Hydroa Vacciniforme

This case report describes recurrent episodes of pruritic vesicular lesions and erosions on the face and photoexposed areas of the arms as well as multiple varioliform scars.

Clinicoprognostic Study of Hydroa Vacciniforme-like Lymphoproliferative Diseases: A Systematic Review

BACKGROUND

Limited clinicopathological and prognostic data are available on hydroa vacciniforme (HV)-like lymphoproliferative diseases (HVLPD).

METHODS

This systematic review searched HVLPD reports in Medline via PubMed, Embase, Cochrane, and CINAHL databases in October 2020.

RESULTS

A total of 393 patients (65 classic HV, 328 severe HV/HV-like T-cell lymphoma [HVLL]) were analyzed. Among severe HV/HVLL cases, 56.0% were Asians, whereas 3.1% were Caucasians. Facial edema, hypersensitivity to mosquito bites, the onset of skin lesion, and percentage of severe HV/HVLL differed significantly by race. Progression to systemic lymphoma was confirmed in 9.4% of HVLPD patients. Death occurred in 39.7% patients with severe HV/HVLL. Facial edema was the only risk factor associated with progression and overall survival. Mortality risk was higher in Latin Americans than in Asians and Caucasians. CD4/CD8 double-negativity was significantly associated with the worst prognosis and increased mortality.

CONCLUSION

HVLPD is a heterogeneous entity with variable clinicopathological features associated with genetic predispositions.

Case report: Cellular therapy for hydroa vacciniforme-like lymphoproliferative disorder in pediatric common variable immunodeficiency with chronic active Epstein-Barr virus infection

Hydroa vacciniforme-like lymphoproliferative disorder (HV-LPD) is a cutaneous form of chronic active Epstein-Barrvirus (EBV) infection, which can develop into the extremely rare systemic lymphoma. Patients with Inborn errors of immunity (IEI), such as common variable immunodeficiency (CVID), are at higher risk of developing a severe course of infections especially viral and malignancies than the general population. The aim of the study was to present complex diagnostic and therapeutic management of HV-LPD. The clinical diagnosis was confirmed at the histological and molecular level with next generation sequencing. HV-LPD was diagnosed in a patient with CVID and chronic active Epstein–Barr virus (CAEBV) infection. The patient was refractory to CHOP chemotherapy and immunosuppressive treatment in combination with antiviral drugs (prednisone, bortezomib, gancyclovir). The third-party donor EBV-specific cytotoxic T cells (EBV-CTL, tabelecleucel) were used, which stabilised the disease course. Finally, matched unrelated donor hematopoietic cell transplantation (MUD-HCT) was performed followed by another cycle of EBV-CTL.

The aim of the measurement of Epstein-Barr virus DNA in hydroa vacciniforme and hypersensitivity to mosquito bites

Epstein-Barr virus (EBV) DNA load in the blood increases in posttransplant lymphoproliferative disorders and chronic active EBV infection. In this report, we analyzed the EBV DNA load in the peripheral blood mononuclear cells (PBMCs) and plasma of patients with hydroa vacciniforme (HV) and/or hypersensitivity to mosquito bites (HMB) to understand the clinical significance of EBV DNA load. All 30 patients showed high DNA loads in the PBMCs over the cut-off level. Of 16 plasma samples, extremely high in two samples obtained from patients with hemophagocytic lymphohistiocytosis (HLH). The amount of cell-free DNA in plasma was correlated to the serum levels of lactate dehydrogenase and inversely correlated to platelet counts. These results indicate that the EBV DNA load in PBMCs can provide one of the diagnostic indicators for HV and HMB and marked elevation of cell-free EBV DNA in plasma might be related to cytolysis such as that observed in HLH.

Hydroa vacciniforme-like cutaneous T-cell lymphoma in a child: A case report

RATIONALE

Hydroa vacciniforme (HV)-like T-cell lymphoma is a rare malignancy in childhood associated with Epstein-Barr virus infection.

PATIENT CONCERNS

A 6-year old girl presented with complaint of 3-year history of recurrent skin lesions, 3 months of fever accompanied by cough for 8 days.

DIAGNOSES

Skin biopsy revealed a HV-like lymphoma presentation and positive signals of EBER were detected by in situ hybridization. TCR-γ gene monoclonal rearrangement was present. A HV-like cutaneous T-cell lymphoma was diagnosed.

INTERVENTIONS

The girl was treated with cyclosporine and CHOP.

OUTCOMES

The girl's condition had been stable for 6 months.

LESSONS

Our case highlights the necessity for taking the HV-like lymphoma as a differential diagnosis especially when a patient manifests as recurrent skin lesions accompanied by systemic involvement.

Recurrent scarring papulovesicular lesions on sun-exposed skin in a 22-year-old man

KEY TEACHING POINTS.

Hydroa vacciniforme: a rare photodermatosis

Hydroa vacciniforme (HV) is a rare photodermatosis characterized by a recurrent vesiculopapular eruption with varioliform scarring. The pathogenesis remains unknown. Herein we present a case to emphasize the importance of recognizing this condition and its clinical mimickers, which include other photodermatoses and lymphoma.

A survey examination of patients with hydroa vacciniforme

Hydroa vacciniforme is a rare acquired photosensitivity disorder that manifests in childhood. We sought to identify the demographics, disease progression, symptoms, risk factors, and treatment efficacy associated with hydroa vacciniforme using a questionnaire. Nineteen surveys were included in the data analysis. Symptoms occurred throughout the year and the most common dermatologic manifestations included redness, blisters, bumps, scars, itching, and burning, predominantly on sun-exposed areas. The most common associated symptoms included oral ulcers, abdominal pain, and eye ulcers. Most participants limited their sun exposure to less than 10 hours weekly and stated sunscreen somewhat helped prevent breakouts. Most participants had no to limited improvement of their symptoms with treatments.

Antiviral therapy in children with hydroa vacciniforme

Hydroa vacciniforme is a rare, usually quite severe, photo-dermatosis. Association with Epstein-Barr virus infection and a possibly increased risk of lymphoproliferative malignancy have been demonstrated. We describe here four patients with Epstein-Barr virus-associated hydroa vacciniforme treated with acyclovir/valacyclovir therapy with a good clinical response. The children were reported to have less fatigue, fewer eruptions, less scarring, and increased ability to spend time outdoors without provoking new eruptions. This was also in agreement with clinical observations. However, one patient progressed into an anaplastic lymphoma kinase-1-negative anaplastic large-cell lymphoma in the upper jaw. This was preceded by an increase in EBV viral load. Acyclovir/valacyclovir therapy is a safe treatment. Further studies are required to confirm these results.

Allergic hypersensitivity skin reactions following sun exposure

Photoallergic dermatoses are skin lesions following sun exposure, characterized by activation of immunological mechanisms, involving photosensitizers and photoallergens that can cause photosensibilization in some individuals. In this group of disorders, photoallergic contact dermatitis should be accentuated. It manifests as contact allergic dermatitis on sun-exposed skin areas, following direct contact with photoallergens during UV exposure (predominantly UVA). Under influence of light, photosensitizers get activated, followed by fusion with cutaneous proteins which renders them to complete antigens, and consequential initiation of immunological mechanisms with resulting pathological skin lesions. The most common photoallergens are: sulfonamide antibiotics, phenothiazines, and halogenated salicylanilides. Photoallergic dermatoses are comprised of several disorders, although the causative photoallergen remains unknown (e.g. solar urticaria, polymorphous light eruption and hydroa vacciniforme). Solar urticaria is a rare, acute urticarial reaction on both sun-exposed and covered skin areas, which appears soon after exposure to sun or artificial lighting. Polymorphous light eruption is a relatively common polymorphous skin eruption, which usually appears in spring. Its pathogenesis is unknown, presumably photoallergic reaction. Hydroa vacciniforme is a rare photodermatosis of unknown etiology, which usually presents in summer-time. It is characterized by vesicobullous eruptions, with residual nonesthetic varioliform scarring.

Hydroa vacciniforme with oral mucosal involvement

We report the occurrence of oral ulcers in a 6-year-old girl with hydroa vacciniforme. This finding has not hitherto been reported in the literature.

Artificial reproduction of atypical hydRoa vacciniforme caused by latent EpStein-Barr virus infection

BACKGROUND

Cases of hydroa vacciniforme-like eruptions caused by latent Epstein-Barr virus (EBV) infection have been reported in Asia and Mexico, some of which progressed to lymphoproliferative disorders. The precise clinical features of the disease are not, however, clear.

METHODS

We performed an artificial provocation test with repeated exposures of ultraviolet A (UVA) and UVB in an 8-year-old Korean girl who had severe hydroa vacciniforme-like skin eruptions on exposed areas.

RESULTS

The patient showed features of latent EBV infection serologically, and an in situ hybridization study indicated that most infiltrating mononuclear cells in the dermis were positive for EBV. After three exposures to UVA irradiation with a total dose of 90 J/cm2, erythema and vesicles appeared on the UVA-irradiated site but not on the UVB-irradiated site.

CONCLUSIONS

Atypical hydroa vacciniforme caused by latent EBV infection could be reproduced by repeated UVA irradiation. Further study on the photo-protection would be necessary to prevent its progression to lymphoproliferative malignancies.

Hydroa vacciniforme-like eruptions in a patient with chronic active EB virus infection

We report a case of chronic active Epstein-Barr (EB) virus infection (CAEBV) associated with skin eruptions mimicking hydroa vacciniforme (HV) in a 4-year-old boy. The patient had repeated episodes of vesiculo-necrotic eruptions on the face, scalp, and bilateral forearms one year before the first visit to our department. General symptoms including fever, hepatosplenomegaly, abnormal liver function, and cervical lymph node swelling were noted three months before the first visit. At the first visit, small, bean-sized, erythemic papules with central necrosis were observed on the face and anterior chest wall. Thumb-sized ulcers with crust were present on the bilateral forearms. Histopathological examination of an erythematous lesion in the submandibular area revealed parakeratosis with a thick crust, mild spongiosis in the epidermis, and a dense infiltration of lymphoid cells into the dermis and perivascular space. Laboratory examination showed EBNA x 40, EBV VCA IgG x 1,280, and EBV DNA (PCR) 8 x 10(4). EBV-encoded small nuclear RNA (EBER) positive cells were detected in the dermis by an in situ hybridization (ISH) method. Large granular lymphocytes (65%) with the NK cell phenotype were found in the peripheral blood. A real time PCR method showed 171,741 copies/ micro g DNA in CD 16 positive cells. Although latent EBV infection-associated eruptions have been documented, detailed skin manifestations in CAEBV are less well known.

The idiopathic photodermatoses

The idiopathic photodermatoses present a challenge for dermatologists. Although, as in other specialty areas, the classical clinical presentation produces few problems, it is the severe forms and overlap cases that cause the most difficulty. It is fortunate that the semi-objective investigation of phototesting is available, which, when conducted carefully, reveals so much about the nature of this group of conditions. This essential investigation not only helps achieve a diagnosis, but also affords material for study and a means of monitoring therapy response or progress towards spontaneous resolution. Although these conditions are grouped together, throughout this century we have seen a continuing process of distinct diseases emerging as a consequence of careful clinical observation and investigation.

Hydroa vacciniforme with ocular involvement

A 7-year-old Thai boy had several episodes of hydroa vacciniforme which were accompanied by an anterior uveitis with corneal clouding and stellate keratic precipitates. Wearing sunglasses prevented additional eye symptoms despite recurrence of the skin lesions. Repetitive UVA phototesting reproduced the typical skin lesions with fever and malaise. No reproduction of skin lesions was revealed by repetitive UVB phototesting. One should be aware of eye involvement in hydroa vacciniforme, and those who experience the eye involvement should be advised to wear protective sunglasses.

[Hydroa vacciniforme]

HISTORY AND CLINICAL FINDINGS

For three years, each time the day after intensive exposure to the sun a 5-year-old girl developed moderately painful erythema and blisters on uncovered parts of her body which subsequently healed with scarring. There was no increased photosensitivity among members of her family. There were numerous blisters and bullae, some of them confluent, filled with serous fluid on her back, on her arms an in the face. There were varioliform scars on the extensor surfaces of her arms.

INVESTIGATION

There were no porphyrins in red cells, serum or urine. The characteristic skin changes were reproduced on exposure to UV-A. These findings established the diagnosis of hydroa vacciniforme.

TREATMENT AND COURSE

Prolonged sun exposure was to be avoided and protective ointment was prescribed together with administration of beta-carotene, 25 mg twice daily.

CONCLUSION

In children light-induced skin changes which heal with scarring may be due to hydroa vacciniforme.

Edematous, scarring vasculitic panniculitis: a new multisystemic disease with malignant potential

BACKGROUND

Hydroa vacciniforme (HV) is a disease of unknown origin characterized by erythema, vesicles, necrosis, and varicelliform scars in light-exposed skin. Systemic involvement is absent. A few patients have been reported with "severe HV" with systemic involvement, development of non-Hodgkin's lymphoma, and a poor prognosis.

OBJECTIVE

Our purpose was to characterize and differentiate our patients' disease from HV.

METHODS

We performed a retrospective clinicopathologic study of 14 children previously diagnosed as having "severe HV."

RESULTS

The extension and severity of the cutaneous lesions, fever, wasting, failure to thrive, hepatosplenomegaly, vasculitis, panniculitis, and potential development of lymphoma are features that clearly differentiate edematous scarring vasculitic panniculitis from HV.

CONCLUSION

Edematous scarring vasculitic panniculitis is a novel multisystemic disease with malignant potential that is not related to classic HV.

Hydroa vacciniforme. Diagnosis by repetitive ultraviolet-A phototesting

Hydroa vacciniforme is a rare disorder manifested in early childhood by recurrent photoinduced vesicles that heal with scarring. We report a case in which repetitive exposures to artificial ultraviolet light in the A range reproduced the clinical findings induced by natural sunlight. Phototesting may be viewed as an important diagnostic aid, as the induction of lesions clinically identical to hydroa vacciniforme can provide a reliable criterion for the diagnosis.

[Experimental induction of skin manifestations in hydroa vacciniforme]

In a 34-year-old patient who had been suffering from hydroa vacciniforme since he was 4 years old, typical skin lesions were induced on his arm, back and in the oral mucosa by means of repeated UV-A exposure. His eyes were found to have intracorneal scars.

Hydroa vacciniforme: induction of lesions with ultraviolet A

Hydroa vacciniforme is a rare photosensitivity disorder with onset in childhood. The distinctive lesion is a vesicle which heals with scarring. We report a case of hydroa vacciniforme in which an abnormal minimal erythema dose to wavelengths of 322 to 370 nm within the ultraviolet A (UVA) range was demonstrated. Vesicles could be induced only with multiple exposures to UVA. Increased tolerance to UVA erythema was induced by multiple UVB exposures, although tanning was poor. Of note were the presence of several halo nevi and a history of the loss of ability to tan. The clinical features and appropriate laboratory evaluation of hydroa vacciniforme are reviewed.

Hydroa vacciniforme: diagnosis and therapy

Hydroa vacciniforme is a rare, chronic photodermatosis with onset in childhood. Multiple exposures to UV-A reproduced the symptoms and the vesicular and scarring lesions typical of the sun-induced disease in our patient. Treatment with hydroxychloroquine sulfate, but not indomethacin, reduced the photosensitivity both to sunlight and to artificial UV-A light. Serum complement levels were low while the disease was active and returned to normal after treatment of the patient with hydroxychloroquine.

[Hydroa vacciniforme Bazin (author's transl)]

Hydroa vacciniforme Bazin is a rare photodermatosis characterized by bullous skin lesions and distinctive scarring. Early diagnosis is important to provide disfiguring scarring at the light exposed areas of the skin. The onset of the disease occurs predominantly in early childhood and involutes spontaneously at puberty. The case of a 5 years old girl is reported and differentiation from other photodermatoses is discussed.