.A., Beitia-Mazuecos J.M., Cardenas-Contreras R., Vega-Castro A., Mateo-Borrega B. Ibuprofen-Induced exudative erythema multiforme after 1 week of continued therapy following oral challenge // Journal of Investigational Allergology and Clinical Immunology. – 2012. – Vol. 22(5). – P. 376-377.
  • 12. Van Furth R. Human monocytes and cytokines // Research in immunology. – 1998. – Vol. 149(7). – P. 719-720.
  • 13. Vargas-Hitos J.A., Manzano-Gamero M.V., Jiménez-Alonso J. Erythema multiforme associated with Mycoplasma pneumoniae // Infection. - 2014. Vol. 42(4). – P. 797-798.
  • 14. Williams P.M., Conklin R.J. Erythema multiforme: A review and contrast from Stevens-Johnson syndrome/toxic epidermal necrolysis // Dent Clin North Am. – 2005. – Vol. 49. – P. 67–76.
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Comments: 6

Tegza Alexandra

Уважаемый Юрий Владимирович и соавторы! Спасибо за интересную, показательную работу! Обширные, исследования аллергических реакций в настоящее время, когда стремительно расширяется спектр медицинских препаратов, являются актуальными и своевременными. Желаю Вам и в дальнейшем интересных, глубоких исследований! С уважением Александра Тегза

Lakhtin Yuriy Vladimirovich

Уважаемая Александра Алексеевна! Благодарим Вас за признание нашей работы и добрые пожелания. С уважением, авторский коллектив.

Ruden' Vasyl' Volodymyrovych

Як завжди - цікаве, змістовне і потрібне для практичної охорони здоров'я наукове дослідження. Бажаю, шановному Юрію Володимировичу і науковій команді, подальших творчих успіхів! З повагою, проф Василь Рудень

Lakhtin Yuriy Vladimirovich

Дякуємо, шановний Василь Володимирович, за високу оцінку нашої роботи. З найкращими побажаннями, колектив авторів.

Kuliyeva Hokuma

Уважаемые авторы! Я не врач, вообще не медик, но с 18 -ти лет (так уж получилось, надо было работать и учиться) я работала в больницах. И в настоящее время как автор книги "Медицинская энтомология" (2016) мне интересны результаты работ, проведенные в этой области. Из названия вашей работы видно, что она имеет значение, а после ознакомления результатами и представленными иллюстративными материалами, можно убедительно отметить, что Ваши исследования заслуживают положительной оценки. Тема актуальная, выполнена на соответствующем уровне. Желаю Вам благополучия и успехов в ваших дальнейших исследованиях. hokuma kuliyeva

Lakhtin Yuriy Vladimirovich

Многоуважаемая профессор Хокума Кулиева! Спасибо за положительную оценку нашей работы. После публикации на сайте к нам обратились еще два пациента с многоформной экссудативной эритемой (изолированной в полости рта). Из анамнеза выяснено, что они принимали один и тот же препарат сульфаниламидной группы. Так что проблема токсико-аллергических реакций в медицине остается актуальной. Желаем Вам добра, новых научных идей и успехов. С уважением, коллектив авторов.
Comments: 6

Tegza Alexandra

Уважаемый Юрий Владимирович и соавторы! Спасибо за интересную, показательную работу! Обширные, исследования аллергических реакций в настоящее время, когда стремительно расширяется спектр медицинских препаратов, являются актуальными и своевременными. Желаю Вам и в дальнейшем интересных, глубоких исследований! С уважением Александра Тегза

Lakhtin Yuriy Vladimirovich

Уважаемая Александра Алексеевна! Благодарим Вас за признание нашей работы и добрые пожелания. С уважением, авторский коллектив.

Ruden' Vasyl' Volodymyrovych

Як завжди - цікаве, змістовне і потрібне для практичної охорони здоров'я наукове дослідження. Бажаю, шановному Юрію Володимировичу і науковій команді, подальших творчих успіхів! З повагою, проф Василь Рудень

Lakhtin Yuriy Vladimirovich

Дякуємо, шановний Василь Володимирович, за високу оцінку нашої роботи. З найкращими побажаннями, колектив авторів.

Kuliyeva Hokuma

Уважаемые авторы! Я не врач, вообще не медик, но с 18 -ти лет (так уж получилось, надо было работать и учиться) я работала в больницах. И в настоящее время как автор книги "Медицинская энтомология" (2016) мне интересны результаты работ, проведенные в этой области. Из названия вашей работы видно, что она имеет значение, а после ознакомления результатами и представленными иллюстративными материалами, можно убедительно отметить, что Ваши исследования заслуживают положительной оценки. Тема актуальная, выполнена на соответствующем уровне. Желаю Вам благополучия и успехов в ваших дальнейших исследованиях. hokuma kuliyeva

Lakhtin Yuriy Vladimirovich

Многоуважаемая профессор Хокума Кулиева! Спасибо за положительную оценку нашей работы. После публикации на сайте к нам обратились еще два пациента с многоформной экссудативной эритемой (изолированной в полости рта). Из анамнеза выяснено, что они принимали один и тот же препарат сульфаниламидной группы. Так что проблема токсико-аллергических реакций в медицине остается актуальной. Желаем Вам добра, новых научных идей и успехов. С уважением, коллектив авторов.
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