Pathology · patient case question
A biopsy shows separation of the epithelium from the basement membrane. Referral to which specialist is most appropriate?
Patient case: Two white lesions and a brown one
demo: Three patients seen in one session
chief: Assorted mucosal lesions identified during routine examination.
history: The first is a 24-year-old with a lifelong asymptomatic finding whose brother has the same appearance. The second is a 41-year-old with bilateral buccal findings. The third is a 52-year-old who has chewed betel nut for twenty years.
meds: None relevant.
findings: Patient one has a diffuse, thick, spongy, folded white lesion of the floor of the mouth and buccal mucosa that does not rub off. Patient two has a diffuse blue-grey filmy opacity of both buccal mucosae that fades when the cheek is stretched. Patient three has brownish-red clustered staining of the buccal mucosa near teeth 18 and 19 with a marbled pallor and reduced mouth opening.
Show answer and explanation
Correct answer: C. Ophthalmologist
- A. Renal involvement does not feature in mucous membrane pemphigoid.
- B. There is no endocrine association with pemphigoid.
- C. Correct. Subepithelial separation at the basement membrane zone indicates mucous membrane pemphigoid. Its most serious complication is ocular involvement: conjunctival scarring, symblepharon and, if unrecognised, blindness. Ophthalmological referral is urgent even when the eyes appear normal, because early disease is easily missed.
- D. Haematological referral would be relevant to a bleeding or marrow disorder, not to a subepithelial blistering disease.
Note: Contrast this with pemphigus vulgaris, in which the split is intraepithelial from acantholysis, direct immunofluorescence shows a fishnet pattern, and the Tzanck test shows acantholytic cells.