Difficulties in the Diagnosis of Pemphigus Vulgaris. Case report

Pemphigus vulgarisis a rare, potentially fatal autoimmune disease characterized by intraepidermal blister formation and extensive erosions affecting the skin and mucous membranes. Despite considerable progress in understanding its pathogenesis and treatment, accurate diagnosis remains challenging due to nonspecific initial manifestations, particularly when presenting as oral mucosal erosions and aphthous-like lesions that are frequently misinterpreted, leading to diagnostic delays. This diagnostic difficulty is further exacerbated by insufficient awareness among primary care physicians, including dentists, otolaryngologists, and general practitioners. Establishing the diagnosis requires a comprehensive approach involving thorough history-taking to identify potential triggers, careful evaluation of clinical manifestations, cytological detection of Tzanck cells, histopathological confirmation of suprabasal acantholysis, direct and indirect immunofluorescence testing for intercellular IgG deposits, and serological detection of anti-desmoglein 1 and 3 antibodies. Many patients endure prolonged periods between symptom onset and definitive diagnosis, during which they may receive inappropriate management. This article is dedicated to the difficulties in diagnosing pemphigus vulgaris. The possible causes of diagnostic errors are considered, taking into account the similarity with other bullous dermatoses, as well as granulomatous diseases and neoplasms. We have described a clinical case of pemphigus vulgaris which the incorrect interpretation of acantholytic cells detected in smear preparations obtained from the surface of fresh erosions led to a misdiagnosis and an inappropriate treatment strategy.