Carlson J Andrew, Chen Ko-Ron
Division of Dermatology, Albany Medical College, MC-81, Albany, NY 12208, USA.
Am J Dermatopathol. 2007 Feb;29(1):32-43. doi: 10.1097/01.dad.0000245198.80847.ff.
Most biopsies of cutaneous vasculitis will exhibit a small vessel neutrophilic vasculitis [leukocytoclastic vasculitis (LCV)] that is associated with immune complexes on direct immunofluorescence examination or, less commonly, antineutrophilic cytoplasmic antibodies (ANCA) by indirect immunofluorescence testing. Is in uncommon for skin biopsy to reveal solely a neutrophilic arteritis signifying the presence of cutaneous polyarteritis nodosa or, if accompanied by significant lobular panniculitis, nodular vasculitis/erythema induratum. In other cases, cutaneous vascular damage (fibrinoid necrosis, muscular vessel wall disruption, or endarteritis obliterans) will be mediated by a nonneutrophilic inflammatory infiltrate. Eosinophilic vasculitis can be a primary (idiopathic) process that overlaps with hypereosinophilic syndrome, or it can be a secondary vasculitis associated with connective tissue disease or parasite infestation. Authentic cutaneous granulomatous vasculitis (versus vasculitis with extravascular granulomas) can represent a cutaneous manifestation of giant cell arteritis, an eruption secondary to systemic disease such as Crohn's disease or sarcoidosis, or a localized disorder, often a post-herpes zoster (HZ) phenomenon. Lymphocytic vasculitis is a histologic reaction pattern that correlates with broad clinical differential diagnosis, which includes connective tissue disease - mostly systemic lupus erythematosus (SLE), endothelial infection by Rickettsia and viruses, idiopathic lichenoid dermatoses such as perniosis or ulcerative necrotic Mucha-Habermann disease, and angiocentric cutaneous T-cell lymphomas. Skin biopsy extending into the subcutis, identifying the dominant inflammatory cell and caliber of vessels affected, extravascular histologic clues such as presence of lichenoid dermatitis or panniculitis, and correlation with clinical data allows for accurate diagnosis of these uncommon vasculitic entities.
大多数皮肤血管炎活检显示为小血管嗜中性血管炎[白细胞破碎性血管炎(LCV)],在直接免疫荧光检查中与免疫复合物相关,或较少见地通过间接免疫荧光检测与抗中性粒细胞胞浆抗体(ANCA)相关。皮肤活检仅显示嗜中性动脉炎提示皮肤结节性多动脉炎的存在并不常见,或者,如果伴有显著的小叶性脂膜炎,则提示结节性血管炎/硬结性红斑。在其他情况下,皮肤血管损伤(纤维蛋白样坏死、肌性血管壁破坏或闭塞性动脉内膜炎)将由非嗜中性炎症浸润介导。嗜酸性血管炎可以是与高嗜酸性粒细胞综合征重叠的原发性(特发性)过程,也可以是与结缔组织病或寄生虫感染相关的继发性血管炎。真正的皮肤肉芽肿性血管炎(与伴有血管外肉芽肿的血管炎相对)可表现为巨细胞动脉炎的皮肤表现、继发于克罗恩病或结节病等全身性疾病的皮疹,或一种局限性疾病,通常是带状疱疹后(HZ)现象。淋巴细胞性血管炎是一种组织学反应模式,与广泛的临床鉴别诊断相关,包括结缔组织病——主要是系统性红斑狼疮(SLE)、立克次体和病毒引起的内皮感染、特发性苔藓样皮肤病如冻疮或溃疡性坏死性穆查-哈伯曼病,以及血管中心性皮肤T细胞淋巴瘤。皮肤活检深入皮下组织,确定主要炎症细胞和受累血管的管径、血管外组织学线索如苔藓样皮炎或脂膜炎的存在,并与临床数据相关联,有助于准确诊断这些不常见的血管性疾病。