Mete Baba

The value of Tzanck smear test in diagnosis of erosive, vesicular, bullous, and pustular skin lesions

BACKGROUND Tzanck smear is generally used for the diagnosis of the pemphigus group of autoimmune bullous diseases and mucocutaneous herpesvirus infections. There are only a few studies in the literature investigating its diagnostic value. OBJECTIVES We aimed to investigate Tzanck smear findings and to determine the diagnostic value of this test in moist (erosive, vesicular, bullous, and pustular) skin lesions. We also aimed to develop an algorithmic approach for the diagnosis of these types of skin lesions according to the Tzanck smear findings. METHODS Samples were stained with May-Grünwald-Giemsa and evaluated by the same dermatologist. In some patients, methylene blue and Gram staining or direct immunofluorescence examinations were additionally performed. In all of the study cases, after the evaluation of clinical and laboratory findings (including, when appropriate, potassium hydroxide examination; viral serology; bacterial and fungal cultures; histopathology; direct and indirect immunofluorescence; patch testing), the definite diagnosis was established. We also determined the sensitivity and the specificity of certain Tzanck smear findings. RESULTS Tzanck smear was performed in a total of 400 patients with moist skin lesions. The sensitivities of multinucleated giant cells and acantholytic cells in herpetic infections, dyskeratotic acantholytic cells and cocci in bullous impetigo, pseudohyphae in candidiasis, acantholytic cells in pemphigus and more than 10 tadpole cells (magnification x100) in spongiotic dermatitis were 84.7%, 92%, 100%, 100%, and 81.5%, respectively. LIMITATIONS Because Tzanck smears were evaluated by the same dermatologist, no comment could be made regarding the interobserver reliability of this test and how the level of experience with this technique might affect the results. Also, the sensitivity and the specificity of Tzanck smear test findings for certain diseases could not be calculated because of an insufficient number of patients. CONCLUSION The Tzanck smear test is an inexpensive, useful, and an easy diagnostic tool for certain skin diseases.

More experiences with the Tzanck smear test: cytologic findings in cutaneous granulomatous disorders.

BACKGROUND Granulomatous dermatitis is a distinctive histopathologic cutaneous reaction pattern against various infectious and noninfectious agents. Cytologically, granulomatous dermatitis shows granulomas and multinucleated giant cells. Various etiologic agents of granulomatous diseases can also be identified. OBJECTIVE We aimed to investigate Tzanck smear findings in granulomatous skin diseases. METHODS Patients who had granulomas and/or multinucleated giant cells of Langhans, foreign body- and/or Touton type in Tzanck smear tests were included in the study. In these patients, Tzanck preparations were then further evaluated for additional cytologic findings. Samples stained with May-Grünwald-Giemsa stain were evaluated by the same dermatologist throughout the study. In some patients, methylene blue, Gram and/or Erlich-Ziehl-Nielsen stains were also performed. In all of the study cases, the final diagnosis was established after the evaluation of clinical and laboratory findings (including, when appropriate, potassium hydroxide examination; bacterial, leishmanial, and fungal cultures; histopathology; tuberculosis and leishmania polymerase chain reaction). We also calculated the sensitivity and specificity of the Leishman-Donovan body for cutaneous leishmaniasis. RESULTS Over a 2-year period, 94 of 950 patients (9.9%) in whom Tzanck smear tests were performed had cytologic findings consistent with a granulomatous reaction. In 74 (78.7%) and 20 (21.3%) patients, the granulomatous reaction was due to infectious and noninfectious causes, respectively. Infectious causes included cutaneous leishmaniasis in 65 patients (87.8%), candidal granuloma in two patients, botyromycosis in two patients, and aspergillosis, blastomycosis, mucormycosis, leprosy, and cutaneous tuberculosis in one patient each. In 58 of 74 patients (78.4%) with infectious granulomatous dermatitis, the causes of the granulomas were identified. Noninfectious granulomatous reactions were due to granuloma annulare in 7 patients, sarcoidosis in 5 patients, a foreign body in 4 patients, necrobiosis lipoidica in 2 patients, and juvenile xanthogranuloma in 2 patients. In 17 of 20 patients (85%) with noninfectious granulomatous reactions, the cytologic findings were characteristic of the final diagnoses. The sensitivity and specificity of Leishman-Donovan bodies for cutaneous leishmaniasis were 76.9% and 100%, respectively. LIMITATIONS All of the samples were evaluated by the same dermatologist throughout the study; therefore no comment could be made regarding the reliability of the Tzanck smear test. In addition, the sensitivity and specificity of Tzanck smear test findings for diseases other than cutaneous leishmaniasis could not be calculated because of an insufficient number of patients. CONCLUSION The Tzanck smear test may be a useful diagnostic tool for certain granulomatous skin diseases.

Cutaneous manifestations in brucellosis: a prospective study.

Brucellosis remains an important public health problem in Turkey, just as it is in other regions of the world. This study was conducted to determine the types and rates of cutaneous lesions that occur in patients with brucellosis. Brucellosis was diagnosed by standard tube agglutination testing forBrucella antibodies at a titer of 1/160 or higher in the presence of compatible clinical findings. A total of 140 patients who had been given a diagnosis of brucellosis were prospectively observed in the dermatology clinic. Of these patients, 102 (72.9%) were female, with a mean age of 44.11±18.22 y, and 38 (27.1%) were male, with a mean age of 46.44±14.58 y. The duration of symptoms was less than 2 mo (acute) in 75 patients (53.5%), from 2 to 12 mo (subacute) in 30 patients (21.4%), and longer than 12 mo (chronic) in 35 patients (25.0%). Cutaneous findings related to brucellosis were observed in 8 (5.71%) of the 140 cases. Maculopapular eruptions were observed in 2 patients (25%), erythema nodosum-like lesions in 2 (25%), psoriasiform lesions in 1 (12.5%), palmar erythema in 1 (12.5%), malar eruption in 1 (12.5%), and palmar eczema in 1 (12.5%). The investigators concluded that although cutaneous findings encountered in brucellosis are generally not specific to this disease, the presence of these findings may be useful in diagnosing brucellosis in persons who live in, or used to live in, endemic regions.

Dermatoscopy versus Tzanck smear test: a comparison of the value of two tests in the diagnosis of pigmented skin lesions.

BACKGROUND Dermatoscopy is the most commonly used noninvasive tool for the diagnosis of pigmented skin lesions, but few studies have investigated the value of cytology in the identification of those lesions. OBJECTIVE We compared the accuracy of dermatoscopy with that of the Tzanck smear test in the diagnosis of pigmented skin lesions, and in differentiating melanocytic from nonmelanocytic lesions. METHODS Two dermatologists used either dermatoscopy or the Tzanck smear test to evaluate pigmented skin lesions, and the diagnostic accuracy of those methods was determined. RESULTS Two hundred pigmented skin lesions (110 melanocytic and 90 nonmelanocytic) were evaluated. Cytology was superior to dermatoscopy in differentiating melanocytic pigmented lesions from nonmelanocytic pigmented lesions, but the overall diagnostic accuracy of those methods was the same (90.5%) for all lesions. The diagnostic accuracy of the Tzanck smear test was higher than that of dermatoscopy for both melanocytic and nonmelanocytic malignant pigmented lesions; however, those differences were not significant. LIMITATIONS Pigmented skin lesions were not evaluated by a dermatologist who used a combination of dermatoscopy and the Tzanck smear test. No conclusion was made about the reliability of those two methods or whether the experience of the dermatologist affected the results. Immunohistochemical staining of the cytologic samples was not performed. CONCLUSION The diagnostic accuracy of the Tzanck smear test in assessing pigmented skin lesions is similar to that of dermatoscopy. The Tzanck smear test may be a useful diagnostic adjunct to dermatoscopy for determining the melanocytic or nonmelanocytic origin of certain pigmented skin lesions.

Diagnostic reliability of the Tzanck smear in dermatologic diseases

Background  The Tzanck smear is a simple, easily applicable, rapid, and inexpensive test for the diagnosis of erosive vesiculobullous, tumoral, and granulomatous diseases. The diagnostic accuracy of the Tzanck smear is known, but its diagnostic reliability has been evaluated only in herpetic infections and basal cell carcinoma.

Pimecrolimus: a new choice in the treatment of vitiligo?

keratinocytes cultured on the DED, expression of differentiation markers such as keratin 1, keratin 10 and filaggrin was much decreased or absent. These results indicate that dermal fibroblasts controls epidermal morphogenesis in three-dimensional culture models by delaying keratinocyte differentiation. However, further studies are required to evaluate the components of epidermal differentiation by biochemical analysis.

A case with two unusual findings: cutaneous leishmaniasis presenting as panniculitis and pericarditis after antimony therapy.

Background  Cutaneous leishmaniasis is a parasitic disease caused by a Protozoan. Clinically and histopathologically, it can be confused with various dermatologic diseases.

A Useful Alternative Approach for the Treatment of Well‐Demarcated Basal Cell Carcinoma: Surgical Excision and Margin Control with Tzanck Smear Test

OBJECTIVE To analyze the accuracy of the Tzanck smear test (TST) for margin control in surgery for well‐demarcated basal cell carcinoma (BCC). METHODS AND MATERIALS Twenty‐one patients with well‐demarcated BCC were included in this study. After local anesthesia, the tumors were excised. The pathologist examined the frozen sections. If the tumor cells were observed in the margin, a re‐excision was done. This procedure was repeated until the margin was tumor free. After each excision, Tzanck smear samples were taken from the defect area. The samples obtained were stained with May‐Grünwald‐Giemsa and examined. The accuracy of TST was then analyzed by comparison of the TST results with those of frozen section examination. RESULTS The sensitivity and specificity of TST for margin assessment were 1.00 (95% confidence interval (CI)=1.00–1.00) and 0.99 (95% CI=0.98–1.00), respectively. Positive and negative predictive values and the diagnostic accuracy for TST were 0.94 (95% CI=0.84–1.05), 1.00 (95% CI=1.00–1.00), and 1.00 (95% CI=0.99–1.00), respectively. No recurrences were observed in the average 2‐year follow‐up period. CONCLUSION The high accuracy of TST for margin control is encouraging to develop a practical alternative approach for the treatment of well‐demarcated BCC.

Localized Hair Breakage Caused by Ants

duced a clearance in his acne after 7 months. The clinical features and management of the three previous patients compared with our patient are outlined in Table 1. In the previous reported patients 2 and 3, a history of an inflamed acne lesion prior to localized facial swelling led the authors to postulate that a nodulocystic flare secondary to isotretinoin was the cause of the subsequent severe inflammatory reaction (2). The flare of acne lesions observed with isotretinoin is thought to be due to a sudden change in the microenvironment of Propionobacteria acnes and the death of these organisms causing release of soluble inflammatory mediators into the circulation (4). The presence of a large number of macrocomedones is considered to be a focus for inflammatory mediators transforming macrocomedones into inflamed lesions (4). Our patient had a large number of macrocomedones and had new inflamed acne lesions detected just prior to facial swelling. This suggests that he may have had a similar nodulocystic flare while on isotretinoin, leading to facial swelling. He also showed a rapid response to stopping isotretinoin and commencement of oral steroids. Only one previous instance of generalized facial swelling during isotretinoin treatment has been reported, and this patient was diagnosed as having facial cellulitis (1). An association of S. aureus colonization and isotretinoin treatment is well known (5,6). The clinical features of our patient, however, were not typical of facial cellulitis or erysipelas, and he was systemically well. Antibiotics were added as a precaution in our patient while oral steroids were commenced. We feel this reaction cannot be explained by an infective cause alone and suggest that isotretinoin is involved in precipitating severe facial erythema and swelling, even in low doses. Antibiotics used alone have not been successful in controlling this reaction (2). Clearance of acne can be obtained after careful reintroduction of isotretinoin under oral steroid cover. Combining isotretinoin and oral steroids at the beginning of treatment for nodulocystic acne has been suggested as beneficial in preventing flares of acne (7) and may also prevent this severe reaction of facial swelling.