Cutaneous Chromoblastomycosis Mimicking Tuberculosis Verrucosa Cutis: Look for Copper Pennies!

Chromoblastomycosis is a rare chronic fungal infection of skin and subcutaneous tissue. It is primarily a disease of tropical and subtropical regions and affects mainly the agricultural workers following trauma with vegetable matter. Cutaneous Chromoblastomycosis may clinically mimic cutaneous tuberculosis as both the condition usually presents with hyper pigmented verrucous lesion of skin. Here in we report a case of chronic cutaneous Chromoblastomycosis in a middle aged woman from north eastern part of India, who was initially misdiagnosed as Tuberculosis verrucosa cutis. In histopathology characteristic brown colored spores of the fungus (also known as copper pennies) were seen within dermal abscess. The organism isolated from culture of the biopsy material was Fonsecaea pedrosoi thus confirming our diagnosis of cutaneous chromoblastomycosis. The patient responded well to oral Itraconazole. The dermatologists and pathologists should be aware of this condition especially when dealing with verrucous lesion of the skin. The pathologists should search for fungal spores in cutaneous lesion with pseudoepitheliomatous hyperplasia and dermal abscess.

[Clinical algorithm of cutaneous extragenital wart treatment]. / Klinischer Algorithmus zur Therapie von kutanen, extragenitalen HPV-induzierten Warzen.

Various human papillomavirus of the genera α-, ß-, γ-, µ- and η-papillomavirus induce type-specific extragenital warts. Plantar, common and plane warts are the most common types. The closely related Alpha-papillomaviruses HPV 2, 27 and 57 are responsible for the majority of therapy-resistant common warts. A wide armamentarium of surgical, physical, chemical or drug therapies is available but no modality cures all patients. In order to avoid overtreatment it is mandatory to differentiate between indolent warts which will spontaneously resolve, warts which cause acute discomfort and warts without any tendency to heal spontaneously. HPV type, wart type, localization, size, disease duration as well as age and immune status are parameters influencing self-healing and should be considered when choosing the appropriate wart therapy.

[Human papillomavirus-associated warts in organ transplant recipients. Incidence, risk factors, management]. / Humane Papillomvirus-assoziierte Warzen bei organtransplantierten Patienten. Inzidenz, Risikofaktoren, Management.

Human papillomaviruses infect the squamous epithelia of the skin and cause warts, and are occasionally found in squamous cell carcinomas. Since cell-mediated immunity plays a crucial role in the control of HPV-infections, organ transplant recipients, unable to mount an adequate T-helper 1 cell-mediated immune surveillance, frequently develop widespread and resistant induced warts. Skin tumors, especially squamous cell carcinomas, are the most common post-transplantation neoplasm. Warts, actinic keratoses and invasive squamous cell carcinomas are known to develop at the same time in the areas. The role of HPV in the development of invasive squamous cell carcinoma under immunosuppression, remains to be elucidated in respect to common risk factors and increased numbers of warts potentially identifying patients at increased risk for carcinoma. We prospectively studied 1690 organ transplant recipients in the dermatology clinic at the Charité University Hospital in Berlin, to evaluate risk factors being involved in the development of HPV-induced warts and to assess a potential association of with the development of non-melanoma skin cancers in this population. The cumulative incidence of warts steadily increased throughout the post-transplant years. The presence of more than 10 verrucae was associated with the development of actinic keratoses, invasive squamous cell carcinoma and basal cell carcinoma. This study shows clear evidence that certain risk factors of skin carcinogenesis in organ transplant recipient such as increased age at transplantation, a high dose of immunosuppression related to a specific type of graft and use of azathioprine or cyclosporine are strongly associated with an increased incidence of warts. Furthermore, HPV-induced verrucae vulgares could be used as a potential predictor for the development of coincidental non melanoma skin cancer in organ transplant recipients and therefore could serve as an early identification marker of skin cancer high-risk patients. The challenging management of warts in organ transplantation patients is reviewed.

Lesion formation and antibody response induced by papillomatous digital dermatitis-associated spirochetes in a murine abscess model.

Papillomatous digital dermatitis (PDD), also known as hairy heel wart, is a growing cause of lameness of cows in the U.S. dairy industry. Farms with PDD-afflicted cows experience economic loss due to treatment costs, decreased milk production, lower reproductive efficiency, and premature culling. While the exact cause of PDD is unknown, lesion development is associated with the presence of anaerobic spirochetes. This study was undertaken to investigate the virulence and antigenic relatedness of four previously isolated Treponema phagedenis-like spirochetes (1A, 3A, 4A, and 5B) by using a mouse abscess model with subcutaneous inoculation of 10(9), 10(10), and 10(11) spirochetes. Each of the PDD isolates induced abscess formation, with strain 3A causing cutaneous ulceration. Lesion development and antibody responses were dose dependent and differed significantly from those seen with the nonpathogenic human T. phagedenis strain. Strains 3A, 4A, and 5B showed two-way cross-reactivity with each other and a one-way cross-reaction with T. phagedenis. Strain 5B showed one-way cross-reactivity with 1A. None of the isolates showed cross-reactivity with T. denticola. In addition, distinct differences in immunoglobulin G subclass elicitation occurred between the PDD strains and T. phagedenis. From these data, we conclude that spirochetes isolated from PDD lesions have differential virulence and antigenic traits in vivo. Continuing investigation of these properties is important for the elucidation of virulence mechanisms and antigenic targets for vaccine development.

Novel HPV types present in oral papillomatous lesions from patients with HIV infection.

Patients infected with the human immunodeficiency virus (HIV) often develop multiple papillomatous lesions of the oral cavity. In the present study, a total of 67 biopsies from benign oral lesions were analyzed for the presence of human papillomavirus (HPV) DNA using Southern-blot hybridization in combination with a polymerase chain reaction designed to detect all known HPV types, as well as unidentified types. These samples, collected at random from a high-risk population, were subsequently divided into 57 biopsies originating from patients with confirmed HIV infection and 10 biopsies from patients with unknown HIV status. Each sample was amplified with 7 different combinations of degenerate primers. All amplified products were sequenced. HPV DNA sequences were detected in 67% (45/67) of the samples. HPV 7 (19%) and HPV 32 (28%) were the predominant HPV types. HPV 32 was present in 2/4 fibromas tested. Two new HPV types, HPV 72 and HPV 73, were identified in oral warts with atypia. The complete genomes of these viruses were cloned and sequenced. Other HPV types detected were HPV 2a, HPV 6b, HPV 13, HPV 16, HPV 18, HPV 55, HPV 59 and HPV 69.

Electronmicroscopic diagnosis of human papilloma virus in verruca plantaris.

The purpose of this study was to identify the human papilloma virus in verruca plantaris by transmission electron microscopy and study the cellular effect of human papilloma virus at both the transmission electron microscopy and light histochemistry level. The authors discuss the cellular pathology in relation to early studies and keratin disorders. Features identified by transmission electron microscopy are consistent with characteristics of human papilloma virus-1.

Use of HPV 1 capsids produced by recombinant vaccinia viruses in an ELISA to detect serum antibodies in people with foot warts.

A sandwich ELISA was developed to detect HPV antibodies using HPV 1 capsids that were purified from recombinant vaccinia virus-infected cells and a monoclonal antibody to the HPV 1 L1 protein. Sera from 91 college-aged women who had been previously screened for HPV 1 antibodies by immune precipitation of capsid proteins were tested by ELISA. A cutoff point was established independently of other criteria based on the assumption that the ELISA values came from a mixture of two Normal distributions representing seropositive and seronegative individuals. It was found that the data fit this model best when the natural log of the ELISA (+0.5 to make all of the values positive) was used. Positive sera were shown to react with a conformational epitope(s) on the L1 protein. In the population reporting foot warts, 16 of 18 (89%) had ELISA values above the cutoff. This compared to 38 of 73 (53%) positives in the population reporting no history of foot warts. The odds ratio for the association of the ELISA reactivity with foot warts was 7.23 (95% CI 1.53, 69.4; P < 0.01). There was no significant association between the ELISA reactivity and wart infections reported at other sites. The average of the log ELISA values for individuals never reporting foot warts was -0.223 (SD 0.468), whereas the average value for individuals reporting foot warts within 10 years was 0.191 (SD 0.450) (P = 0.001). There was a negative correlation between the magnitude of ELISA reactivity and the time elapsed since the last appearance of foot warts. This apparent loss of seroreactivity over time may indicate that HPV 1 is usually eliminated from the host after infection or that inadequate levels of HPV 1 capsid antigen are produced during latent foot warts to maintain antibody levels.

Double infection with human papillomavirus 1 and human papillomavirus 63 in single cells of a lesion displaying only an human papillomavirus 63-induced cytopathogenic effect.

BACKGROUND: Specific histologic features are associated with the presence of certain human papillomaviruses (HPV) in verrucous lesions of the skin. HPV 1 is known to be associated with eosinophilic keratohyalin-like intracytoplasmic inclusion bodies, granular in appearance, whereas the recently described HPV 63 seems to induce inclusion bodies displaying a filamentous structure. Although an infection by two distinct HPV types within a single cell has not been previously reported, we have recently treated a plantar punctate keratotic wart in which only the histologic features seen in an HPV 63-induced lesion were seen, in spite of the detection of double infection of both HPV 1 and HPV 63 DNAs, thus posing the question as to the role of the HPV 1 present in the lesion. EXPERIMENTAL DESIGN: To localize the genomes of these two viruses within the lesion, double fluorescence in situ hybridization was performed using biotin-labeled HPV 63 DNA and digoxigenin-labeled HPV 1 DNA. The distribution of the genomes of these two viruses was examined in comparison with the histologic features in the lesion. The copy numbers of HPV 63 and HPV 1 were compared on agarose gel electrophoresis, stained with ethidium-bromide. RESULTS: We demonstrated the presence of the DNA of both HPV 1 and HPV 63 within the same nucleus of a plantar wart. In spite of the double infection of these two viruses in a cell and more or less equal copy numbers of the viruses, the cytopathogenic effect of only HPV 63 was seen in the cells. CONCLUSIONS: This is the first report of double infection of two different types of HPV within the same nucleus. Our findings suggest the possible interference that two HPV types could have on each other in inducing the HPV type specific cytopathogenic effects.

Human papillomavirus and cutaneous warts in meat handlers.

The association of papillomavirus and hand warts in meat handlers was examined. Human papillomavirus (HPV) DNA was found in 23 (88%) of 26 cutaneous warts, with HPV 7 (27%) and a yet unidentified HPV (HPV X) (42%) being the predominant types. HPV 2 was found in two (7.5%) patients, and HPV 4 was found in three (11.5%) patients. No bovine papillomavirus sequences were detected. In most patients, the warts developed in less than 2 years after they started working with meat. A possible HPV transmission route by protection gloves and professional equipment is suggested.

Anogenital warts in children.

Fourteen children presenting with anogenital (AG) warts and their close family members were studied; 28.6 and 8.3% of presenting children and other child household members, respectively, had non-genital cutaneous warts; 42.8% of children with AG warts had one or more adult household member with common hand warts. Fifty per cent of all mothers had subclinical cervical papilloma virus (PV) infection; only one male adult had subclinical PV infection of the penis without concurrent AG warts. Of the children with AG warts 42.8% had one or more adult household member with AG warts. Human papilloma virus (HPV) deoxyribonucleic acid (DNA), type 6/11 most frequently, was detected in 38.5% AG wart biopsies from children, and 67% AG wart biopsies from adults. HPV 31/33/35 was detected in 28.5% of cervical preneoplasias and type 6/11 in the one case of subclinical PV infection of the penile shaft. Detection of HPV types 6/11, 16/18, or 31/33/35 in AG warts in children was significantly associated with vertical (from an HPV-infected maternal birth canal during vaginal delivery) or sexual transmission of these warts (Fisher exact probability P = 0.031).

Detection of cutaneous and genital HPV types in clinical samples by PCR using consensus primers.

Two sets of consensus PCR primers consisting of a common 3' primer CP-I and two 5'-primers, CP-IIG (primer set A) and CP-IIS (primer set B), in the E1 open reading frame of the human papillomavirus (HPV) genome are presented. These two primer sets enabled the detection of a 188 base pair (bp) fragment of HPV 1, 2, 3, 4, 5, 6b, 7, 8, 9, 10a, 11, 12, 14a, 16, 17, 18, 19, 20, 21, 22, 24, 25, 31, 33, 36, 37, 38, 39 and 46. HPV types 15, 23, 49 and 50 were poorly amplified and HPV type 41 was not amplified. The method is suitable for the detection of HPV DNA sequences in clinical samples of both cervical and cutaneous lesions.

Production and characterization of human proliferative T-cell clones specific for human papillomavirus type 1 E4 protein.

Human papillomavirus type 1 (HPV1) virions and E4 protein purified from cutaneous warts were tested in lymphocyte proliferation assays using normal individuals. Both antigens were found to be capable of eliciting good lymphoproliferative responses. Several T-cell clones specific for wart E4 protein were obtained from a donor who had consistently responded very well to E4 in these initial assays. They were maintained in culture by repeated stimulation with antigen and interleukin-2, using an autologous mitomycin-treated lymphoblastoid cell line as a source of antigen-presenting cells. Two of these clones (3F5 and 4A8), which behaved identically, have been studied in more detail. A series of overlapping synthetic peptides covering the entire E1 E4 protein sequence was used to identify a single T-cell epitope which maps to a strongly hydrophilic region spanning amino acid residues 38 to 50. We have also tested the ability of a panel of major histocompatibility complex class II-matched and -mismatched lymphoblastoid cell lines to present this peptide to the T-cell clones in proliferation assays. The study reports that the epitope is restricted through HLA-DQ7 and that it can be recognized by T cells with different T-cell receptor gene rearrangements.

Demonstration of human papillomavirus type 1 DNA in a wart with bowenoid histologic changes.

A verrucous lesion on the forearm of a 6-year-old boy was found to be a human papillomavirus type 1 (HPV-1)-induced wart. In addition to typical intracytoplasmic inclusion bodies, the specific cytopathogenic effect of HPV-1 infection, bowenoid changes, were noted on histopathological examination.

Common warts from immunocompetent patients show the same distribution of human papillomavirus types as common warts from immunocompromised patients.

We studied the papillomaviruses (HPV) found in 131 common warts from 111 immunocompetent patients by amplification of viral DNA sequences with the general-primer-mediated polymerase chain reaction (PCR). The virus types were determined by restriction-enzyme cleavage and reverse-blot analysis. Results were confirmed by using the Southern blot technique. Forty patients harboured HPV 2a, 25 individuals showed HPV 2c and 13 yielded HPV 57. Common warts from 16 patients were induced by a variant of HPV 57. HPV 7 was found in four patients. HPV 1 was identified in two patients, and there was evidence for HPV 4 in only one case. One individual yielded an HPV type which was only weakly related to HPV 2. Three patients were infected by more than one HPV type. PCR did not demonstrate HPV-DNA in warts from six individuals. The distribution and variation of HPV types found in the common warts of immunocompetent patients were similar to the findings in immunocompromised patients reported by other authors.

Varied clinical morphology of HPV-1-induced warts, depending on anatomical factors.

The clinical and histological features of 49 lesions induced by human papillomavirus type 1 (HPV-1) were studied. The majority of cases showed the typical clinical features and location of such lesions. They were usually located on the ventral or lateral surfaces of the hands or feet, and were dome-shaped lesions with a central depression. However, HPV-1-induced lesions located on other body areas displayed different clinical features, such as those of common warts, a digitate wart, and a cutaneous horn. One lesion on a healing burn scar had a herpes-like appearance. As these 49 lesions were induced by the same type of HPV (HPV-1), differences in their clinical features are likely to have been due to host-related factors.

Detection of human papillomavirus-related oral verruca vulgaris among Venezuelans.

A sensitive in situ hybridization test under low stringency conditions (LCS) with a set of digoxigenin-labeled human papillomavirus mixed probes (D-L HPV MP) revealed a positive reaction in 8 of 10 cases of oral verruca vulgaris (OVV). Ages ranged from 5 to 37 years with a mean of 14.5 years. 50% of all cases were located intraorally on the hard palate, followed in frequency by the commissures. These preliminary findings provide evidence of the role of HPV in OVV from a sample of the Venezuelan population. We show that in situ hybridization conducted under LSC is useful in HPV detection (regardless of the type) and the digoxigenin-labeling system is a rapid, relatively easy and specific method. In addition, this technique permits the retrospective evaluation of routinely processed material, thus widening the investigative spectrum for HPV.

Characterization and analysis of human papillomaviruses of skin warts.

We analysed human papillomavirus (HPV) infections in 61 tissue specimens of skin warts of Taiwanese patients by DNA hybridization. The prevalence of HPV infection was 69% by Southern blot hybridization. The typing of HPVs was performed by dot blot hybridization under highly stringent conditions with each probe separately. The prevalence of HPV-1, 2/3, 4, 5, 8, 11, 16 and 18 in skin warts was 13, 7, 16, 2, 0, 5, 2 and 8%, respectively. Chi-squared analysis revealed that there was a correlation between HPV type and copy number. Most HPV-4-induced warts were verruca vulgaris. HPV-1 DNA was detected in verruca plantaris and verruca vulgaris. No specific histopathological features were found to be indicative of the presence or absence of HPV, or of the various types of HPV infection.

Detection of human papillomavirus type 2a DNA in verrucae vulgares by electron microscopic in situ hybridization.

Electron microscopic in situ hybridization (EMISH) of common warts (verrucae vulgares) of the hands was performed using a biotinylated human papillomavirus type 2a (HPV-2a) DNA probe and immunogold labelling of ultrathin sections of 2% glutaraldehyde-fixed, Lowicryl K4M-embedded tissues. It was first established that the warts contained HPV-2a DNA by light microscopic in situ hybridization. The HPV-2a probe chiefly labelled cells in the horny, granular and upper spinous layers of the epidermis, and labelling decreased towards the basal cell layer. The gold particles were located precisely on the viral particles in the nuclei of granular cells. The lower limit of detection by EMISH was found to be the keratinocytes of the third cellular layer above the basal cells. These keratinocytes showed evidence of a viral cytopathic effect, suggesting that vegetative DNA replication in infected keratinocytes occurs at least as early as this level of the epidermis.

DNA of bovine papillomavirus type 1 and 2 in equine sarcoids: PCR detection and direct sequencing.

Nucleotide sequences of bovine papillomavirus (BPV) DNA amplified by the polymerase chain reaction (PCR) from samples of equine sarcoid skin tumours were determined. All naturally occurring sarcoids (n = 58 tumours from 32 horses and 2 donkeys) contained BPV-DNA. All but 3 of the genome fragments belonged to the BPV type 1 strain (BPV-1); the remaining were BPV type 2. Similar results were obtained with cutaneous bovine papillomas used as controls (n = 20). One of the horses, carrying 2 sarcoids, was particularly interesting; one tumour contained BPV-1 DNA whilst the other sarcoid yielded BPV-2 DNA, suggesting that horses are not immune to super-infection. BPV-DNA was even amplified from the sarcoid samples which had yielded negative results in previous investigations when DNA isolated from the lesions was used in Southern blot hybridization with BPV probes. In addition, there was no detectable BPV-DNA in any equine or bovine tissue examined other than sarcoids or cutaneous bovine papillomas. Biopsies of normal skin surrounding lesions yielded exclusively negative results. The described nucleotide differences represent a natural genomic variation of this BPV type between geographically distant locations. The identical variations recovered from cattle and horses in Switzerland, a finding of great epidemiological interest, strongly suggest that a uniform variant of BPV-1 is one of the etiologic agents of equine sarcoid and bovine papilloma in a given region.