Search

Background: Pemphigus vulgaris (PV) is a potentially life-threatening mucocutaneous autoimmune disease that affects desmoglein-1 and desmoglein-3, leading to intraepithelial vesiculobullous lesions. In the oral mucosa, PV lesions can mimic other diseases such as mucous membrane pemphigoid, other forms of pemphigus, recurrent aphthous stomatitis, erythema multiforme, Stevens-Johnson syndrome, and virus-induced ulcers like herpes simplex virus (HSV), making diagnosis challenging. The co-occurrence of PV with Crohn's disease is rare and predominantly seen in younger patients. The therapeutic mainstay for both PV and Crohn's disease usually involves systemic corticosteroids combined with immunosuppressants and immunobiological drugs. Literature indicates that the use of these drugs, particularly TNF-alpha inhibitors, for managing autoimmune diseases like Crohn's can potentially induce other autoimmune diseases known as autoimmune-like syndromes, which include episodes of lupus-like syndrome and inflammatory neuropathies. There are few cases in the literature reporting the development of PV in individuals with CD undergoing infliximab therapy. Case report. A young female with severe Crohn's disease, treated with the TNF-alpha inhibitor infliximab, developed friable pseudomembranous oral ulcerations. Histopathological and immunofluorescence analyses confirmed these as PV. The treatment included clobetasol propionate and low-level photobiomodulation, which resulted in partial improvement. The patient later experienced severe intestinal bleeding, requiring intravenous hydrocortisone therapy, which improved both her systemic condition and oral lesions. Weeks later, new ulcerations caused by herpes virus and candidiasis were identified, leading to treatment with oral acyclovir, a 21-day regimen of oral nystatin rinse, and photodynamic therapy, ultimately healing the oral infections. To manage her condition, the gastroenterologists included methotrexate (25 mg) in her regimen to reduce the immunogenicity of infliximab and minimize corticosteroid use, as the patient was in remission for Crohn's disease, and the oral PV lesions were under control. Conclusion: Young patients with Crohn's disease should be referred to an oral medicine specialist for comorbidity investigation, as oral PV and opportunistic infections can arise during immunosuppressive therapy. The use of TNF-alpha inhibitors in patients treated for inflammatory bowel disease, such as Crohn's, should be carefully evaluated for potential side effects, including oral PV. [ABSTRACT FROM AUTHOR]

Background: Assessment of oral epithelial dysplasia is the gold standard for investigating the risk of malignant progression. The World Health Organization (WHO) methods and the binary system have limitations. This study assess the inter- and intra-observer variability of the architectural and cytological criteria and the classification of the presence and degree of epithelial dysplasia in oral lichen planus (OLP) and oral lichenoid lesion (OLL), using both the 2017 WHO criteria and the binary system., Material and Methods: The sample consisted of 65 biopsies from lesions classified as OLP and OLL according to the American Academy of Oral and Maxillofacial Pathology (AAOMP) criteria. The histological slides were reevaluated by two oral pathologists., Results: The individual alterations with most inter-observer disagreement were atypical mitotic figures (43.1%), loss of cohesion between epithelial cells (38.5%) and drop shape rete ridges ridges (38.5%). Inter-observer agreement analysis did not show statistically significant agreement regarding the classification of epithelial dysplasia grade by WHO criteria, only regarding the binary system classification (k=0.257; p =0.035). Intra-observer agreement analysis by evaluator 1 showed that the classification of epithelial dysplasia grade according to both methods had statistically significant agreement (k=0.546; p =0.004, k=0.861; p <0.001). Considering evaluator 2, only the evaluation of the WHO system classification showed statistically significant agreement (k=0.593; p =0.010)., Conclusions: The evaluation of epithelial dysplasia is subjective and focal changes and inflammatory infiltrate, characteristic of OLP and OLL, can increase the degree of disagreement among evaluators. The binary system presents better inter-observer agreement, while the WHO system presents better intra-observer agreement. Key words: Oral lichen planus, oral lichenoid lesion, oral lichenoid disease, dysplasia, inter-observer variation., Competing Interests: Conflicts of interest No conflict of interest to disclose., (Copyright: © 2024 Medicina Oral S.L.)