Gingival pemphigus vulgaris preceding cutaneous lesion: A rare case report
A 36-year-old married female [], resident of Pune, housewife by occupation referred by Department of Dermatology, Command Hospital Pune for the gingival lesion to division of Periodontics, Department of dental surgery, AFMC, Pune, with chief complaint of burning sensation of the oral cavity for the last 3 months. The patient was apparently asymptomatic before 3 months. She noticed ulcers in the mouth [] and felt severe burning sensation, specially aggravated on taking hot and spicy food. The vesicles on the gum ruptured to produce pain and severe itching in the mouth. She also noticed small eruptions over skin on face, back [Figures and ] extremities just 3 weeks before, for which she reported to the dermatologist.\nThe medical history and family history was clear and patient was not taking any other drugs and had no ocular or genital lesions. The patient had a proper oral hygiene habit without any deleterious habits.\nOn general physical examination, the patient was moderately built and nourished with vital signs within normal limits. She had numerous flaccid vesicles and ruptured bullae of varying diameter seen over the back and nose, which are mainly seen as ulcerated eroded surfaces. On extra oral examination no relevant findings were observed.\nOn intra-oral examination, denuded and spontaneously bleeding gingival zones were revealed. The clinical picture of persistent superficial ulcers with a positive Nikolsky's sign strongly suggested a vesicullobulous disorder. Based on the history, clinical signs, and symptoms of both intaoral and extraoral lesions, a provisional diagnosis of desquamative gingivitis was given.\nAfter routine hemogram, urine and blood sugar examination of patient was taken up for incisional perilesional biopsy with intact epithelium. The sample was sent for histopathological examination in normal saline to Department of Pathology.\nThe patient was taken back to Department of Dermatology for opinion and biopsy of skin was taken from back for histopathological examination and for the direct immunofluorescence assay in Michel's solution. On histopathological examination, acantholysis was revealed along areas of ulceration without dysplastic changes with polymorphonuclear leucocytes infiltration. Basal cells of epithelium remained attached to the basement membrane. Higher resolution showed perivesicular edema with loss of cohesiveness and hyperchromatic epithelial cells called “Tzank cells” [Figures and ], suggesting diagnosis of pemphigus vulgaris. The direct immunofluorescence showed intercellular deposition of C3, IgG, and IgM in stratum spinosum [Figures and ] confirming the diagnosis of pemphigus vulgaris.\nThe oral lesions were treated with 0.1% Triamcinolone acetonide ointment and skin lesion with topical application of 0.05% Clobetasol with Soframycin twice daily. Prednisolone 20_mg twice daily with multivitamins was administered systemically. The patient is under control and still under review [].