Epidermodysplasia Verruciformis After Hematopoietic Stem Cell Transplantation in a Patient With Severe Combined Immunodeficiency Syndrome

ABSTRACT

Epidermodysplasia verruciformis (EV) is a rare dermatologic disorder that is characterized by skin-colored-to-light brown flat, discrete or confluent papules resembling verruca plana. EV is divided into 2 forms: a classical genetic form and an acquired form. Classical genetic EV is caused by mutations in EVER1 and EVER2 genes. Acquired EV develops in immunocompromised patients such as HIV-positive patients and transplant recipients. Patients with a prior history of hematopoietic stem cell transplantation (HSCT) have tendency to develop generalized verrucosis. We report an extraordinary case of disseminated epidermodysplasia verruciformis seen in a 7-year-old boy diagnosed with severe combined immunodeficiency syndrome who had undergone HSCT. He had plane, brown papules involving his face, forearms, neck, anterior chest, nape, back, and knees. Cutaneous biopsy showed typical characteristic findings of EV: large cells with gray-blue cytoplasm and keratohyaline granules of different sizes in the granular and spinous layers. Herein, we present an unusual case of disseminated EV in a HSCT patient with typical histopathologic findings and treatment options.

Acquired Epidermodysplasia Verruciformis in the Setting of Renal Transplant

ABSTRACT

Epidermodysplasia verruciformis (EV) is a rare dermatologic condition that is clinically characterized by flat, cutaneous, verrucous papules, pityriasis versicolor-like lesions, and similar lichenoid papules. There are 2 forms of EV: a classic inherited genodermatosis and a secondary acquired form. EV predisposes individuals to infections with certain types of human papillomavirus virus and subsequently increases the risk of cutaneous squamous cell carcinoma. The acquired form occurs in immunosuppressed patients, particularly in patients infected with HIV; however, it has also been described in patients who have undergone stem cell and solid organ transplantation. We report an additional case of renal transplantation and immunosuppressive therapy-associated acquired EV (AEV) in a 78-year-old man with multiple flesh-colored to violaceous, flat-topped papules distributed on the face and trunk clinically mimicking lichen planus. Biopsy was typical for that of EV, demonstrating enlarged keratinocytes with a blue-gray cytoplasm, a thickened granular layer, acanthosis, and hyperkeratosis. Herein, we discuss an unusual presentation of an AEV-mimicking lichen planus with review of the literature.

Inherited Interleukin 2-Inducible T-Cell (ITK) Kinase Deficiency in Siblings With Epidermodysplasia Verruciformis and Hodgkin Lymphoma

Biallelic mutations in the ITK gene cause a T-cell primary immunodeficiency with Epstein-Barr virus (EBV)-lymphoproliferative disorders. We describe a novel association of a homozygous ITK mutation with β-human papillomavirus (HPV)-positive epidermodysplasia verruciformis. Thus, loss of function in ITK can result in broad dysregulation of T-cell responses to oncogenic viruses, including β-HPV and EBV.

The human CIB1-EVER1-EVER2 complex governs keratinocyte-intrinsic immunity to β-papillomaviruses

Patients with epidermodysplasia verruciformis (EV) and biallelic null mutations of TMC6 (encoding EVER1) or TMC8 (EVER2) are selectively prone to disseminated skin lesions due to keratinocyte-tropic human β-papillomaviruses (β-HPVs), which lack E5 and E8. We describe EV patients homozygous for null mutations of the CIB1 gene encoding calcium- and integrin-binding protein-1 (CIB1). CIB1 is strongly expressed in the skin and cultured keratinocytes of controls but not in those of patients. CIB1 forms a complex with EVER1 and EVER2, and CIB1 proteins are not expressed in EVER1- or EVER2-deficient cells. The known functions of EVER1 and EVER2 in human keratinocytes are not dependent on CIB1, and CIB1 deficiency does not impair keratinocyte adhesion or migration. In keratinocytes, the CIB1 protein interacts with the HPV E5 and E8 proteins encoded by α-HPV16 and γ-HPV4, respectively, suggesting that this protein acts as a restriction factor against HPVs. Collectively, these findings suggest that the disruption of CIB1-EVER1-EVER2-dependent keratinocyte-intrinsic immunity underlies the selective susceptibility to β-HPVs of EV patients.

The biology of beta human papillomaviruses

The beta genus comprises more than 50 beta human papillomavirus (HPV) types that are suspected to be involved, together with ultraviolet (UV) irradiation, in the development of non-melanoma skin cancer (NMSC), the most common form of human cancer. Two members of the genus beta, HPV5 and HPV8, were first identified in patients with a genetic disorder, epidermodysplasia verruciformis (EV), that confers high susceptibility to beta HPV infection and NMSC development. The fact that organ transplant recipients (OTRs) with an impaired immune system have an elevated risk of NMSC raised the hypothesis that beta HPV types may also be involved in skin carcinogenesis in non-EV patients. Epidemiological studies have shown that serological and viral DNA markers are weakly, but significantly, associated with history of NMSC in OTRs and the general population. Functional studies on mucosal high-risk (HR) HPV types have clearly demonstrated that the products of two early genes, E6 and E7, are the main viral oncoproteins, which are able to deregulate events closely linked to transformation, such as cell cycle progression and apoptosis. Studies on a small number of beta HPV types have shown that their E6 and E7 oncoproteins also have the ability to interfere with the regulation of key pathways/events associated with cellular transformation. However, the initial functional data indicate that the molecular mechanisms leading to cellular transformation are different from those of mucosal HR HPV types. Beta HPV types may act only at early stages of carcinogenesis, by potentiating the deleterious effects of other carcinogens, such as UV radiation.

Cornoid Lamella-Like Structures in HIV-Associated Epidermodysplasia Verruciformis: A Unique Histopathologic Finding

Epidermodysplasia verruciformis (EV) is an uncommon inherited skin condition with increased vulnerability to widespread infection by certain human papillomavirus types, resulting in extensive verruca plana-like papules coalescing to large confluent plaques. Since the AIDS epidemic starting in the 1980s, an acquired type of EV has been described in patients infected with human immunodeficiency virus. The histopathologic features of EV consist of papillated epidermal hyperplasia with hypergranulosis and a distinct bluish-gray color in the large human papillomavirus-infected keratinocytes in the stratum granulosum. The authors present a case of HIV-associated EV with a unique histopathologic finding of multiple cornoid lamella-like structures. To the authors' knowledge, this finding has not been previously described in the literature.

Epidermodysplasia verruciformis: successful treatment with squaric acid dibutylester

Epidermodysplasia verruciformis (EV) is a rare disorder characterized by disseminated cutaneous warts in predisposed patients who are highly susceptible to genus ß-papillomavirus infections. We present the case of a 40-year-old lymphocytopenic woman with a balanced chromosomal translocation and a 25-year history of refractory EV that was successfully treated with squaric acid dibutylester (SADBE) contact immunotherapy.

Epidermodysplasia verruciformis

Epidermodysplasia verruciformis (EV) is a rare genodermatosis that predisposes certain individuals to developing cutaneous malignancies caused by infectious agents. Mutations in the transmembrane channel gene TMC6 or TMC8 create patient susceptibility to infections by human papillomavirus (HPV) and the development of EV-typical plane warts. Mainly in the UV-exposed regions, affected individuals have a lifelong increased risk for the development of cutaneous malignancy, especially squamous cell carcinoma (SCC). EV is the first disease to correlate cancer and viral infection, therefore EV now serves as the cornerstone to our understanding of viral oncogenesis. The EV model of cutaneous SCC may be applied to the general population; it is suggested that the TMC mutations impair the immunity of the patients, supporting the amplification of specific HPV types. Despite several advances in our comprehension of EV, the pathogenesis of the disease is not well understood.

Multifocal leiomyosarcomatosis in a 6-year-old child with epidermodysplasia verruciformis and immune defect

Leiomyosarcoma and epidermodysplasia verruciformis are rarely encountered in children. The association of either leiomyosarcoma or epidermodysplasia verruciformis with immune deficiency has previously been documented. A 6-year-old girl, who has had multifocal leiomyosarcomatosis after the previous diagnoses of epidermodysplasia verruciformis and immune defect, represents an interesting association of these features.

[Expressions of CD1a and CD83 of Langerhans cells in the local lesions of epidermodysplasia verruciformis patients]

OBJECTIVE

To investigate the expressions of CD1a and CD83 of Langerhans cells (LC) in the lesions of epidermodysplasia verruciformis (EV) patients.

METHODS

We used immunohistochemical method to detect the expressions of CD1a and CD83 in the lesions of 10 patients with EV lesions and in the skins of 10 normal subjects.

RESULTS

No CD83 + LCs was detected in all EV patients and normal controls, but CD1a + LC was found in all cases. The quantity of CD1a + LCs in the lesions of EV patients was significantly lower than that in the normal skin (P < 0.01); furthermore, the distribution of LCs in EV lesions was uneven.

CONCLUSION

The functions of LCs may be inhibited in EV patients.

[Pathogenesis of human papillomavirus infection in patients with epidermodysplasia verruciformis]

Epidermodysplasia verruciformis (EV), a rare inherited disease, is believed to be associated with human papillomavirus (HPV) infection. EVER1/2 genes, dendritic cells, T lymphocytes, and the biological characteristics of HPV itself may play roles in the pathogenesis of HPV infection.

Detection of antibodies against epidermodysplasia verruciformis-associated canine papillomavirus 3 in sera of dogs from Europe and Africa by enzyme-linked immunosorbent assay

The role of papillomaviruses (PVs) in the development of canine cancers is controversial. However, recently a novel canine PV (CPV3) was detected in a dog affected with a condition reminiscent of epidermodysplasia verruciformis (EV). The aim of the present study was to investigate the seroprevalence of CPV3 by using generic enzyme-linked immunosorbent assays (ELISAs) for the detection of antibodies against either canine oral PV (COPV) or CPV3. Therefore, the capsid proteins of both PV types were expressed as glutathione S-transferase fusion protein antigens and adsorbed to glutathione-casein-coated ELISA plates. After showing that PV type-specific antibodies could be detected in the sera from dogs with confirmed COPV or CPV3 infection, CPV3- and COPV-seropositive samples were detected in two sets of canine sera collected in Switzerland and South Africa, respectively. We found specific antibodies against COPV and CPV3 among the tested sera and also a large number that were positive for both antigens. The seroprevalences of PV antibodies of 21.9% (COPV) and 26.9% (CPV3) among the tested dogs from South Africa were higher than those among the dogs from Switzerland at 10.5% (COPV) and 1.3% (CPV3). Our data suggest a need for further CPV-related seroepidemiological surveys in different countries, especially in the context of clinical manifestations and possible breed predispositions. For this purpose, the newly developed ELISAs can be a useful tool.

Epidermodysplasia verruciformis occurring in a patient with human immunodeficiency virus: a case report

Epidermodysplasia verruciformis (EV) is an uncommon dermatosis associated with human papillomavirus (HPV) infection in association with defects in cell-mediated immunity. Malignant transformation to squamous cell carcinoma has been associated with lesions caused by HPV-5, HPV-8, and HPV-14. Clinically, the disease may be confused with verruca plana, seborrheic keratosis, and pityriasis versicolor. We present an unusual case of EV occurring in a human immunodeficiency virus (HIV)-positive man and discuss the clinical and histologic findings. Clinically, the patient had 1- to 3-mm hypopigmented smooth macules covering the entire body. Histopathologic examination of the skin biopsy results demonstrated enlarged keratinocytes with prominent blue-gray cytoplasm and clumping of keratohyalin granules within the granular layer of the epidermis. Although EV typically is viewed as a disease of childhood, sometimes presenting in patients with a family history of the disease, it rarely may be seen in immunocompromised adults.

Genetics of epidermodysplasia verruciformis: Insights into host defense against papillomaviruses

Epidermodysplasia verruciformis (EV) is a rare autosomal recessive genodermatosis associated with a high risk of skin carcinoma. EV results from an abnormal susceptibility to infection by specific human papillomavirus (HPV) genotypes (beta-papillomaviruses) which include the potentially oncogenic HPV5. EV-specific HPVs are considered as harmless for the general population. EV was recently found to be caused by invalidating mutations in two adjacent, related, novel genes, EVER1/TMC6 and EVER2/TMC8. EVER genes encode transmembrane proteins located in the endoplasmic reticulum, which are likely to function as modifiers of ion transporters or channels and to be involved in signal transduction. It was proposed that EV was a primary defect of innate immunity. Our hypothesis is that EVER proteins act as restriction factors for EV-specific HPVs in keratinocytes, and that EV represents a primary deficiency of intrinsic immunity against certain papillomaviruses.

Possible involvement of epidermodysplasia verruciformis human papillomaviruses in the immunopathogenesis of psoriasis: a proposed hypothesis

We have shown previously in psoriasis a very high prevalence of epidermodysplasia verruciforms-associated human papillomavirus 5 (EVHPV5) DNA and antibodies to human papillomavirus 5 (HPV5) virus-like particle (VLP) L1, and we suggested that this benign hyperproliferative disorder could be a reservoir for EVHPVs. Here we provide new data confirming the expression of EVHPVs in psoriasis and present our hypothesis on their possible involvement in the immunopathogenesis of the disorder. The new important finding was detection by radioimmunoprecipitation assay of a very high prevalence of antibodies to E6/E7 HPV5 oncoproteins, known to enhance keratinocyte proliferation. More recently, EV genes were identified, EVER1 and EVER2, whose mutations are responsible for epidermodysplasia verruciformis. Eidermodysplasia verruciforms-associated human papillomaviruses are harmless to the general population as a result of genetic restriction, which in psoriasis appears to be partly alleviated, and this may allow the viral gene expression. We hypothesize that induction of keratinocyte proliferation in psoriasis by various stimuli initiates the EVHPV life cycle with expression of early (E6/E7) and late (L1) viral proteins. The early proteins may, in turn, enhance the keratinocyte proliferation, and the late proteins could serve as target for specific-B- and T-cell-mediated responses. Immune responses against the viral antigens in the epidermis may result in the chemoattraction of leukocytes and Munro abscess formation, as well as in production of the psoriatic process. The novel immunomodulatory therapies could also inhibit immune responses against EVHPV proteins, leading to decreased cytokine production, keratinocyte proliferation and EVHPV expression. Thus the beneficial effect of these therapies is not discordant with the propose hypothesis of possible involvement of EVHPVs in the immunopathogenesis of psoriasis.

Nonspecific cell-mediated immunity in patients with epidermodysplasia verruciformis

Epidermodysplasia verruciformis (EV) is a rare disease that usually begins in childhood and is characterized by a generalized infection by human papilloma virus (HPV), frequent associations with cutaneous carcinomas, and abnormalities of cell-mediated immunity (CMI). We studied nonspecific CMI in 13 patients with EV by bacterial skin tests, allergic reactions to dinitrochlorobenzene (DNCB), measurement of responses to phytohemagglutinin (PHA), and quantification of T lymphocytes and T lymphocytes subsets in peripheral blood. Impairment of CMI was manifested by the cutaneous anergy to a variety of common skin antigens and, by the reduction of the lymphocyte transformation to PHA. There were no correlation between the severity of cases and abnormalities of CMI in our patients, however; the impairment of CMI was lower in cases of short duration, suggesting that the impairment of CMI in EV might reflect a long period of disease.

The histologic spectrum of epidermodysplasia verruciformis in transplant and AIDS patients

BACKGROUND

The purpose of this study was to correlate the histologic findings of skin lesions clinically suspicious for epidermodysplasia verruciformis with the viral findings in patients with organ transplants or AIDS.

METHODS

Thirty-seven skin biopsies from 17 patients (six with AIDS and 11 with transplants) were studied as a non-randomized, controlled, unblinded case series by in situ hybridization for HPV DNA.

RESULTS

Nineteen (51%) of these biopsies were HPV-positive by in situ hybridization either for HPV type 5 (five cases), type 8 (10 cases), type 16 (four cases) or HPV 31 (one case, with one case of dual infection). Only eight of the 19 HPV-positive tissues (42%) showed the classic histologic features of verruca planae. The more common histologic feature significantly associated with HPV detection was a focally thickened and disrupted granular layer (13/19 [68%] vs. 8/18 [44%], p < 0.04). Dysplasia was evident in 12/19 HPV-positive tissues (63%), which was significantly greater than in patients with congenital epidermodysplasia verruciformis (20%).

CONCLUSIONS

Oncogenic HPV types are detected in about one-half of skin biopsies from immunocompromised patients with a clinical presentation suspicious for epidermodysplasia verruciformis. Many of these lesions lack the histologic features of verruca planae, a focally thickened granular layer is a marker for viral detection, and the risk for dysplasia in such lesions is much higher than in epidermodysplasia verruciformis not associated with acquired immunosuppression.

Case-control study in a subtropical Australian population to assess the relation between non-melanoma skin cancer and epidermodysplasia verruciformis human papillomavirus DNA in plucked eyebrow hairs. The Nambour Skin Cancer Prevention Study Group

Epidermodysplasia verruciformis human papillomavirus (EV-HPV) DNA has been demonstrated in malignant and benign skin lesions and in hairs plucked from renal transplant recipients and immunocompetent patients. We investigated the association between EV-HPV DNA in hairs plucked from eyebrows and the occurrence of non-melanoma skin cancer (NMSC) in a community-based study. Within a cohort of residents of a Queensland township (Nambour), nested case-control studies of recently developed NMSC (64 cases), basal-cell carcinoma (BCC) (51 cases) and squamous-cell carcinoma (SCC) (25 cases) were conducted. EV-HPV DNA in hair and a small number of available tumour samples was detected using a nested PCR specific for EV-HPV types. EV-HPV DNA was detected in hairs from 94 of 143 individuals (66%), and 36 (39%) of the samples contained 2 or more different EV-HPV types. Only known or putatively new EV-HPV types were detectable after sequencing 93 samples. EV-HPV status agreed for 12 of 20 subjects who had both hair and skin tumour samples available. In 4 of 5 pairs of positive samples, the same EV-HPV type was found. There were non-significant negative associations between EV-HPV and NMSC (OR 0.77, 95% CI 0.34-1.8) and BCC (OR 0.58, 95% CI 0.23-1.5) but a non-significant positive association with SCC (OR 2.00, 95% CI 0.50-8.0).

Epidermodysplasia verruciformis: association with isolated IgM deficiency and response to treatment with acitretin

We describe a 25-year-old woman, who had extensive, large viral warts consistent with epidermodysplasia verruciformis (EV) since she was 6-year-old. Laboratory studies revealed an isolated IgM-deficiency, but the patient demonstrated no other abnormalities. She was treated with oral acitretin (0.5-1 mg/kg/day) for six months and her skin lesions improved slightly. However, after discontinuing the treatment, the lesions came back but she declined further treatment.

The presence of antibodies against virus-like particles of epidermodysplasia verruciformis-associated humanpapillomavirus type 8 in patients with actinic keratoses

Epidermodysplasia verruciformis-associated human papillomaviruses (EV-HPVs) are possibly involved in the development of actinic keratoses and may play a part in the pathogenesis of squamous cell carcinoma (SCC) of the skin, as the DNA of these viruses is frequently detected in biopsies of such lesions. Properly designed epidemiological studies, using serological tests to investigate the role of infection with EV-HPVs in cutaneous oncogenesis, are still rare. An IgG-specific enzyme-linked immunosorbent assay using virus-like particles composed of the major capsid protein L1 of the EV-specific HPV 8 (HPV 8 VLPs) was developed and used to test the seroprevalence of HPV 8 in 114 inhabitants of a tropical island, of whom 13 had developed SCC, and 19 had developed basal cell carcinoma. Gender, age, eye and hair colour, sun exposure and number of actinic keratoses were recorded for all individuals. The presence of antibodies against HPV 8 VLPs was associated with the development of large numbers of actinic keratoses. After adjusting for gender, age, eye and hair colour, and sun exposure, the odds ratio to develop 37 (the median in this dataset) or more actinic keratoses in the presence of antibodies against HPV 8 VLPs was 2.3 (95% confidence interval: 1.0; 5.3). Similarly, after adjustment for the same factors, the presence of these antibodies was associated with SCC with an odds ratio of 3.1 (0.74; 13.3), but the small number of individuals with SCC does not permit any definite conclusions. The presence of these antibodies did not appear to be associated with basal cell carcinoma as, after adjustment for the same factors, the odds ratio was 0.73 (0.23; 2.4). This study provides serological evidence that infection with EV-HPVs may play a part in the pathogenesis of actinic keratoses. The role of EV-HPVs in the development of SCC, however, remains to be elucidated.

Role of human papillomaviruses in cutaneous and oral manifestations of immunosuppression

Long-term immunosuppressive drug regimes, used to prevent organ transplant rejection, are associated with an increased risk of epithelial malignancies particularly anogenital and cutaneous cancers. Premalignant and malignant lesions of the oral mucosa have also been reported in renal transplant recipients (RTRs), particularly of sun-exposed lip lesions. Many of these anogenital lesions are associated with the detection of high-risk mucosal human papillomaviruses (HPV). Novel degenerate and nested polymerase chain reaction (PCR) techniques have found high levels of epidermodysplasia verruciformis (EV) HPVs (high-risk cutaneous oncogenic HPVs) in cutaneous warts, dysplastic keratoses, and squamous cell carcinomas. Unusual appendageal and spindle cell carcinomas are being observed in RTRs. Increasing survival times of HIV-positive patients may be associated with dysplasia of orogenital mucosal epithelium, and careful epidemiologic studies of cutaneous lesions are needed. The role of HPVs in the development of these lesions has yet to be established.

Epidermodysplasia verruciformis-like eruption complicating human immunodeficiency virus infection

Three human immunodeficiency virus (HIV)-infected patients presented with disseminated pityriasis versicolor-like skin lesions. Histological examination showed features characteristic of epidermodysplasia verruciformis (EV). Hybridization studies demonstrated the presence of human papillomavirus (HPV) type 5 (HPV5) DNA in two patients and HPV20 in one. A relative increase in CD8+, CD57+ cells, which are known to inhibit cell-mediated cytolysis, was observed in all patients. HLA-DQB 0301 haplotype, which has been associated with EV, was detected in two patients. The findings suggest that infection with EV-associated HPV types can complicate HIV infection. Both cellular immune defects and a hitherto unknown genetic background might explain the occurrence of EV in HIV-infected patients.

[Epidermodysplasia verruciformis, human Papillomavirus infection, genital epithelial neoplasia and possible immunodeficiency]

Papilloma virus infections are common in patients with immune defect/suppression. We describe a case of regional localised epidermodysplasia verruciformis in combination with genital intraepithelial neoplasia, refractory anaemia, and impaired immunity as demonstrated by lymphopenia with reduced B-cell/T-cell ratio, but normal T-helper/T-suppressor (CD4/CD8) ratio, and neutrophils with reduced spontaneous migration and chemotaxis. The regional localisation of the lesion and the changes in the cell mediated immunity are not classical for epidermodysplasia verruciformis. It is concluded that an increased tendency to papilloma virus infections and/or intraepithelial neoplasia should alert the clinician to the possibility of an immune defect.

Epidermodysplasia verruciformis accompanied by familial large granular lymphocytosis and a decrease in T lymphocytes

A 40-year-old man with epidermodysplasia verruciformis showed a decrease in peripheral blood T cells and abnormal expansion of large granular lymphocytes, accompanied by increased natural killer cell activity. Surface marker analysis of his large granular lymphocytes demonstrated that the subset, CD 57+ and CD 16+, had increased. His father, who had no skin lesions of epidermodysplasia verruciformis, displayed similar blood changes and his brother showed a decrease in T cells and a slight increase in CD 16+ natural killer cells, whereas his mother revealed only a slight decrease in T cells. Our present study indicates that epidermodysplasia verruciformis might be associated with hereditary abnormal expansion of large granular lymphocytes and a decrease in T cells.

Epidermodysplasia verruciformis as a model of human papillomavirus-induced genetic cancers: the role of local immunosurveillance

Epidermodysplasia verruciformis (EV) presents a genetically determined, unusual susceptibility to infection with EV-specific human papillomaviruses (HPVs) related to abrogation of immunosurveillance exclusively against these viruses. The cutaneous viral carcinogenesis depends upon potentially oncogenic HPVs, the cocarcinogenic effect of ultraviolet irradiation, and genetic host factors, presumably a defect of anti-oncogenes or alleles of major histocompatibility complex and tumor necrosis factor locus involved in antigen presentation.

Human papillomavirus (HPV) types specific of epidermodysplasia verruciformis detected in warts induced by HPV3 or HPV3-related types in immunosuppressed patients

Epidermodysplasia verruciformis (EV) is characterized by an abnormal genetic predisposition to infection with specific types of human papillomavirus (HPV). Specific defects of the cell-mediated immunity and/or of the control of HPV infection in keratinocytes are assumed to be involved in the development of the disease. As a model to test this hypothesis, we have studied the prevalence of EV-specific HPV in skin warts of 56 immunosuppressed patients. All main types of cutaneous HPV (HPV1, 2, 3, 4, 10, and 28) responsible for skin warts in the general population were detected by blot hybridization. EV-specific HPV (HPV5, 20, and 23) were detected in three patients. Four additional patients were found infected with HPV49, first characterized in the course of this study, and found to be related to EV HPV. A most important finding was that HPV5, 20, 23, and 49 were always codetected with HPV3 or the related types HPV10 and 28. None of the specimens showed the typical clinical morphology of EV lesions. In none of these specimens was the specific cytopathic effect of EV recognized; instead that of HPV3 and related types was seen. No evidence for productive EV HPV DNA replication was obtained for the three specimens that could be further analyzed by in situ hybridization. Our data suggest that HPV3 infection favors infection with EV HPV in immunosuppressed patients but that the full expression of EV HPV is usually restricted as in the general population.

Suppression of interleukin-2 production and activity by factor(s) released by peripheral blood mononuclear cells during papillomavirus infections

Supernatant fluids from cultured peripheral blood mononuclear cells (PBMC) obtained from patients with extensive papillomavirus infections such as condyloma acuminatum (CA) and epidermodysplasia verruciformis (EV) depressed the proliferative responses of T cells to phytohemagglutinin-P (PHA-P) and the production of interleukin-2 (IL-2) from those preparations. Fluids from the same cultures also inhibited the mitogenic activity of IL-2 on CTLL-2 cells as IL-2-dependent target cells. These soluble suppressor factors (SSF) from PBMC were present in significantly higher concentrations in fluids from cultured PBMC from patients in comparison to healthy controls. A soluble suppressor factor was characterized also from cultured rabbit PBMC after the rabbits had been infected with Shope papillomaviruses. This suppressor factor likewise inhibited IL-2 production and IL-2 activity.

Antigen presentation and T-cell activation in epidermodysplasia verruciformis

Aberrant immune responses may play a role in the susceptibility of patients with epidermodysplasia verruciformis to human papilloma virus (HPV). We examined the stimulatory capacity of antigen-presenting cells from HPV-infected skin and peripheral blood T-cell responses of patients with epidermodysplasia verruciformis. The percentage of Langerhans cells in relation to total epidermal cells in suspension was slightly reduced in HPV-infected lesions, relative to apparently clinically uninfected epidermis. In addition, the morphologic appearance of Langerhans cells was altered in lesional epidermal sheets. Despite these abnormalities, Langerhans cells were functionally intact in their capacity to present alloantigens to T cells and, in fact, the epidermis of HPV-infected lesions demonstrated enhanced antigen-presenting activity in three of four patients tested. The antigen-presenting activity was entirely abrogated by removal of Langerhans cells and was not associated with increased activity of cytokines with stimulatory activity for the thymocyte co-stimulation assay. Although epidermodysplasia verruciformis T cells were unresponsive to autologous HPV-infected epidermis, they responded well to mitogens, allogeneic mononuclear leukocytes, and allogeneic epidermal cells. Epidermodysplasia verruciformis T cells were inhibited in their capacity to respond to allogeneic epidermal cells when they were simultaneously exposed to autologous epidermal cells from HPV-infected lesional epidermis, but not to normal-appearing epidermis. Thus, although Langerhans cell activity is intact in epidermodysplasia verruciformis, these individuals fail to respond to autologous papillomas, which may, at least in part, be explained by an interaction between papillomal epidermal cells and autologous T cells that results in an inhibited response.

Natural cell-mediated cytotoxicity against various target cells in patients with epidermodysplasia verruciformis

Natural cell-mediated cytotoxicity of peripheral blood mononuclear cells was studied in eight patients with epidermodysplasia verruciformis induced by human papillomaviruses specific for epidermodysplasia verruciformis and in five patients with epidermodysplasia verruciformis-induced exclusively by human papillomavirus type 3. Nine patients with various cutaneous warts and 25 age- and sex-matched healthy persons were control subjects. Natural cell-mediated cytotoxicity against both K-562 erythroleukemic and Sk-v cells was in the normal range in patients with epidermodysplasia verruciformis induced by epidermodysplasia verruciformis-specific human papillomaviruses and in patients with cutaneous warts. The lysis of both targets, however, was significantly decreased in patients with the form of epidermodysplasia verruciformis associated with human papillomavirus type 3. Experiments with normal keratinocytes and with keratinocytes isolated from a malignant lesion bearing human papillomavirus type 5 genomes showed that the latter were susceptible to lysis by the peripheral blood mononuclear cells of healthy persons and of patients with cutaneous warts. Lysis of keratinocytes in epidermodysplasia verruciformis, however, was strongly reduced in patients with epidermodysplasia verruciformis induced by specific human papillomaviruses. This reduction was not associated with a decrease in anti-K-562 natural cell-mediated cytotoxicity. Our results suggest that in patients with epidermodysplasia verruciformis induced by disease-specific human papillomaviruses, there is reduced natural cell-mediated cytotoxicity against epidermodysplasia verruciformis keratinocytes.

Epidermodysplasia verruciformis accompanied by large granular lymphocytosis. Report of a case and immunological studies

A 34-year-old man with epidermodysplasia verruciformis showed increased natural killer (NK) cell activity in his peripheral blood cells, which was found to be due to abnormal expansion of large granular lymphocytes (LGL). Surface marker analysis of LGL in a two-color immunofluorescence test demonstrated that all LGL subsets, Leu-7+11-, Leu-7+11+, and Leu-7-11+, were increased. In contrast, his peripheral blood mononuclear cells showed a remarkable decrease in response to T cell mitogens, which could not be restored by depletion of the LGL subpopulation from the mononuclear cells. Immunohistologic studies for dermal distribution of LGL showed numerous Leu-7+ cells but no Leu-11+ cells at the sites of delayed hypersensitivity reaction or interferon beta- or interferon gamma-injected sites. These findings suggest that the elevated NK cell activity in this patient with epidermodysplasia verruciformis was caused by overall expansion of normal LGL subpopulations, but that the decreased T-cell mitogenic response represented a primary T-cell defect rather than a direct suppression by increased NK cells. It is noteworthy that despite this extraordinary increase of all LGL subpopulations in the blood, Leu-11+ NK cells never appeared in the skin.

[Polyclonal antibody to human papillomavirus-related antigens specific to epidermodysplasia verruciformis]

We have developed a polyclonal antibody for human papillomavirus (HPV)-related antigens specific to epidermodysplasia verruciformis (EV). Using this antibody, immunohistochemical studies on 12 EV patients were performed. The polyclonal antibody was obtained from rabbits immunized with roughly purified virions of HPV from an EV patient. Sections from 12 EV patients were treated with the polyclonal antibody and then the peroxidase-antiperoxidase method was used to observe the reaction. The observations revealed not only papillomavirus genus-specific common structural antigen (pgs-antigen) but also HPV-related antigens specific to EV. Pgs-antigen was observed in the nuclei of the upper keratinized cells of the benign lesions and HPV-related antigens specific to EV were observed in the nuclei and cytoplasm of both keratinizing cells of the benign lesions and malignant skin tumor cells. HPV-related antigens specific to EV were observed in sections of all 12 EV patients infected by HPV-5, 5-related, 14, 20, 21 and 38, but not in sections of other HPV infections. Using the immunoblot technique, we detected the main papillomavirus structural polypeptide (MW, 58 Kd) and two other unknown proteins (MW, 42 Kd and 33 Kd) in the benign lesion of an EV patient. Two proteins (MW, 42 Kd and 33 Kd) were also detected in the malignant tumor of the EV patients we consider these proteins to be HPV-related antigens specific to EV.

Epidermodysplasia verruciformis. A case associated with primary lymphatic dysplasia, depressed cell-mediated immunity, and Bowen's disease containing human papillomavirus 16 DNA

Epidermodysplasia verruciformis is a rare, often hereditary disease characterized by a generalized cutaneous infection with human papillomavirus (HPV), depressed cell-mediated immunity, and a propensity for transformation of the warty lesions to squamous cell carcinoma on primarily sun-exposed areas of the skin. A 37-year-old man with congenital lymphatic dysplasia and a history of squamous cell carcinoma of the groin and foot was observed by us to have edema of all four extremities, numerous flat warts, and pityriasis versicolor-like papules over the trunk and arms. Condylomatous lesions were noted in the groin and a periungual verrucous nodule on the thumb. Biopsies showed the trunk and arm lesions to be verrucae and the thumb lesion to be Bowen's disease. Results of molecular hybridization studies from four lesions of the arms showed the presence of only HPV 3 DNA; HPV 16-related DNA was detected in the intraepidermal carcinoma on the thumb. Immunologic evaluation revealed anergy to routine skin testing, depressed mitogen-stimulated lymphocyte transformation, decreased B-lymphocyte count, and a severe reversal of the T-lymphocyte helper:suppressor ratio.

Epidermodysplasia verruciformis: Langerhans cells, immunologic effect of retinoid treatment and cytogenetics

A case study is presented of a 44-year-old negroid male with epidermodysplasia verruciformis (EV), cutaneous carcinomas, and impaired cell-mediated immunity (CMI), infected with human papillomavirus type 8 and 17. Analysis was made of (a) T6+ and HLA-DR+ Langerhans cells (LCs) by immunoperoxidase staining in lesional and clinically normal skin before and during retinoid treatment, (b) the effect of retinoid treatment on CMI in vivo and in vitro, and (c) cytogenetic aspects related to chromosomal instability. The results showed the virtual absence of T6+ and HLA-DR+ LCs in koilocytic areas of epidermis involved with EV. Light-exposed, clinically normal skin also demonstrated microscopic EV lesions largely devoid of T6+ and HLA-DR+ LCs. Retinoid treatment with etretinate (Ro 10-9359) appeared both to increase the CMI response in vitro to T-cell mitogens and to influence the in situ pattern of T6+ and HLA-DR+ LCs. The cytogenetic study did not show evidence of spontaneous or UV-induced chromosomal instability.

Langerhans cells in epidermodysplasia verruciformis

T cell defect and energy to contact sensitizers are characteristic of the depressed cell-mediated immunity in epidermodysplasia verruciformis (EV). In this disease the generalized infection with human papilloma viruses is associated with a high risk of skin cancers. Langerhans cell density was studied quantitatively in lesions and noninvolved epidermis of EV using OKT6 and anti-HLA-DR monoclonal antibodies with indirect immunofluorescence technique. No significant changes were found in apparently normal skin suggesting no primary defect of Langerhans cells in EV. A marked decrease in Langerhans cell number per unit of epidermal volume could be observed in EV lesions. This additional reduction of immunological surveillance at sites of potentially oncogenic human papilloma virus infection may contribute to the increased risk of malignant transformation in EV lesions.

Partial defects of cell-mediated immunity in patients with epidermodysplasia verruciformis

Different parameters of cell-mediated immunity, including natural cytotoxic reactions, were studied in nine patients with epidermodysplasia verruciformis with or without cutaneous malignancy. We found decreased total number of T lymphocytes and T-helper cells in peripheral blood of the patients, and normal T-suppressor cell number, as detected by monoclonal antibody typing and functional E-rosette test with the use of theophylline. This decrease was found both in active and in late rosette-forming cell subpopulations. Natural killer cell activity of peripheral blood mononuclear cells was found to be increased in four of nine patients with epidermodysplasia verruciformis, whereas antibody-dependent cellular cytotoxicity was within the normal range in all patients studied. Lymphocyte-induced angiogenesis assay, which is a sensitive test for the estimation of the immunocompetence of lymphoid cells, revealed increased angiogenic capability of peripheral blood mononuclear cells in the majority of the patients. Our results suggest that cellular defects in patients with epidermodysplasia verruciformis did not relate to all functions of the immune system.