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

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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 ×100) 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.

Introduction

Cytology is a diagnostic tool used to investigate the characteristics of individual cells. In this method, materials obtained in a variety of ways are transferred to a glass slide, stained with various dyes, and then examined under the light microscope.1 As a method for the diagnosis of cutaneous disorders, cytology was first used by Arnault Tzanck in 1947.1, 2 Although it was suggested as a simple, rapid, and reliable technique to be used in the diagnosis of many diseases during the following 6 decades, the practice of cytodiagnosis has been limited to a few diseases.2 To date, therefore, only a few studies have examined the dermatological use and diagnostic value of this method.2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19 The majority of these studies have related to herpetic infections,3, 4, 5, 6, 7 pemphigus,8, 9 cutaneous leishmaniasis,10 and cutaneous neoplasms, especially basal cell carcinoma.11, 12, 13, 14, 15, 16, 17

In this prospective study, we aimed to describe the Tzanck smear findings in patients with erosive, vesicular, bullous, and pustular skin lesions and determine the sensitivity and specificity of this test in some of the skin diseases studied. We also intended to develop an algorithmic approach for diagnosis of moist skin lesions using Tzanck smear test findings.

Section snippets

Patients

Patients with erosive, vesicular, bullous, and pustular skin lesions who applied to the Department of Dermatology, Başkent University Faculty of Medicine, Adana Hospital between January 2006 and January 2008 and could not be diagnosed only by dermatological physical examination were included in the study. Demographic, clinical, and laboratory data including patients' age, sex, lesion types, characteristic cytologic findings, and the diagnostic methods used were recorded. The local ethical

Results

Four hundred patients (217 [54.2%] women and 183 [45.8%] men) were included in the study. The patients' ages ranged between 2 and 68 years (mean, 36 years). Of the lesions, 176 (44%) were vesicular, 116 (29%) were erosive, 63 (15.8%) were pustular, and 45 (11.2%) were bullous (Table I).

In addition to May-Grünwald-Giemsa staining, methylene blue and Gram staining was performed in 12 (3%) and 25 (6.3%) patients, respectively, while direct immunofluorescence examination was conducted in 28

Discussion

Tzanck smear findings in 400 patients with erosive, vesicular, bullous, and pustular skin lesions reported in this study had skin diseases which are known to be diagnosable by this method as noted in the literature.1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17

For herpes simplex and varicella-zoster infections in which acantholytic and multinucleated giant cells are diagnostic, the percentage of positivity of the Tzanck test for herpes simplex has been reported between 53.1%3 and 86%,

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  • Cited by (0)

    Funding sources: None.

    Conflicts of interest: None declared.

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