From : Date: 16 /11/2010

The Prof and Head,

Dept of Pathology,

Vijayanagara Institute of Medical Sciences,

Bellary-583104.

To:

The Registrar,

Rajiv Gandhi University of Health sciences,

Bangalore-560041.

THROUGH PROPER CHANNEL

Respected Sir,

Subject: Submission of synopsis for Registration of subject for Dissertation

As per the regulation of the university for dissertation topic, the following post graduate student in M.D (Pathology) has been allotted the dissertation topic as Follows:-

NAME / TOPIC / GUIDE
Dr. ANITHA. M
Post Graduate Student in M.D. Pathology,
Dept of Pathology,
V.I.M.S, Bellary. / “HISTOPATHOLOGICAL STUDY OF NONINFECTIOUS VESICULOBULLOUS LESIONS OF SKIN”. / DR. SHANTHI. M
Professor
Dept. of pathology
VijayanagraInstitute of Medical Sciences, Bellary.

Therefore, I kindly request you to communicate after the acceptance of the dissertation topic allotted to the PG student at an early date.

Thanking you,

Yours faithfully,

DR. NARASIMHA MURTHY

Professor and Head

Dept. of Pathology

V.I.M.S, Bellary.

From : Date: 16 /11/2010

Dr. ANITHA. M

Post Graduate Student in Pathology (M.D)

Dept of Pathology

V.I.M.S, Bellary.

To:

The Principal,

Vijayanagar Institute of Medical sciences,

Bellary.

THROUGH PROPER CHANNEL

Respected Sir,

Subject: Submission of synopsis for Registration of subject for Dissertation

In accordance with fulfillment of the MD Pathology course. I, the undersigned studying PG course in M D Pathology have been allotted the dissertation topic. “HISTOPATHOLOGICAL STUDY OF NONINFECTIOUS VESICULOBULLOUS LESIONS OF SKIN”. Under the guidance of DR SHANTHI M, Dept. of Pathology, Vijayanagar Institute of Medical Sciences, Bellary.

I request you to kindly forward the synopsis in the prescribed form to the University for approval.

Thanking you,

Yours faithfully,

Signature of the guide DR. ANITHA M

DR SHANTHI M

Professor

Dept. of Pathology

Vijayanagar Institute of Medical Sciences,

Bellary.

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA, BANGALORE.

ANNEXURE II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1 / Name of the candidate and
address / DR.ANITHA. M
POST GRADUATE IN M.D. PATHOLOGY
DEPARTMENT OF PATHOLOGY,
VIMS, BELLARY.
2 / Name of the Institution / VIJAYANAGAR INSTITUTE OF
MEDICAL SCIENCES, BELLARY.
3 / Course of the study and subject / MD IN PATHOLOGY.
4 / Date of admission to the course / 17.06.2010
5 / Title of the topic / HISTOPATHOLOGICAL STUDY OF NONINFECTIOUS VESICULOBULLOUS LESIONS OF SKIN.
BRIEF RESUME OF INTENDED WORK
6.1. Need for study
Skin forms not only a protective covering but is a part of the specialized immune
apparatus of the body. Immune perturbations as a part of disease pathogenesis are reflected in the skin and compared with other organ systems of the body. It is easily accessible for biopsy. By histopathology and direct immunofluorescence (DIF), presence of immune complexes in the skin biopsy at various locations such as the dermo-epidermal junction (DEJ), dermal blood vessels, etc. help to arrive at a diagnosis The aim of this study is to analyze the contribution of immunofluorescence in diagnosing noninfectious bullous lesions of the skin in comparison with histopathology and clinical diagnosis. The study is also undertaken to analyze the prevalence of various bullous lesions in the skin that are amenable to biopsy and are referred to an immunopathologist for definite diagnosis. This would help in understanding the relative prevalence of different vesiculobullous lesions presenting to a tertiary care center, VIMS,Bellary.
6.2 Review of Literature.
The bullous diseases have a history as old as that of medicine. In the early 1950’s, Lever was able to differentiate most of these by using histological criteria 1. The term pemphigus refers to a group of autoimmune blistering diseases of skin and mucous membranes which are characterized histologically by intraepidermal blisters due to acantholysis. Acantholysis is the characteristic feature of the bullae of pemphigus2 and is defined immunopathologically by the finding in vivo, of bound and circulating IgG directed against the cell surface of keratinocytes 1.
Acantholysis, a process by which epidermal cells lose their cohesiveness is the essential abnormality in the pemphigus group of disorders. Cytological examination (Tzanck smear) of the intact bulla is one of the methods for the demonstration of these acantholytic cells.2
A retrospective study at St. Johns hospital of 100 DIF’s( direct immunofluorescence),histology and clinic data on suspected vesiculobullous lesions of skin showed that sensitivity of DIF was 88% in Pemphigus group.82% in Bullous pemphigoid,and 28% in Dermatitis Herpetiformis.DIF is of great value in the diagnosis of vesiculobullous lesions, specially in clinical /histologic dilemma. 3
A Clinicopathological Study Of 22 Cases Of Pemphigus at JSS Medical College showed an accurate histological diagnosis is essential for the therapy. The association of clinical and histopathological features helps to arrive at the diagnosis in most cases. The study also revealed additional features which are not encountered normally, like the extrusion of adnexal structures into the bulla cavity and the extension of spongiosis and acantholysis into the adnexal epithelium.. Immunofluorescence study helped in confirming the diagnosis where histopathology and clinical features alone were inconclusive.4
A study done in Pakistan showed Pemphigus vulgaris was found to be the most frequent autoimmune blistering lesion of skin and Bullous pemphigoid was the most frequent subepidermal autoimmune blistering lesions.Direct immunofluorescent staining and subsequent microscopy is a useful tool in establishing the exact diagnosis of vesiculobullous disorders of skin..5
The most important techniques for the investigation of patients with noninfectious vesiculobullous disease are histopathology, and direct and indirect immunofluorescence. Research techniques such as immunoblotting and immunoelectron microscopy may refine the diagnosis in the individual patient but do not replace the clinical findings 6
Pemphigus may be precipitated by drugs (with or without antibody formation): penicillamine, captopril, enalapril and others and Neoplasia like lymphoma, bronchogenic squamous cell carcinoma and others8.
OBJECTIVES OF THE STUDY
1. To study the incidence of noninfectious vesiculobullous lesions in VIMS , Bellary
2 To correlate clinical, histologic findings and direct immunofluorescence study of various noninfectious vesiculobullous lesions.
MATERIALS AND METHODS
7.1. SOURCE OF DATA
The Clinical data and biopsies taken from the patients admitted or attending outpatient of Department of Skin &STD, VIMS, Bellary form the subjects and material for our study.
7.2. a) METHOD OF COLLECTION OF DATA
A written informed consent are taken from all patients included in the
Study. History-taking, relevant clinical findings and Tzanck’s smear will be done for these patients Skin biopsies obtained from these patients are submitted to Department of Pathology for a study period of one year, January 2011 to June 2012. The histopathological and immunofluorescent evaluations of biopsies are done in the Department of Pathology. Two biopsies are taken from each patient ,one is sent in 10% formalin for histopathology study and other in Michelle’s medium for DIF.The biopsy material sent in 10% formalin are subjected to routine processing and paraffin embedding. Multiple serial sections are taken from each biopsy and are stained with hematoxylin and eosin and special stain like PAS when required. Biopsies for DIF are obtained in holding fluid (Michelle's medium containing a saturated solution of ammonium sulfate in buffer at room temperature and stored at 4°C) is processed as follows. Before cutting, the biopsies are washed thrice in phosphate-buffered saline (PBS) (pH 7.2) for 15 min each time. Sections are taken with cryostat at 4– 5 micron thickness (minimum 10 sections) .For staining,the sections are first brought to room temperature. Optimally diluted fluorescein isothiocyanate (FITC)-labeled monospecific immunoglobulin’s (IgG, IgA, IgM, C3) are layered onto the sections and incubated at 37°C for 45 min– 1 h. Then, the sections were washed in PBS (pH 7.2, 0.1 M) thrice and mounted in buffered glycerin and finally viewed under Immunofluorescent microscope ,OLYMPUS-UCMAD-3,Prog ResCT3
INCLUSION CRITERIA
All patients presenting with Noninfectious vesiculobullous lesions including Drug eruptions presenting to Department of Skin And STD during January 2011 to June 2012.
EXCLUSION CRITERIA
Patients with genetic blistering diseases, bullous lesions due to physical ,chemical, biological, metabolic factors and eczemas.
b) SAMPLE SIZE AND DURATION OF STUDY:
Patients with vesiculobullous lesions presenting to Department of Skin &STD, are taken up for study at histopathology and immunology section of Pathology Department, VIMS Bellary between January 2011 to June 2012, subject to inclusion/exclusion criteria.
7.3. DOES THE STUDY REQUIRE ANY INVESTIGATIONS OR
INTERVENTIONS TO BE CONDUCTED ON PATIENTS OR OTHER
HUMANS OR ANIMALS?
Histopathology and Immunofluorescence are carried out with informed consent of patients. These investigations form part of special clinical management of patient. Histopathological and Immunofluorescence examination are done in Department of Pathology under guidance and supervision of guide.
7.4  . HAS ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR
INSTITUTION?
Yes, Ethical Clearance has been obtained from Institutional Ethical Committee (IEC) of VIMS, Bellary.
LIST OF REFERENCES:
1. Wu H, Schapiro B, Harrist TJ. Noninfectious vesiculobullous and vesiculopustular diseases. In Elder DE, Elenitsas R, Johnson BLJ, Murphy GF. ed.
Lever’s histopathology of skin, 9th ed. Philadelphia:
Lippincott Williams and Wilkins, 2005..Lever WF. Pemphigus and pemphigoid. Charles C. Thomas. Spring field, IL: 1965
2 Minz RW, Chhabra S, Singh S, Radotra BD, Kumar B. Direct immunofluorescence of skin biopsy: Perspective of an immunopathologist. Indian J Dermatology Venereal Leprol [serial online] 2010 [cited 2010 Oct 19];76:150-73.
3. Indian Journal of pathology- 2007 Oct;50(4):730-2 .Cohen LM, Skopicki DK, Harrist TJ, Clark WH Jr. Noninfectious vesiculobullous and vesiculopustular diseases
4. JCDR original article June 2010 Vol-4.Issue 3
5 Pak J Med Sci April - June 2010 Vol. 26 No. 2 411-415,. Non infectious vesiculobullous and vesiculopustular diseases..
6 .Rook’s Text book of Dermayology; Eighth Edition ;Volume 2 Immunobullous Diseases, 40.1 F. Wojnarowska & V.A. Venning
7. Swarnalatha G, Reddy JS. Direct fluorescence on Tzanck smears: A rapid test to confirm Pemphigus. Indian J Dermatol Venereol Leprol 2001;67:218
8.http:// dermnetnz.org/contact.html-Blistering skin disease. Created 2008, updated 15 June 2009, NZDSI
9 / Signature of the candidate
10 / Remarks of the guide
11 / Name and designation of the
11.1. Guide / Dr. SHANTHI M
PROFESSOR
DEPARTMENT OF PATHOLOGY,
VIMS, BELLARY.
11.2. Signature
11.3.Co Guide / Dr.VEERESH
PROFESSOR
DEPARTMENT OF SKIN&STD
VIMS,BELLARY.
11.4 Signature
11.5. Head of the Department / Dr. NARASIMHA MURTHY.
PROFESSOR & HEAD,
DEPARTMENT OF PATHOLOGY
VIMS, BELLARY.
11.6. Signature
12 / 12.1. Remarks of the Chairman
and Principal
12.2. Signature.