Viral glycoproteins in herpesviridae granulomas

A case of an atypical resistant granulomatous HSV-1 and HSV-2 ulceration in an AIDS patient treated with intralesional cidofovir

We report a case of a granulomatous skin lesion in an AIDS patient whereby biopsy revealed both HSV-1 and HSV-2. This lesion was resistant to acyclovir and successfully treated with intralesional cidofovir without recurrence to date. This is the only known reported case of a granulomatous skin lesion in an HIV patient, whereby both HSV-1 and HSV-2 were isolated.

Disseminated, persistent, and fatal infection due to the vaccine strain of varicella-zoster virus in an adult following stem cell transplantation

Live attenuated varicella vaccine is recommended for healthy individuals who are susceptible to varicella. Although the vaccine is safe, effective, and used worldwide, serious adverse events have been reported, mainly in immunocompromised patients who subsequently recovered. Here, we describe the fatality of an immunocompromised patient who received the varicella vaccine. His medical history provides a cautionary lens through which to view the decision of when vaccination is appropriate. A middle-aged man with non-Hodgkin lymphoma received chemotherapy and a stem cell transplant. He was vaccinated 4 years post-transplantation, despite diagnosis of a new low-grade lymphoma confined to the lymph nodes. Within 3 months of vaccination, he developed recurrent rashes with fever, malaise, weakness, hepatitis, weight loss, and renal failure. The syndrome was eventually determined to be associated with persistent disseminated zoster caused by the vaccine virus. This case illustrates a circumstance when a live viral vaccine should not be used.

Granuloma annulare as an isotopic response to herpes zoster

BACKGROUND

Wolf's isotopic response is the phenomenon of a new skin disease occurring at the site of another unrelated and already healed skin disorder. Most cases in the literature report herpes zoster (HZ) as the original disease; however, the isotopic responses vary greatly. Including this case, our literature search revealed 32 cases of isotopic granuloma annulare (GA) following HZ.

CASE REPORT

An 82-year-old male presented with GA localized to the right T9 dermatome that later appeared at other sites on the trunk and extremities. The patient had an episode of shingles involving the same dermatome 4 years earlier.

DISCUSSION

To our knowledge, this is the first case report of GA occurring initially as an isotopic response in an HZ scar and subsequently becoming generalized. Thirty-eight percent (12 of 32) of patients with isotopic GA following HZ were immunocompromised, which is similar to the published rate of immunodeficiency in patients with HZ.

Live rubella virus vaccine long-term persistence as an antigenic trigger of cutaneous granulomas in patients with primary immunodeficiency

Granulomas may develop as a response to a local antigenic trigger, leading to the activation of macrophages and T-lymphocytes. Primary immunodeficiency (PID) is associated with the development of extensive cutaneous granulomas, whose aetiology remains unknown. We performed high-throughput sequencing of the transcriptome of cutaneous granuloma lesions on two consecutive index cases, and RT-PCR in a third consecutive patient. The RA27/3 vaccine strain of rubella virus-the core component of a universally used paediatric vaccine-was present in the cutaneous granuloma of these three consecutive PID patients. Controls included the healthy skin of two patients, non-granulomatous cutaneous lesions of patients with immunodeficiency, and skin biopsy samples of healthy individuals, and were negative. Expression of viral antigens was confirmed by immunofluorescence. Persistence of the rubella vaccine virus was also demonstrated in granuloma lesions sampled 4-5 years earlier. The persistence of the rubella virus vaccine strain in all three consecutive cutaneous granuloma patients with PID strongly suggests a causal relationship between rubella virus and granuloma in this setting.

Granulomatous skin lesions complicating Varicella infection in a patient with Rothmund-Thomson syndrome and immune deficiency: case report

Rothmund-Thomson syndrome (RTS)(OMIM 268400) is a rare autosomal recessive genodermatosis characterized by poikiloderma, small stature, skeletal and dental abnormalities, cataract and an increased risk of cancer. It is caused by mutations in RECQL4 at 8q24. Immune deficiency is not described as a classical feature of the disease. Here we report the appearance of granulomatous skin lesions complicating primary Varicella Zoster Virus infection in a toddler with Rothmund Thomson syndrome and immune deficiency. Although granulomatous disorders are sometimes seen after Herpes zoster, they are even more rare after Varicella primary infection. Granulomas have hitherto not been described in Rothmund-Thomson syndrome. With this report we aim to stress the importance of screening for immune deficiency in patients with Rothmund-Thomson syndrome.

Chronic mucocutaneous herpes simplex virus and varicella zoster virus infections

Chronic herpes simplex virus (CHSV) and chronic varicella zoster virus (CVZV) are defined as atypical mucocutaneous wart-like and/or ulcerative HSV or VZV infections, persisting for at least 1 month. Both are commonly associated with HIV infection and may occasionally present with other types of immunosuppression. CHSV and CVZV occur despite the immune restoration effect of highly active antiretroviral therapy for HIV. The clinical polymorphism of CHSV and CVZV makes recognition difficult. Histology, immunohistology, PCR and viral culture all help to confirm the diagnosis. Treatment is frequently complicated by resistance to thymidine kinase (TK)-dependent antivirals, including acyclovir, valacyclovir and famciclovir. Viral culture remains an essential tool for antiviral drug susceptibility testing. Therapeutic alternatives include non-TK-dependent antivirals, such as foscarnet or cidofovir, which directly target viral DNA polymerase. With few exceptions, CHSV and CVZV infections do not constitute significant risk factors for disseminated cutaneous or systemic infection. This review compares the similarities of and differences between CHSV and CVZV infections.

Cutaneous Vasculitis Update: Neutrophilic Muscular Vessel and Eosinophilic, Granulomatous, and Lymphocytic Vasculitis Syndromes

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.

Granuloma annulare on herpes zoster scars in a Hodgkin's disease patient following autologous peripheral stem cell transplantation

Various cutaneous lesions including granulomatous reactions may occur at sites of resolved herpes zoster infection. A 46-year-old man with Hodgkin's disease developed localized granuloma annulare lesions on herpes zoster scars 3 months after allogeneic peripheral stem cell transplantation. This is the first case of granuloma annulare localized on herpes zoster scars that developed following peripheral stem cell transplantation.

Varicella-Zoster-Virus Folliculitis Promoted Clonal Cutaneous Lymphoid Hyperplasia

Post herpes zoster (HZ) reactions have been associated with panoply of neoplastic, inflammatory, and fibro-inflammatory cutaneous disorders. Varicella zoster virus (VZV) DNA has not been identified in most of these reports. After an episode of HZ, a healthy, active 90-year-old female developed ulcerative nodules in the affected trigeminal V1 dermatome and the contra-lateral trigeminal region over a 1-year period. Excision and/or biopsy of all these lesions showed similar pathologic changes that consisted of herpetic folliculitis, adjacent dense mixed nodular lymphocytic infiltrates with germinal centers (cutaneous lymphoid hyperplasia (CLH)), and in the deeper excision specimens, an obliterative vasculitis of a vessel with smooth muscle in its wall. Immunophenotype analysis revealed a mixed, predominate T- and B-cell population without loss of pan-T cell antigens or aberrant expression by B cells of T-cell antigens. Polymerase chain reaction for herpetic DNA was positive for VZV DNA. Lymphocyte gene rearrangement analysis revealed 2 distinct, anatomically and chronologically, monoclonal B-cell populations and a monoclonal T-cell population in one nodule. Treatment with valacyclovir has lead to almost complete resolution of her cutaneous nodules after 6 months of therapy. In this case, it can be surmised that persistence of VZV infection and lack of effective cell-mediated immunity lead to development of both immunopathology (vasculitis) and excessive lymphoid cell proliferation (CLH).

Granulomatous folliculitis at sites of herpes zoster scars: Wolf's isotopic response

Cutaneous eruptions described on herpes zoster scars are variable. We present a case of granulomatous folliculitis occurring 4 weeks after an episode of herpes zoster infection in a woman with cutaneous T-cell lymphoma. The pathogenesis of the lesions remains unclear. The viral genome was detected only in early lesions.

Isotopic response after herpesvirus infection: an update

The term postherpetic isotopic response describes the occurrence of a new, unrelated disease that appears at the same location as a previously healed herpetic infection. When dealing with the pathogenetic mechanism involved in the isotopic response, several possibilities should be considered: a viral origin, an immunologic origin, a vascular origin, and a neural origin. The aim of this article is to review and discuss the different pathogenetic mechanisms with particular attention to new information related to the possible neural origin of this abnormal response of the skin.

Granuloma annulare in herpes zoster scars

A 54-year-old Japanese female developed granuloma annulare twice in herpes zoster scars. Soon after the second event, she developed ulcerative colitis, which was well controlled by sulfonamides and corticosteroid suppository. She had no history of diabetes mellitus. There was no recurrence of granuloma annulare by June of 1999. Granuloma annulare might have contributed to the complications of ulcerative colitis, although this had not been noticed before.

Design of a case control etiologic study of sarcoidosis (ACCESS). ACCESS Research Group

Sarcoidosis is a chronic granulomatous disorder of unknown cause, characterized by activation of T-lymphocytes and macrophages. A Case Control Etiologic Study of Sarcoidosis (ACCESS) is a multicenter study designed to determine the etiology of sarcoidosis. The study organization includes 10 Clinical Centers, a Clinical Coordinating Center, specialized Core Laboratories, a Central Specimen Repository, and a Project Office at the National Heart, Lung, and Blood Institute. In addition to etiology, ACCESS will examine the socioeconomic status and clinical course of patients with sarcoidosis. We propose to enroll 720 newly diagnosed cases of sarcoidosis and compare them to 720 age, sex, and race matched controls and follow the first 240 cases for two years. Leads to the etiology of sarcoidosis have come from diverse sources: in clinical laboratory investigations, alveolitis has been found to precede granulomatous inflammation; in case control studies, familial aggregation has been identified; and in case reports, recurrence of granulomatous inflammation has been observed after lung transplantation. We describe the rationale for the study design based on genetic, environmental, infectious, and immune dysregulation hypotheses and the methods used for selecting controls. The cause may not prove to be a single, known exposure. Interactions of exposures with genetic predispositions would have important implications for our understanding of immune responses as well as the pathogenesis of sarcoidosis.

Herpes zoster in seven disparate dermatomes (zoster multiplex): report of a case and review of the literature

Noncontiguous multidermatomal herpes zoster is very rare in both immunocompetent and immunocompromised persons. Most of the reported cases have been limited to 2 noncontiguous dermatomes. This unique presentation has been referred to as zoster duplex unilateralis or bilateralis, depending on whether one or both halves of the body are involved. Granulomatous dermatitis at sites of herpes zoster scars, a rare isotopic response, has only been reported in persons with contiguous dermatomes of zoster. We describe an immunocompromised patient who developed herpes zoster in 7 disparate dermatomes. Three months after resolution of the zoster, the patient developed a granulomatous dermatitis in a zosteriform distribution at the sites of previous infection.

Chronic herpes simplex virus type I glossitis in an immunocompromised man

Herpes simplex virus (HSV) type 1 (HSV-1) infection of the tongue commonly accompanies acute primary herpetic gingivostomatitis. However, recurrent infection of the tongue is exceptional and is restricted to immunocompromised individuals. A 57-year-old man with corticosteroid-dependent chronic obstructive pulmonary disease and sciatica presented with a chronic median glossitis due to HSV-1. The main clinical and histological feature was massive necrosis of the entire mucosa. Immunohistochemistry demonstrated a considerable amount of HSV gB, gC and gD envelope glycoproteins dispersed in the chorion. In contrast, HSV-1 DNA was detected only in a limited number of epithelial cells using in situ hybridization. The extent of necrosis and the pattern of viral DNA and envelope protein distribution represent unique features of median herpetic glossitis, which are not found in more common types of HSV infection.

Cutaneous reactions at sites of herpes zoster scars: an expanded spectrum

Several types of cutaneous lesions have previously been described at the sites of herpes zoster scars. We describe 16 patients with cutaneous lesions which had developed on herpes zoster scars. Biopsies were taken from these lesions, and a polymerase chain reaction assay was used to detect the viral genome in paraffin-embedded specimens. Histopathological findings enabled diagnosis of nonspecific granulomatous dermatitis in five patients, granulomatous vasculitis in two patients, lichen sclerosus in two patients, and pseudolymphoma, keloid, sarcoidal granuloma, granuloma annulare, granulomatous folliculitis, lichen planus and cutaneous Rosai-Dorfman disease, each in one patient. Varicella-zoster virus DNA was not identified in any of the patients. Granulomatous folliculitis, lichen sclerosus and cutaneous Rosai-Dorfman disease have not previously been described in herpes zoster scars, but they are three new cutaneous reaction patterns that may have developed within these scars. Our investigations indicate that the cutaneous reactions appearing in herpes zoster scars are not due to the persistence of varicella-zoster virus DNA within the lesions.

Distribution of varicella zoster virus and herpes simplex virus in disseminated fatal infections

AIMS

To study the cutaneous and visceral distribution of herpes simplex virus (HSV) and varicella zoster virus (VZV) in fatal infections.

METHODS

Standard histology, immunohistochemistry (monoclonal antibodies VL8 and VL2 and polyclonal antibody IE63 directed against VZV; monoclonal antibodies IBD4 and HH2 and polyclonal antibodies directed against HSVI and HSVII) and in situ hybridisation (anti-HSV and anti-VZV probes) were applied to formalin fixed, paraffin wax sections.

RESULTS

On histological examination, Herpesviridae infection was evident in various organs including the lungs, liver and skin. In addition, immunohistochemistry and in situ hybridisation revealed the presence of HSV and VZV antigens and nucleic acids in several cell types and tissues showing no cytopathological alterations suggestive of Herpesviridae infection. The organs with histological evidence of infection also contained VZV or HSV antigens and their genes.

CONCLUSIONS

These findings suggest that organ failure in disseminated VZV and HSV infections is primarily caused by HSV or VZV induced cell damage and lysis. They also indicate that immunohistochemistry and in situ hybridisation can provide an accurate, type-specific diagnosis on formalin fixed, paraffin wax embedded tissue even when classic histological and cytological characteristics are lacking.

Recognition and treatment of shingles

Varicella zoster virus (VZV) is responsible for a primary infection (varicella) followed by a latency, eventually resulting in herpes zoster (shingles). The replication cycle of VZV is normally interrupted after varicella. Consequently, VZV remains dormant in the organism. Reactivation occurs after viraemia, and the development of tissue alterations (skin and viscera) depends on the immunological status of the patient. Diagnosis of herpes zoster relies on clinical recognition and cytological and histological evaluations combined with immunohistochemistry and molecular biology techniques. Treatment of herpes zoster primarily relies upon antiviral drugs and incidentally on immunomodulating agents, specific immunoglobulins, antimicrobial agents, antiviral enzymes and corticosteroids. Drugs with a clinically relevant activity against varicella zoster virus infections include aciclovir, adenosine monophosphate, bromodeoxyuridine, desciclovir, fiacitabine, idoxuridine, interferon-alpha and vidarabine. Among them, aciclovir appears to be a first-line agent. Its efficacy has been well established by many clinical studies. Promising drugs for the future include famciclovir, penciclovir, valaciclovir and other molecules currently under investigation. Recent and promising improvements in antiviral drug development may increase patient compliance, cost-benefit ratios and therapeutic efficacy.