Review Question - QID 214331

A 24-year-old woman presents to the emergency department for extreme oral pain with eating and multiple painful blisters. She has a past medical history of lupus and was treated for lower extremity cellulitis with antibiotics 2 weeks ago. She has no additional past medical history and takes no medications. She has had a sore throat, malaise, and fever (103°F on home thermometer) for 3 days. Her temperature is 98.2°F (36.8°C), blood pressure is 110/70 mmHg, pulse is 64/min, and respirations are 14/min. On physical exam she has multiple painful, vesiculobullous skin lesions located on her trunk and extremities, which are estimated to affect 9% of her body surface area. There are multiple ulcers on the mucosal surface of both her oral and genital regions. The lesions demonstrate a positive Nikolsky sign. Figure A demonstrates the lesions. A biopsy is obtained and sent for staining and direct immunofluorescence. Which of the following microscopic findings is most consistent with this condition?