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Cervical intraepithelial neoplasia associated with epidermodysplasia verruciformis HPV in an HIV-infected patient: a manifestation of immune restoration syndrome

European Journal of Dermatology. Volume 17, Number 2, 149-52, March-April 2007, Clinical report

DOI : 10.1684/ejd.2007.0129

Summary

Author(s) : Isabelle Mermet, Jean Sébastien Guerrini, Sandrine Cairey-Remonnay, Christine Drobacheff, Brigitte Faivre, Marie Gaillard, Bernadette Kantelip, Jean Luc Pretet, Didier Riethmuller, François Aubin , Dpt of Dermatology Medical School and University Hospital, IFR 133, 25000 Besançon, France, Dpt of Cell and Molecular Biology, EA 3181, Medical School and University Hospital, IFR 133, 25000 Besançon, France, Dpt of Obstetrics and Gynecology, Medical School and University Hospital, IFR 133, 25000 Besançon, France, Dpt of Pathology IFR 133, 25000 Besançon.

Summary : We report a case of a cervical intraepithelial neoplasia associated with epidermodysplasia verruciformis human papillomavirus (HPV) type 5 and HPV type 16 in a human immunodeficiency virus-infected patient. Furthermore, epidermodysplasia verruciformis-like cutaneous eruptions after initiation of highly active antiretroviral therapy has never been described as a manifestation of an immune restoration syndrome.

Keywords : human papillomavirus, epidermodysplasia verruciformis, immune restoration syndrome, immune reconstitution inflammatory syndrome, human immunodeficiency virus, cervical intraepithelial neoplasia

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ARTICLE

Auteur(s) : Isabelle Mermet¹, Jean Sébastien Guerrini², Sandrine Cairey-Remonnay¹, Christine Drobacheff¹, Brigitte Faivre¹, Marie Gaillard³, Bernadette Kantelip⁴, Jean Luc Pretet², Didier Riethmuller³, François Aubin^1,2

¹Dpt of Dermatology Medical School and University Hospital, IFR 133, 25000 Besançon, France
²Dpt of Cell and Molecular Biology, EA 3181, Medical School and University Hospital, IFR 133, 25000 Besançon, France
³Dpt of Obstetrics and Gynecology, Medical School and University Hospital, IFR 133, 25000 Besançon, France
⁴Dpt of Pathology IFR 133, 25000 Besançon

accepté le 13 Septembre 2006

Human papillomaviruses (HPV) are increasingly recognized as human carcinogens. According to tissue tropism and DNA sequence homology, three broad taxonomic groups, including the genus alpha-papillomavirus (old mucosal (group A), cutaneous (group B2), and epidermodysplasia verruciformis (EV)-associated (group B1) are distinguished [1]. High risk (HR) mucosal HPV infection is associated with an increased incidence and severity of HPV-related cervical dysplasia and cervical cancer in women with human immunodeficiency virus (HIV) infection [2]. The presence of mucosal HPV types has been already well documented in non-melanoma skin cancer (NMSC) and extragenital Bowen’s disease of non-immunosuppressed patients [3, 4]. However, to our knowledge, there is only one report demonstrating EV HPV in the female genital area of an EV woman [5]. Herein, we report a case of a cervical intraepithelial neoplasia (CIN) associated with EV HPV type 5 and HPV type 16 in a HIV-infected patient, as a manifestation of an immune restoration syndrome (IRS).

Case report

A 38-year-old Italian woman was known to be at stage B3 of HIV infection since 1986. She refused any antiretroviral therapy and her CD4 cell count was less than 300/mm³ with a viral load of 17,900 HIV copies/ml. Her past medical history included intravenous drug abuse and hepatitis B. There was no known family history of skin problems nor any history of consanguinity. During the observation period, the patient developed a CIN 3 treated in Italy by conization in 1994, followed in 1996, 2000 and 2002 by the excision of four consecutive cutaneous Bowen’s lesions located on the neck and shoulders. In December 2003, while her immunological status decreased (196 CD4 cells/mm³ and viral load of 11,000 copies/ml), 3 new cutaneous Bowen’s lesions along with one microinvasive squamous cell carcinoma occurred on the same areas. All these lesions were removed and presented with a typical histological aspect of HPV-induced koilocytosis (large keratinocytes with a pale stained and finely granular cytoplasm and voluminous vacuolated nuclei). Then, the patient accepted treatment by highly active antiretroviral therapy (HAART: stavudine, lamivudine, lopinavir, ritonavir). Three months later, along with a continuous increase of CD4 T cell numbers to 259/mm³ and a decreasing viral load up to 42 copies/ml, our patient developed an asymptomatic, cosmetically disturbing, skin eruption, progressing slowly on her face, neck, chest, extremities and genital area. Examination showed about 50 disseminated lesions on sun-exposed skin (figure 1). There were either flat, warty, slightly keratotic papules or whitish, sharply bordered macules. Lesions measured 2 to 8 mm in diameter and were round or irregular in shape. Biopsies from warty lesions of the neck, dorsal side of the hand and pubis showed characteristic histological features of EV HPV infection with koilocytosis (figure 2). Topical treatment with imiquimod was then introduced without evident improvement. Cervix examination (cytology, colposcopy and biopsy) revealed a CIN 1 which was treated by loop electrosurgical excision procedure. Several pathological specimens were obtained and HPV analysis was performed following DNA extraction from paraffin-embedded biopsies. Cutaneous and cervix biopsies were taken at different times, in different rooms, and by different physicians to prevent cross-contamination between skin and cervix. The DNA quality was tested by amplification of a 268-bp fragment of the β-globin gene using GH20/PCO4 primers. A negative template control (water instead of DNA) was also used as a non-contamination control. Two different microtomes were used skin and cervix sample to reduce the risk of cross-contamination. The presence of HPV DNA was carried out using MY09/MY11 primers which allowed the detection of a broad spectrum of mucosal HPV by production of a 450-bp amplicon. The amplicons were then typed with internal 5’ biotinylated probes for low risk HPV6, 11, or for high risk HPV 16, 18, 31, 33, 35, 45, 51, 52, 58, 68 using the Hybridowell kit^®. The FAP59/FAP64 primers by generating amplicons of 480-bp allowed the detection of a broad range of cutaneous HPV, including EV-associated HPV types but also mucosal HPV types. Four specific primer sets MY5 1/2, MY5 3/4, and MY8 1/2, MY8 3/4 were also used to identify HPV5 and 8 respectively. EV HPV5 DNA was detected in cutaneous warty lesions located on the neck and dorsal side of the hands and on the pubis. HR genital HPV16 DNA was detected on cutaneous lesion of pubis and on CIN1. Unexpectedly, CIN1 was also positive for EV HPV5 DNA. None of the pathological specimens contained HPV DNA of EV HPV8 (figure 3) and (Table 1). Unfortunately, the patient moved to Italy and no additional tissue was available for more detailed virological analysis.
Table 1

Clinical lesion	Pathology	HPV16	HPV5	HPV8
1994: Cervix (Italy)	CIN3	NA	NA	NA
1996: Cutaneous (neck)	Bowen’s disease with koilocytosis	+	–	–
2000: Cutaneous (shoulders)	Bowen’s disease with koilocytosis	+	–	–
2002: Cutaneous (shoulders)	Bowen’s disease with koilocytosis	+	–	–
2003: Cutaneous (neck)	Bowen’disease with koilocytosis	+	–	–
2004: Cervix	CIN1	+	+	–
2004: Cutaneous
– pubis – V of chest	EV-like EV-like	+ +	+ +	– –

Discussion

It is well known that HIV infection is accompanied by a wide variety of infectious muco-cutaneous diseases, including viral infections. However, only few cases of widespread warty lesions associated with EV HPV5 have been reported in the literature [5-8]. EV is a rare genodermatosis characterized by the development of multiples papules, ressembling flat warts and macular skin lesions that with time give rise to squamous cell carcinoma in up to 60% of patients in ultraviolet-exposed skin. EV patients present a genetically determined unusual susceptibility to infection with EV-specific HPV [9]. The EV HPV group has also been detected at high prevalence in inflammatory skin diseases such as psoriasis, in the epidermal repair process and in NMSC both in immunocompetent and immunosuppressed organ transplant recipients [10]. EV-associated HPV genotypes appear to cause widespread silent infection in the general population, suggesting the commensal nature of these viruses and the role of host immune response that inhibits the development of overt clinical disease. Indeed, a much higher incidence of EV-associated HPV infection has been reported in immunosuppressed patients, especially in renal transplant recipients [10], but also in patients with Hodgkin’s disease, systemic lupus erythematosus or malignant neoplasms associated with severe immunodeficiency. There is intuitive concern that immunosuppression linked to the HIV infection might hasten the development of clinical lesions induced by EV-associated HPV. It is thus conceivable that cellular immunodeficiency induced by HIV infection predisposes to cutaneous HPV infection. In addition, remission of EV-like skin eruptions has been reported in a HIV-positive patient after introduction of HAART [11] highlighting the role of host immune reconstitution. However, the incidence of EV during HIV infection is still very low, suggesting a major role for the genetic background and innate immunity.

It is remarkable that our patient developed EV-like cutaneous eruptions after initiation of HAART, suggesting an immune restoration syndrome (IRS). IRS was recognized after the introduction of HAART in the mid-1990s and several names have been applied to these situations including immune restoration disease and immune reconstitution inflammatory syndrome. While HAART induces protective immune responses against a variety of pathogens, for a subset of patients, immune reconstitution is associated with a pathological inflammatory response. Risk factors for IRS include a low CD4 count, the presence of latent infection(s), and a robust virologic and immunologic response to HAART [12-14]. IRS is characterized by worsening clinical, laboratory, or radiological findings despite improvements in the HIV RNA level and CD4 count after the introduction of antiretroviral therapy. IRS may occur during or shortly after the treatment of an opportunistic infection as a “new” clinical syndrome ranging from worsening of a treated opportunistic infection, or the atypical appearance of a previously unrecognized occult infection or even autoimmune or malignancy-related conditions. During the initial months of HAART, immune reconstitution is complicated by adverse clinical phenomena in which either previously subclinical infections are “unmasked” or pre-existing partly treated opportunistic infections clinically deteriorate [12-14]. However, to our knowledge, HPV-associated lesions have never been reported as a manifestation of IRS and our observation may thus reflect the progression of a quiescent EV HPV infection.

We cannot explain why infection with other more common HPV types is not a more common event after introduction of HAART. In an unpublished report, French et al described patients with disseminated warts occurring after > 3 years of therapy in absence of cutaneous DTH responses despite substantial increases of CD4 T cell counts [15]. IRS is supposed to be the result of an excessive response by the recovering immune system to a high antigen burden [13]. The low viral DNA load and the low level of proteins expression associated with cutaneous HPV-infected lesions [16] may account for the lack of local inflammatory response and the poor immune response [17] even after introduction of HAART. Together, these mechanisms may explain the persistence of these lesions even in immunocompetent hosts and the rarity of IRS after HAART introduction.

IRS is not a new phenomenon, nor is it specific to HIV-infected individuals receiving HAART. Indeed, the potential for IRS exists whenever patients who have been severely immunocompromised have rapid restoration of their immune function. Thus, similar phenomena are recognized following a steroid reduction or withdrawal, and among patients in whom the absolute neutrophil count recovers in the blood following either cytotoxic chemotherapy or bone marrow transplantation [18]. The pathogenesis of these reactions has not yet been clearly defined, but increase of memory cells (CD4+CD45RO+) and CD8+ T lymphocytes after HAART may explain their development. Studies have shown that recovery of lost responses to specific infectious antigens may occur as soon as 2 weeks after HAART [13]. Pathogenesis may also involve exacerbated production of pro-inflammatory cytokines or a lack of immune regulation [15, 19]. Disease susceptibility genes for specific subsets of IRS have also been identified [20, 21].

In addition, we demonstrate the presence of cutaneous EV HPV in the mucosal genital area. We do not have any clear explanation for this loss of tissue tropism. An atypical appearance of an unrecognized clinically silent infection has been previously described during IRS [13, 14] and there is one report demonstrating EV HPV in the female genital area of an EV woman [5]. Furthermore, genital HPV infection is associated with a higher antigen burden than cutaneous infection [16] and may thus favour IRS in susceptible patients. Furthermore, our observation demonstrates that the historical grouping into mucosal and cutaneous HPV types should no longer be upheld as supported by modern taxonomy [1]. Indeed, in the new classification of HPV based on taxonomy rather than on phenotypic characteristics, the clinically most important genus is referred to as the alpha-papillomavirus and contains all HPV types associated with mucosal and genital lesions but also cutaneous HPV associated with most common warts and “butcher’s warts”. The pathogenic role of co-infection by HR-HPV16 and EV-HPV5 in the development of CIN1 is not clear. The carcinogenic role of oncoproteins E6 and E7 of mucosal HR-HPV is now well established [22]. The transforming potential of EV-HPV in vitro is low, and it is currently believed that EV-HPV may act only as co-carcinogen with an absolute requirement of ultraviolet light [10]. Although it may be conceivable that EV-HPV5 infection plays no role in HR-HPV16 associated-CIN1 and is only coincidental, we can not exclude a synergy between oncoproteins E6 and E7 of each virus [23].

In conclusion, our observation raises two interesting points: first, the occurrence of a cutaneo-mucosal infection by HPV as a manifestation of IRS after HAART and secondly, the unexpected presence of cutaneous EV-HPV in the uterine cervix.

Acknowledgements

We thank Sylviane Coumes-Marquet and Elisabeth Homacell for their excellent technical assistance. Financial support: None. Conflict of interest: None.

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