Case and Research Letter
Acquired Epidermodysplasia Verruciformis in a Patient With Congenital HIV Infection
Epidermodisplasia verruciforme adquirido en un paciente con infección congénita por VIH
G.A. Castro-Perez
, I. Sorin, A.I. Bravo, L.D. Mazzuoccolo
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Departamentos de Dermatología, Anatomía Patológica y Unidad de Inmunopatología, Hospital Interzonal General de Agudos “Eva Perón”, Buenos Aires, Argentina
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Castro-Perez, I. Sorin, A.I. Bravo, L.D. Mazzuoccolo" "autores" => array:4 [ 0 => array:4 [ "nombre" => "G.A." "apellidos" => "Castro-Perez" "email" => array:1 [ 0 => "gimecastroperez@yahoo.com.ar" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "I." "apellidos" => "Sorin" ] 2 => array:2 [ "nombre" => "A.I." "apellidos" => "Bravo" ] 3 => array:2 [ "nombre" => "L.D." "apellidos" => "Mazzuoccolo" ] ] "afiliaciones" => array:1 [ 0 => array:1 [ "entidad" => "Departamentos de Dermatología, Anatomía Patológica y Unidad de Inmunopatología, Hospital Interzonal General de Agudos “Eva Perón”, Buenos Aires, Argentina" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Epidermodisplasia verruciforme adquirido en un paciente con infección congénita por VIH" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1250 "Ancho" => 1667 "Tamanyo" => 449936 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Large keratinocytes with voluminous nuclei, basophilic cytoplasm, and perinuclear halos in the epidermis (hematoxylin and eosin, original magnification 40×).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Epidermodysplasia verruciformis (EV) is a rare autosomal recessive genodermatosis characterized by a defect in cell-mediated immunity and increased susceptibility to infections by group B human papillomavirus (HPV).<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> Its main clinical features are a rash resembling pityriasis versicolor and flat warts distributed in sun-exposed areas. In the last decade, several cases of acquired EV have been reported, particularly in immunocompromised patients.</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 19-year-old White man with congenital human immunodeficiency virus (HIV) infection presented with a skin eruption of 4 years’ duration. Physical examination revealed a macular and papular eruption on the trunk and arms. There were multiple erythematous macules with desquamation on the chest and arms (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) and hundreds of disseminated small pink-brownish papules, with the appearance of flat warts, on the back of the trunk and on the shoulders and arms (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). The papules were arranged in a linear pattern (Koebner phenomenon). The lesions were asymptomatic, but had increased in number in recent months. At the time of his first evaluation the patient had a CD4 count of 544 cells/mm<span class="elsevierStyleSup">3</span> and an undetectable viral load. He was receiving highly active antiretroviral therapy (HAART) with raltegravir, ritonavir, tenofovir, and darunavir.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Skin biopsy of a papule on the trunk showed large keratinocytes with voluminous nuclei, basophilic cytoplasm, and perinuclear halos (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). HPV type 5 was isolated using the nested polymerase chain reaction technique at the department of oncogenic viruses of the National Institute of Infectious Diseases Dr. Carlos Malbran.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Based on the above clinical and histological features, we made a diagnosis of EV-like eruption.</p><p id="par0025" class="elsevierStylePara elsevierViewall">For treatment we decided to divide the back into 4 quadrants. The first quadrant was treated with topical tretinoin 0.05% cream, applied once daily for 2 months, while the second quadrant was treated with topical imiquimod 5% gel, applied once daily for 3 months. The third and fourth quadrants were treated with electrocauterization and cryosurgery, respectively. The patient was also advised to take sun protection measures.</p><p id="par0030" class="elsevierStylePara elsevierViewall">After 3 months of treatment, we found that none of the therapeutic options had yielded satisfactory results. The patient is still receiving HAART and undergoes periodic skin examination. No signs of malignant transformation have been detected.</p><p id="par0035" class="elsevierStylePara elsevierViewall">EV-like eruption is an HPV-related disease that is rarely seen in immunocompromised patients.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–6</span></a> It is caused by mutations in two genes, <span class="elsevierStyleItalic">EVER1</span> and <span class="elsevierStyleItalic">EVER2</span>, located on chromosome 17q25. It was first described in kidney transplant recipients<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> and then in HIV-positive patients.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In the HIV-positive population, men and women are equally affected. Lowe et al.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>proposed that this entity was more frequent in young, vertically HIV-infected patients than in adults infected later in life. This would be because younger patients would be infected by HPV when their cell-mediated immunity was already affected by HIV. On the contrary, by the time older patients are infected with HIV, they have developed better immune mechanisms against HPV infection.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> The skin lesions appear years after HIV diagnosis following a long period of immunosuppression, and tend to be chronic and refractory to the different therapies available.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2,6</span></a> The mucosal membranes are usually unaffected.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Typical histological findings are acanthosis, a prominent granular layer, vacuolated keratinocytes with perinuclear halos and blue-gray pallor cytoplasm, and rare koilocytotic keratinocytes.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">According to the literature, the progression of cutaneous lesions is not influenced by the immunological status of the patient and response to treatment is poor.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2–6</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The most frequent HPV strains implicated in skin eruptions are HPV subtypes 5 and 8.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2,5,6,8,9</span></a> Co-infection with other HPV types has also been documented in several publications.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2,6</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">When oncogenic HPV subtypes are involved, cutaneous lesions can progress to invasive nonmelanoma skin cancer (mostly Bowen disease and invasive squamous cell carcinomas<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>) after several years of cellular immunodeficiency and sun exposure.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">While this is not the first report of EV-like eruption in a patient with congenital HIV, we believe that it is of educational value and would like to stress the importance of determining the type of HPV involved in the development of disease in order to estimate the degree of oncogenic potential. We also believe it is important to closely follow all patients with EV-like eruptions, with periodic complete skin examinations, skin biopsy of suspicious lesions, avoidance of radiation therapies, improvement of immunological status, and strong recommendations to avoid sun exposure.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1221 "Ancho" => 1584 "Tamanyo" => 176373 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Pityriasis versicolor-like macules on the chest and arms.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1667 "Ancho" => 1252 "Tamanyo" => 259960 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Hundreds of flat warts on the back of the trunk and on the shoulders and arms (Koebner phenomenon).</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1250 "Ancho" => 1667 "Tamanyo" => 449936 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Large keratinocytes with voluminous nuclei, basophilic cytoplasm, and perinuclear halos in the epidermis (hematoxylin and eosin, original magnification 40×).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Epidermodysplasia verruciformis in human immunodeficiency virus-infected patients" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S. 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 7 | 9 | 16 |
| 2024 Octubre | 58 | 55 | 113 |
| 2024 Septiembre | 81 | 26 | 107 |
| 2024 Agosto | 103 | 55 | 158 |
| 2024 Julio | 77 | 35 | 112 |
| 2024 Junio | 68 | 31 | 99 |
| 2024 Mayo | 65 | 31 | 96 |
| 2024 Abril | 78 | 23 | 101 |
| 2024 Marzo | 63 | 30 | 93 |
| 2024 Febrero | 91 | 27 | 118 |
| 2024 Enero | 74 | 30 | 104 |
| 2023 Diciembre | 79 | 13 | 92 |
| 2023 Noviembre | 66 | 25 | 91 |
| 2023 Octubre | 34 | 15 | 49 |
| 2023 Septiembre | 46 | 25 | 71 |
| 2023 Agosto | 47 | 15 | 62 |
| 2023 Julio | 117 | 34 | 151 |
| 2023 Junio | 58 | 22 | 80 |
| 2023 Mayo | 75 | 27 | 102 |
| 2023 Abril | 58 | 16 | 74 |
| 2023 Marzo | 64 | 21 | 85 |
| 2023 Febrero | 123 | 21 | 144 |
| 2023 Enero | 74 | 23 | 97 |
| 2022 Diciembre | 93 | 43 | 136 |
| 2022 Noviembre | 101 | 40 | 141 |
| 2022 Octubre | 100 | 35 | 135 |
| 2022 Septiembre | 103 | 38 | 141 |
| 2022 Agosto | 71 | 56 | 127 |
| 2022 Julio | 84 | 52 | 136 |
| 2022 Junio | 134 | 54 | 188 |
| 2022 Mayo | 117 | 24 | 141 |
| 2022 Abril | 108 | 47 | 155 |
| 2022 Marzo | 82 | 62 | 144 |
| 2022 Febrero | 85 | 25 | 110 |
| 2022 Enero | 92 | 39 | 131 |
| 2021 Diciembre | 91 | 33 | 124 |
| 2021 Noviembre | 96 | 53 | 149 |
| 2021 Octubre | 79 | 50 | 129 |
| 2021 Septiembre | 75 | 35 | 110 |
| 2021 Agosto | 63 | 24 | 87 |
| 2021 Julio | 68 | 31 | 99 |
| 2021 Junio | 47 | 33 | 80 |
| 2021 Mayo | 39 | 47 | 86 |
| 2021 Abril | 146 | 88 | 234 |
| 2021 Marzo | 72 | 36 | 108 |
| 2021 Febrero | 57 | 43 | 100 |
| 2021 Enero | 47 | 22 | 69 |
| 2020 Diciembre | 37 | 13 | 50 |
| 2020 Noviembre | 33 | 20 | 53 |
| 2020 Octubre | 35 | 11 | 46 |
| 2020 Septiembre | 40 | 15 | 55 |
| 2020 Agosto | 35 | 19 | 54 |
| 2020 Julio | 30 | 13 | 43 |
| 2020 Junio | 22 | 25 | 47 |
| 2020 Mayo | 28 | 12 | 40 |
| 2020 Abril | 26 | 24 | 50 |
| 2020 Marzo | 37 | 21 | 58 |
| 2020 Febrero | 7 | 3 | 10 |
| 2020 Enero | 2 | 3 | 5 |
| 2019 Diciembre | 8 | 3 | 11 |
| 2019 Noviembre | 2 | 0 | 2 |
| 2019 Septiembre | 10 | 1 | 11 |
| 2019 Agosto | 4 | 5 | 9 |
| 2019 Julio | 4 | 5 | 9 |
| 2019 Junio | 4 | 6 | 10 |
| 2019 Mayo | 7 | 7 | 14 |
| 2019 Abril | 3 | 5 | 8 |
| 2019 Marzo | 0 | 8 | 8 |
| 2019 Febrero | 7 | 1 | 8 |
| 2019 Enero | 2 | 0 | 2 |
| 2018 Diciembre | 2 | 4 | 6 |
| 2018 Noviembre | 3 | 3 | 6 |
| 2018 Octubre | 2 | 1 | 3 |
| 2018 Septiembre | 6 | 1 | 7 |
| 2018 Julio | 0 | 3 | 3 |
| 2018 Mayo | 0 | 1 | 1 |
| 2018 Abril | 0 | 1 | 1 |
| 2018 Marzo | 0 | 3 | 3 |
| 2018 Febrero | 91 | 2 | 93 |
| 2018 Enero | 103 | 5 | 108 |
| 2017 Diciembre | 105 | 6 | 111 |
| 2017 Noviembre | 84 | 4 | 88 |
| 2017 Octubre | 88 | 7 | 95 |
| 2017 Septiembre | 111 | 9 | 120 |
| 2017 Agosto | 124 | 8 | 132 |
| 2017 Julio | 126 | 5 | 131 |
| 2017 Junio | 116 | 13 | 129 |
| 2017 Mayo | 81 | 9 | 90 |
| 2017 Abril | 42 | 8 | 50 |
| 2017 Marzo | 39 | 43 | 82 |
| 2017 Febrero | 124 | 10 | 134 |
| 2017 Enero | 70 | 7 | 77 |
| 2016 Diciembre | 73 | 12 | 85 |
| 2016 Noviembre | 156 | 12 | 168 |
| 2016 Octubre | 172 | 25 | 197 |
| 2016 Septiembre | 165 | 7 | 172 |
| 2016 Agosto | 50 | 7 | 57 |
| 2016 Julio | 42 | 6 | 48 |
| 2016 Junio | 10 | 11 | 21 |
| 2016 Mayo | 6 | 0 | 6 |
| 2016 Abril | 6 | 0 | 6 |
| 2016 Marzo | 4 | 0 | 4 |
| 2016 Febrero | 11 | 4 | 15 |
| 2016 Enero | 12 | 0 | 12 |
| 2015 Diciembre | 18 | 8 | 26 |
| 2015 Noviembre | 6 | 0 | 6 |
| 2015 Octubre | 7 | 0 | 7 |
| 2015 Septiembre | 4 | 1 | 5 |
| 2015 Agosto | 8 | 3 | 11 |
| 2015 Julio | 179 | 0 | 179 |
| 2015 Junio | 127 | 0 | 127 |
| 2015 Mayo | 111 | 0 | 111 |
| 2015 Abril | 115 | 1 | 116 |
| 2015 Marzo | 174 | 1 | 175 |
| 2015 Febrero | 154 | 1 | 155 |
| 2015 Enero | 115 | 0 | 115 |
| 2014 Diciembre | 139 | 0 | 139 |
| 2014 Noviembre | 90 | 0 | 90 |
| 2014 Octubre | 119 | 0 | 119 |
| 2014 Septiembre | 119 | 0 | 119 |
| 2014 Agosto | 93 | 0 | 93 |
| 2014 Julio | 87 | 0 | 87 |
| 2014 Junio | 92 | 0 | 92 |
| 2014 Mayo | 91 | 0 | 91 |
| 2014 Abril | 66 | 0 | 66 |
| 2014 Marzo | 122 | 8 | 130 |
| 2014 Febrero | 98 | 19 | 117 |
| 2014 Enero | 99 | 12 | 111 |
| 2013 Diciembre | 58 | 5 | 63 |
| 2013 Noviembre | 55 | 10 | 65 |
| 2013 Octubre | 22 | 26 | 48 |
| 2013 Septiembre | 5 | 4 | 9 |
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