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

HPV Infections-Classification, Pathogenesis, and Potential New Therapies

To date, more than 400 types of human papillomavirus (HPV) have been identified. Despite the creation of effective prophylactic vaccines against the most common genital HPVs, the viruses remain among the most prevalent pathogens found in humans. According to WHO data, they are the cause of 5% of all cancers. Even more frequent are persistent and recurrent benign lesions such as genital and common warts. HPVs are resistant to many disinfectants and relatively unsusceptible to external conditions. There is still no drug available to inhibit viral replication, and treatment is based on removing lesions or stimulating the host immune system. This paper presents the systematics of HPV and the differences in HPV structure between different genetic types, lineages, and sublineages, based on the literature and GenBank data. We also present the pathogenesis of diseases caused by HPV, with a special focus on the role played by E6, E7, and other viral proteins in the development of benign and cancerous lesions. We discuss further prospects for the treatment of HPV infections, including, among others, substances that block the entry of HPV into cells, inhibitors of viral early proteins, and some substances of plant origin that inhibit viral replication, as well as new possibilities for therapeutic vaccines.

Prevalence of HPV and Assessing Type-Specific HPV Testing in Cervical High-Grade Squamous Intraepithelial Lesions in Poland

The prevalence and distribution of oncogenic human papillomavirus (HPV) genotypes in women who underwent screening for cervical cancer in the Wielkopolska region, Poland, were assessed, and the correlation of genotypes with the histological results was evaluated. Cervical samples were collected from 2969 women for cervical cancer screening. Participants were screened by liquid-based cytology and HPV genotyping (n = 1654) and referred to colposcopy and punch biopsy (n = 616) if recommended. HPV genotypes 16, 31, 52, 66, 53, and 51 are the most frequent types in the studied population. Genotypes 16 and 31 account for nearly one-fifth of the infections of diagnosed HPV infections. HPV 16, 31, and 52 are found in nearly 80% of premalignant HSIL lesions (CIN 2 and CIN 3). That leads to the conclusion that vaccination programs should cover as many types of HPV as possible and shows the urgent need to vaccinate the Polish population with a 9-valent vaccine.

Viral metagenomics updated the prevalence of human papillomavirus types in anogenital warts

To investigate the composition of human papillomavirus (HPV) types in anogenital warts (AGWs), viral nucleic acid in 110 AGWs, pooled into 11 specimen pools, were subjected to viral metagenomic analysis. After finding HPV7 in AGWs, conventional PCR screening was performed for HPV7 in other 190 individual AGW specimens. Viral metagenomic results indicated that 29 different types of HPV were recovered, with HPV11 and HPV6 showing the highest proportion of sequence reads. HPV7 was detected in 7 of 11 pools, 5 of which contained abundant HPV7 sequence reads. 24 complete genomes of HPV were acquired in viral metagenomic analysis, including 5 HPV7 genomes, based on which phylogenetic analysis and pairwise sequence comparison were conducted. PCR screening for HPV7 in other 190 individual AGW specimens revealed 25 positive cases (13.16%), of which the amplified fragments were sequenced and confirmed to be HPV7 sequences. Although HPV7 was generally found in hand warts and recently also in warts in toe webs, our data suggested that the role of HPV7 in AGW should be considered in the future clinical test and vaccine development for AGWs.

Phylogenetic analysis of Alphapapillomavirus based on L1, E6 and E7 regions suggests that carcinogenicity and tissue tropism have appeared multiple times during viral evolution

Members of the Alphapapillomavirus genus are causative agents for cervix cancer and benign lesions in humans. These viruses are classified according to sequence similarities in their L1 region. Yet, viral carcinogenicity has been associated with variations in the proteins encoded by the E6 and E7 genes. In order to relate evolutionary history with origin of carcinogenicity, we performed phylogenetic reconstructions using both nucleotide and predicted amino acid sequences of the L1, E6 and E7 genes. Whilst phylogenetic analysis of L1 reconstructed genus evolutionary history, phylogenies based on E6 and E7 proteins support the idea that mutations at amino acids S/Tx [V/L] (E6) and LxCxE (E7) might be responsible for carcinogenic potential. These findings indicate that virulence within Alphapapillomavirus have appeared multiple times during evolution. Our results reveal that oncogenic potential is not a monophyletic clade-specific adaptation but might be the result of positive selection on random mutations occurring on proteins involved in host infection during viral diversification.

Classification and evolution of human papillomavirus genome variants: Alpha-5 (HPV26, 51, 69, 82), Alpha-6 (HPV30, 53, 56, 66), Alpha-11 (HPV34, 73), Alpha-13 (HPV54) and Alpha-3 (HPV61)

HPV variants from the same type can be classified into lineages and sublineages based on the complete genome differences and the phylogenetic topologies. We examined nucleotide variations of twelve HPV types within the species Alpha-5 (HPV26, 51, 69, 82), Alpha-6 (HPV30, 53, 56, 66), Alpha-11 (HPV34, 73), Alpha-13 (HPV54) and Alpha-3 (HPV61) by analyzing 1432 partial sequences and 181 complete genomes from multiple geographic populations. The inter-lineage and inter-sublineage mean differences of HPV variants ranged between 0.9-7.3% and 0.3-0.9%, respectively. The heterogeneity and phylogenies of HPV isolates indicate an independent evolutionary history for each type. The noncoding regions were the most variable regions whereas the capsid proteins were relatively conserved. Certain variant lineages and/or sublineages were geographically-associated. These data provide the basis to further classify HPV variants and should foster future studies on the evolution of HPV genomes and the associations of HPV variants with cancer risk.

HLA Immunogenotype Determines Persistent Human Papillomavirus Virus Infection in HIV-Infected Patients Receiving Antiretroviral Treatment

A proportion of human immunodeficiency virus (HIV)-infected patients develop persistent, stigmatizing human papillomavirus (HPV)-related cutaneous and genital warts and anogenital (pre)cancer. This is the first study to investigate immunogenetic variations that might account for HPV susceptibility and the largest to date to categorize the HPV types associated with cutaneous warts in HIV-positive patients. The HLA class I and II allele distribution was analyzed in 49 antiretroviral (ART)-treated HIV-positive patients with persistent warts, 42 noninfected controls, and 46 HIV-positive controls. The allele HLA-B*44 was more frequently identified in HIV-positive patients with warts (P = .004); a susceptible haplotype (HLA-B*44, HLA-C*05; P = .001) and protective genes (HLA-DQB1*06; P = .03) may also contribute. Cutaneous wart biopsy specimens from HIV-positive patients harbored common wart types HPV27/57, the unusual wart type HPV7, and an excess of Betapapillomavirus types (P = .002), compared with wart specimens from noninfected controls. These findings suggest that HLA testing might assist in stratifying those patients in whom vaccination should be recommended.

Human papillomavirus genotyping by Linear Array and Next-Generation Sequencing in cervical samples from Western Mexico

BACKGROUND

The Linear Array® (LA) genotyping test is one of the most used methodologies for Human papillomavirus (HPV) genotyping, in that it is able to detect 37 HPV genotypes and co-infections in the same sample. However, the assay is limited to a restricted number of HPV, and sequence variations in the detection region of the HPV probes could give false negatives results. Recently, 454 Next-Generation sequencing (NGS) technology has been efficiently used also for HPV genotyping; this methodology is based on massive sequencing of HPV fragments and is expected to be highly specific and sensitive. In this work, we studied HPV prevalence in cervixes of women in Western Mexico by LA and confirmed the genotypes found by NGS.

METHODS

Two hundred thirty three cervical samples from women Without cervical lesions (WCL, n = 48), with Cervical intraepithelial neoplasia grade 1 (CIN I, n = 98), or with Cervical cancer (CC, n = 87) were recruited, DNA was extracted, and HPV positivity was determined by PCR amplification using PGMY09/11 primers. All HPV- positive samples were genotyped individually by LA. Additionally, pools of amplicons from the PGMY-PCR products were sequenced using 454 NGS technology. Results obtained by NGS were compared with those of LA for each group of samples.

RESULTS

We identified 35 HPV genotypes, among which 30 were identified by both technologies; in addition, the HPV genotypes 32, 44, 74, 102 and 114 were detected by NGS. These latter genotypes, to our knowledge, have not been previously reported in Mexican population. Furthermore, we found that LA did not detect, in some diagnosis groups, certain HPV genotypes included in the test, such as 6, 11, 16, 26, 35, 51, 58, 68, 73, and 89, which indicates possible variations at the species level.

CONCLUSIONS

There are HPV genotypes in Mexican population that cannot be detected by LA, which is, at present, the most complete commercial genotyping test. More studies are necessary to determine the impact of HPV-44, 74, 102 and 114 on the risk of developing CC. A greater number of samples must be analyzed by NGS for the most accurate determination of Mexican HPV variants.

Oral Human Papillomavirus Infection and Oral Lesions in HIV-Positive and HIV-Negative Dental Patients

We evaluated the risk factors associated with oral human papillomavirus (HPV) infection and oral lesions in 161 human immunodeficiency virus (HIV)-positive patients and 128 HIV-negative patients presenting for oral examination at 2 urban healthcare centers. Patients were interviewed on risk factors and provided oral-rinse samples for HPV DNA typing by polymerase chain reaction. Statistical associations were assessed by logistic regression. Oral HPV was prevalent in 32% and 16% of HIV-positive patients and HIV-negative patients, respectively, including high-risk HPV type 16 (8% and 2%, respectively; P = .049) and uncommon HPV types 32/42 (6% and 5%, respectively; P = .715). Among HIV-negative patients, significant risk factors for oral HPV included multiple sex partners (≥21 vs ≤5; odds ratio [OR], 9.1; 95% confidence interval [CI], 1.7-49.3), heavy tobacco smoking (>20 pack-years vs none; OR, 9.2; 95% CI, 1.4-59.4), and marijuana use (OR, 4.0; 95% CI, 1.3-12.4). Among HIV-positive patients, lower CD4(+) T-cell count only was associated with oral HPV detection (≤200 vs ≥500 cells/mm(3); OR, 4.5; 95% CI, 1.3-15.5). Detection of high-risk HPV was also associated with concurrent detection of potentially cancerous oral lesions among HIV-negative patients but not among HIV-positive patients. The observed risk factor associations with oral HPV in HIV-negative patients are consistent with sexual transmission and local immunity, whereas in HIV-positive patients, oral HPV detection is strongly associated with low CD4(+) T-cell counts.

Oral human papillomavirus and human herpesvirus-8 infections among human immunodeficiency virus type 1-infected men and women in Italy

BACKGROUND

Oral human papillomavirus (HPV) and human herpesvirus-8 (HHV8) infections are sexually transmitted and respectively associated with the development of oropharyngeal carcinoma and Kaposi sarcoma. The aim of the study was to evaluate HPV prevalence and its possible correlation with HHV8 oral shedding, in relation to sex, human immunodeficiency virus (HIV) behavioral risk factor, and immune function.

METHODS

The study population comprised 100 HIV-infected individuals divided into 3 groups: (1) 38 men who have sex with men (MSM), (2) 24 heterosexual men, and (3) 38 women. DNA was obtained from cells of unstimulated whole saliva. Human papillomavirus sequences were searched for by polymerase chain reaction (PCR) with MY09/MY11 primers or by nested PCR with GP5+/GP6+ primers as the second step. Typing was accomplished by restriction fragment length polymorphism analysis or by direct sequencing or by reverse line blot. Human herpesvirus-8 sequences were detected and quantified by nested PCR and real-time PCR, respectively.

RESULTS

Oral HPV infection was present in 37 (prevalence, 37%) of 100 (13 with high-risk and 24 with low-risk types) patients; the most frequent types were HPV16, HPV6, HPV10, HPV61, HPV66, and HPV83. Human herpesvirus-8 DNA was detected in 46 (46%) of 100 subjects. Both infections had the highest prevalence among MSM and the lowest among women; women had a lower prevalence of high-risk HPV types than did both male groups (P = 0.05). An inverse correlation was observed with concomitant oral HHV8 infection (P = 0.007).

CONCLUSIONS

High prevalence of oral HPV and HHV8 infections was observed; MSM had the highest figures, despite better control of HIV infection.

Oral Sex and HPV: Population Based Indications

Human pappilloma virus (HPV) is well established in etiology of uterine cervical cancers, but its role in head and neck cancer is strongly suggested through many epidemiological and laboratory studies. Although HPV-16 induced oropharyngeal cancer is a distinct molecular entity, its role at other sub-sites (oral cavity, larynx, nasopharynx, hypopharynx) is less well established. Oral sex is supposedly the most commonly practiced unnatural sex across the globe and may prove to be a potential transmitting link between cancers of the uterine cervix and the oropharynx in males particularly in those 10-15% non-smokers. In India with the second largest population (higher population density than China) the oral sex is likely to be a common 'recreation-tool' amongst the majority (poor) and with the concurrent highly prevalent bad cervical/oral hygiene the HPV is likely to synergize other carcinogens. Hence in accordance (or coincidently), in India the cervical cancer happens to be the commonest cancer amongst females while oral/oropharyngeal cancer amongst males. Oral sex as a link between these two cancer types, can largely be argued considering a poor level of evidence in the existing literature. The modern world has even commercialized oral sex in the form of flavored condoms. The inadequate world literature currently is of a low level of evidence to conclude such a relationship because no such specific prospective study has been carried out and also due to wide (and unpredictable) variety of sexual practices, such a relationship can only be speculated. This article briefly reviews the existing literature on various modes and population based indications for HPV to be implicated in head and neck cancer with reference to oral sexual practice.

Proteomic signatures of human oral epithelial cells in HIV-infected subjects

The oral epithelium, the most abundant structural tissue lining the oral mucosa, is an important line of defense against infectious microorganisms. HIV infected subjects on highly active antiretroviral therapy (HAART) are susceptible to comorbid viral, bacterial and fungal infections in the oral cavity. To provide an assessment of the molecular alterations of oral epithelia potentially associated with susceptibility to comorbid infections in such subjects, we performed various proteomic studies on over twenty HIV infected and healthy subjects. In a discovery phase two Dimensional Difference Gel Electrophoresis (2-D DIGE) analyses of human oral gingival epithelial cell (HOEC) lysates were carried out; this identified 61 differentially expressed proteins between HIV-infected on HAART subjects and healthy controls. Down regulated proteins in HIV-infected subjects include proteins associated with maintenance of protein folding and pro- and anti-inflammatory responses (e.g., heat-shock proteins, Cryab, Calr, IL-1RA, and Galectin-3-binding protein) as well as proteins involved in redox homeostasis and detoxification (e.g., Gstp1, Prdx1, and Ero1). Up regulated proteins include: protein disulfide isomerases, proteins whose expression is negatively regulated by Hsp90 (e.g., Ndrg1), and proteins that maintain cellular integrity (e.g., Vimentin). In a verification phase, proteins identified in the protein profiling experiments and those inferred from Ingenuity Pathway Analysis were analyzed using Western blotting analysis on separate HOEC lysate samples, confirming many of the discovery findings. Additionally in HIV-infected patient samples Heat Shock Factor 1 is down regulated, which explains the reduced heat shock responses, while activation of the MAPK signal transduction cascade is observed. Overall, HAART therapy provides an incomplete immune recovery of the oral epithelial cells of the oral cavity for HIV-infected subjects, and the toxic side effects of HAART and/or HIV chronicity silence expression of multiple proteins that in healthy subjects function to provide robust innate immune responses and combat cellular stress.

Oropharyngeal cancer: a potential consequence of concomitant HPV and HIV infection

PURPOSE OF REVIEW

Oral human papillomavirus (HPV) infection is the principal cause of a distinct form of oropharyngeal cancer (OPCA) that has been rising in incidence in the United States since 1973, particularly among young men. The possible contribution of the HIV-epidemic to this increase is unclear.

RECENT FINDINGS

Incidence rates for HPV-related OPCA increased with age and were strongly influenced by year of birth in the United States (cohort effect). Persons with HIV/AIDS are at increased risk ( approximately two to six-fold) for OPCA relative to the general population. However, this excess risk may be attributable to tobacco smoking rather than the three-fold higher prevalence of oral HPV infection in this population. Consistent with a viral attribution, however, is the apparent increase in risk of OPCA with severity of AIDS-related immunosuppression. Analogous to other HPV-related cancers (e.g. cervical and anal cancer), trends over time do not appear to be influenced by highly active antiretroviral (HAART) therapy.

SUMMARY

Healthcare providers may encounter HPV-related OPCA more frequently among individuals with HIV/AIDS as this population ages and due to the strong birth cohort effects observed in the general population. However, there is no evidence in support of different incidence trends over time among persons with and without HIV/AIDS.

Epithelial maturation and molecular biology of oral HPV

Human papillomavirus (HPV) is widespread and can cause latent infection in basal cells, with low HPV DNA copy-number insufficient for transmission of infection; can cause subclinical infection that is active but without clinical signs; or can cause clinical infection leading to benign, potentially malignant or malignant lesions. The HPV cycle is influenced by the stage of maturation of the infected keratinocytes, and the production of virions is restricted to the post-mitotic suprabasal epithelial cells where all the virus genes are expressed.Low-risk HPV genotypes are associated with the development of benign oral lesions, whereas high-risk HPV genotypes are implicated in the development of malignant epithelial neoplasms. The rôle of high-risk HPV as a causative agent in epithelial malignancy is different at different anatomical sites: it is almost invariably implicated in squamous cell carcinoma of the uterine cervix, fairly frequently implicated in squamous cell carcinoma of the oropharynx, and it is seldom implicated in squamous cell carcinoma of the mouth.

Association of human papillomavirus 7 with warts in toe webs

BACKGROUND

There have been no studies on the prevalence of types of human papillomavirus (HPV) in cutaneous warts that focus on warts in toe webs (WTW). There is no documented association between HPV 7 and WTW.

OBJECTIVES

To explore the clinical and histopathological features of WTW, and the distribution of HPV genotypes in patients with WTW.

METHODS

The study group consisted of 20 patients with WTW; 31 patients with typical verruca vulgaris (VV) were enrolled as the disease control group, and 53 patients with tinea pedis and 48 healthy volunteers were enrolled as the disease-negative control group. Tissue specimens were analysed for clinical and histological features and distribution of HPV genotypes. Polymerase chain reaction (PCR)-based direct sequencing, TA cloning and type-specific PCR (TS-PCR) were performed in the WTW and VV groups. Interdigital scale specimens from patients with tinea pedis and from healthy volunteers were analysed for HPV DNA by nested PCR and TS-PCR (HPV 7).

RESULTS

All the patients with WTW were male and nearly all were immunocompetent; their mean age was 41 +/- 10 years. The lesions presented mainly as soft, friable and vegetating clusters. HPV 7 was the predominant genotype in WTW with a frequency of 80% (16/20). Fourteen specimens were taken for histopathological examination. The most frequent histological results (seven out of 14) revealed characteristics of HPV 7 infections such as heavily stained cells containing medium-sized keratohyaline granules and a pronounced hyperkeratosis with parakeratosis. TA cloning showed that the sequence shared 90% or more homology with the HPV genotype in direct sequencing. No HPV 7 DNA was found in the scales taken from toe webs without warts.

CONCLUSIONS

This is the first study evaluating the prevalence of HPV types in WTW and the first report of the association between HPV 7 and specific subgroups of patients with warts.

Development and validation of a HPV-32 specific PCR assay

BACKGROUND

Human Papillomavirus-32 (HPV-32) has traditionally been associated with focal-epithelial-hyperplasia (FEH). It is also present in 58% of oral warts of HIV-positive individuals whose prevalence is increasing. Current methods for the detection of HPV-32 are labor-intensive and insensitive so the goal of this work was to develop a highly sensitive and easy to use specific polymerase chain reaction (PCR) assay.

MATERIALS AND METHODS

An HPV-32 L1 specific PCR assay was developed and optimized. The sensitivity and specificity was compared to previous assays utilized for detection (PGMY and MY09/11 PCR with dot blot hybridization) using cloned HPV-32 L1, the closely related HPV-42 L1 as well as clinical samples (oral swabs and fluids from 89 HIV-positive subjects).

RESULTS

The HPV-32 specific PCR assay showed improved sensitivity to 5 copies of HPV-32 as compared to the PGMY PCR, MY09/11 PCR and dot blot which had a limit of detection of approximately 3,000 copies. Using the HPV-32 dot blot hybridization assay as the gold standard, the HPV-32 specific PCR assay has a sensitivity of 95.8% and 88.9% by sample and subject, respectively, and specificity was 87.8% and 58.8% by sample and subject, respectively. The low sensitivity is due to the HPV-32 specific PCR assays ability to detect more HPV-32 positive samples and may be the new gold standard.

CONCLUSION

Due to the ease, sensitivity, and specificity the HPV-32 specific PCR assay is superior to previous assays and is ideal for detection of HPV-32 in large cohorts. This assay provides an excellent tool to study the natural history of HPV-32 infection and the development of oral warts.

Quantitative Proteomic Analysis of Formalin Fixed Paraffin Embedded Oral HPV Lesions from HIV Patients

Human immunodeficiency virus (HIV) infection is associated with dysplastic changes in oral human papilloma virus (HPV) lesions, suggesting changes in keratinocytes. In the present study, we seek to identify proteomic changes in oral HPV lesions between HIV(+) and HIV(-) patients. While fresh tissues represent the most desirable samples for proteomic investigations, they are often difficult to obtain in large numbers under clinical settings. We therefore have developed a new method to identify protein changes in formalin fixed and paraffin-embedded (FFPE) oral HPV lesions utilizing iTRAQ™ technology in conjunction with Liquid Tissue® sample preparation method. Using this method, we identified nine proteins that were differentially expressed in oral HPV lesions as a result of HIV infection. The quantitative proteomic method presented here will be valuable for others who plan to analyze FFPE tissues.

Relationship between prevalent oral and cervical human papillomavirus infections in human immunodeficiency virus-positive and -negative women

Human papillomavirus (HPV) is an etiologic agent for both oropharyngeal and cervical cancers, yet little is known about the interrelationship between oral and cervical HPV infections. Therefore, we compared the prevalences and type distributions of oral and cervical HPV infections and evaluated infection concordance in a cross-sectional study within the Women's Interagency HIV Study cohort. Oral rinse and cervical-vaginal lavage samples were concurrently collected from a convenience sample of 172 human immunodeficiency virus (HIV)-positive and 86 HIV-negative women. HPV genomic DNA was detected by PGMY09/11 L1 consensus primer PCR and type specified by reverse line blot hybridization for 37 HPV types and beta-globin. Only 26 of the 35 HPV types found to infect the cervix were also found within the oral cavity, and the type distribution for oral HPV infections appeared distinct from that for cervical infections (P<0.001). Oral HPV infections were less common than cervical infections for both HIV-positive (25.2% versus 76.9%, P<0.001) and HIV-negative (9.0% versus 44.9%, P<0.001) women. Oral HPV infections were more common among women with a cervical HPV infection than those without a cervical HPV infection (25.5% versus 7.9%, P=0.002). The majority of women (207; 93.7%) did not have simultaneous oral and cervical infections by the same HPV type; however, the number of women who did (14; 6.3%) was significantly greater than would be expected by chance (P=0.0002). Therefore, the oral and cervical reservoirs for HPV infection are likely not entirely independent of one another.

Oral bowenoid papulosis in an HIV-positive male

Bowenoid papulosis (BP) is a condition triggered by human papillomavirus infection and characterized by the development of 1 or more warty lesions, usually in the anogenital region. Although the oral cavity has been known to host several types of warts, thus far only 4 cases of BP have been reported in this anatomic site. We describe a 42-year-old male with AIDS who presented with numerous papillary lesions of the labial mucosa and vermilion. Biopsy yielded a diagnosis of BP. Treatment of the condition consisted of intralesional and subcutaneous injections of interferon-alpha followed by topical application of imiquimod 5% cream. Neither regimen resulted in resolution of the lesions. To our knowledge, this represents the first case of BP arising in the oral mucosa of an HIV-infected individual.

The impact of highly active antiretroviral therapy and immunodeficiency on human papillomavirus infection of the oral cavity of human immunodeficiency virus-seropositive adults

BACKGROUND

Prevalence of human papillomavirus (HPV)-associated oral condylomas has reportedly increased in HIV-infected individuals since the introduction of highly active antiretroviral therapy (HAART). The relationships between HIV therapy regimen, overall health, and subclinical oral HPV have not been examined.

GOAL

To determine oral HPV genotype prevalence and the impact of HAART and health in the HIV+ population.

STUDY

An L1 consensus-primer polymerase chain reaction and linear array assay were used to examine the prevalence of 27 HPV genotypes in saliva of 98 HIV+ individuals. Risk assessment variables were compared to oral HPV status.

RESULTS

Oral HPV was detected in 37% of HIV+ African American individuals. Caucasians were at greater risk of oral HPV infection than African Americans. Markers of advanced HIV disease did not predict HPV status. Therapy status was associated with HPV detection.

CONCLUSIONS

Treatment of HIV, rather than HIV immunosuppression, appears to play a role in oral HPV infections in HIV+ individuals.

Application of viable bacille Calmette-Guérin topically as a potential therapeutic modality in condylomata acuminata: A placebo-controlled study

OBJECTIVES

To evaluate the efficacy of topical application of viable bacille Calmette-Guérin (BCG) as a primary line of treatment in patients with condylomata acuminata.

METHODS

We recruited 50 patients from the Department of Andrology and Sexually Transmitted Diseases, Cairo University Hospital complaining of genital warts. Patients were divided into two groups. Group 1 consisted of 25 patients who received BCG as a weekly topical treatment for 6 consecutive weeks. If still resistant, another intensive three-times-a-week course for 3 consecutive weeks was given. Group 2 consisted of 25 patients who received 0.9% saline solution as a placebo solution with the same procedure and follow-up as for group 1. All patients were followed up for 6 consecutive months. During the treatment course, the local response, wart state and size, and any side effects were reported.

RESULTS

A complete response with the disappearance of all condylomata acuminata was achieved in 20 (80%) of the 25 patients after a maximum of six BCG applications. Three patients (12%) needed another, more extensive, course, resulting in complete clearance 3 weeks later. Only 2 patients (8%) did not achieve a full response even after application of the intensified BCG course. No response was detected in the placebo group, with no improvement during follow-up. No recurrence developed in any responder. Minimal side effects, such as transient erythema and fever, were recorded during the study.

CONCLUSIONS

Topical BCG in the treatment of genital warts attained a high success rate in our study compared with the placebo solution, with insignificant side effects and no recurrence.

Human papillomaviruses in the normal oral cavity of children in Japan

The purpose of this study was to determine the frequency of human papillomavirus (HPV) infections in the normal oral cavity of children in Japan. Oral squamous cell specimens were collected from 77 children (44 boys and 33 girls), aged 3 and 5 years. Extracted DNA was evaluated for HPV infections by polymerase chain reaction (PCR) methods, using consensus primers for the L1 region, specific primers, and direct DNA sequencing analysis. Thirty-seven of 77 specimens (48.1%) were positive for HPV DNA. Positive rates of boys and girls in all specimens were 28.3 (22/77) and 19.5 (15/77)%, respectively. The positive rate in 3-year-old children was 45.2 (14/31)%, and positive rates in boys and girls were 52.6 (10/19) and 33.3 (4/12)%, respectively. The positive rate in 5-year-old children was 50.0 (23/46)%, and positive rates in boys and girls were 48.0 (12/25) and 52.4 (11/21)%, respectively. HPV types were determined by specific PCR and direct DNA sequencing analysis. Frequent HPV types in the specimens of all children were HPV-16 (11/37; 29.7%),-1 (6/37; 16.2%),-2 (6/37; 16.2%),-75 (6/37; 16.2%). The results of the present investigation indicate that many HPVs, including HPV-16 (a high-risk type for cancer), are present in the oral cavity of 3- and 5-year-old children. It is suggested, therefore, that the oral cavity is already a reservoir of HPVs in childhood where later HPV-associated diseases, such as oral cancer and other oral lesions, may develop.

Human papillomavirus infection of the epididymis and ductus deferens: an evaluation by nested polymerase chain reaction

CONTEXT

Human papillomaviruses (HPVs) play an important role in the etiology of squamous cell carcinoma of the uterine cervix. The possible role of the male urogenital tract as a reservoir of HPV infection is not fully understood. We inferred from our previous observation of HPV-31 in epididymal tissue in a case of chronic epididymitis that HPV might be commonly present in cases of epididymitis caused by sexually transmitted pathogens.

OBJECTIVE

To assess the presence of HPV in the epididymis and ductus deferens in nontuberculous epididymitis.

DESIGN

Epididymal samples obtained from 17 patients and epididymal and ductus deferens samples from 5 patients surgically treated for nontuberculous epididymitis were analyzed by nested polymerase chain reaction for the presence of HPV DNA. In positive samples, the HPV type was determined by DNA sequencing.

SETTING

Tertiary-care academic hospital and national reference laboratory for papillomaviruses.

RESULTS

Low-risk HPV type 6 and high-risk HPV types 16, 33, 35, 55, and 73 were detected in 7 patients (31%). Neither koilocytes nor dysplastic changes were found in the epididymis and ductus deferens.

CONCLUSION

Low-risk and high-risk HPV types were detected in the epididymis and ductus deferens of patients with nontuberculous epididymitis. The infection was not accompanied by koilocytic atypia or dysplasia. Our findings support the hypothesis that the male urogenital tract serves as a reservoir of HPV infection.

Chapter 7: Human papillomavirus and cancer of the upper aerodigestive tract

We discuss current evidence of the role of human papillomavirus (HPV) in some cancers of the upper aerodigestive tract, including the oral cavity, the pharynx, and the larynx. Cancers of the oral cavity and the pharynx are associated mainly with tobacco and alcohol exposure, but there is evidence from case series, from case-control studies, and from cohort studies that HPV plays a role in a fraction of these cancers, particularly cancer in the oropharynx and tonsil. The HPV type most commonly associated with cancers in these locations is HPV 16. Laboratory evidence indicates that the virus is integrated and that HPV oncogenes are transcriptionally active in these tumors. Many aspects of the association remain to be investigated, including the epidemiology and natural history of HPV infection in the mouth, the role of cofactors, and the potential use of HPV testing and vaccines in the prevention of these tumors. An analogous role for the virus at other anatomic sites in the upper aerodigestive tract such as the larynx is less clear. The relationship between HPV infection and laryngeal cancer is of particular interest, given that recurrent respiratory papillomatosis is clearly caused by benign proliferative growths induced by HPV 6 or 11 infection of the laryngeal epithelium. Although HPV genomic DNA has been detected in a proportion of laryngeal cancers and despite the many efforts made during the last 15 years, there is not yet compelling evidence that HPV plays a substantial role in laryngeal cancer.

Human papillomavirus infections and oral tumors

In the past 20 years, there has been an increasing interest in human papillomaviruses (HPV) because of their potential role in the pathogenesis of malignant tumors. In 1983, we published the first evidence that HPV might be involved in oral squamous cell carcinomas. The identification of morphological similarities between oral and cervical mucosa lead us to this original proposal. In a recent meta-analysis, HPV was indeed confirmed as an independent risk factor for oral carcinoma. To date, totally more than 100 types of HPV have been identified. As in anogenital cancers, HPV type 16 is the most prevalent type in oral carcinomas. The benign oral lesions, associated with HPV infection, include squamous cell papilloma, condyloma acuminatum, verrucca vulgaris and focal epithelial hyperplasia (FEH). Papillomas and condylomas are mostly caused by HPV type 6 or 11, while oral verrucas are associated with the skin types 2 or 4. A family history of FEH has been suggested. The FEH lesions are caused by HPV types 13 and 32, only detected in oral epithelium. In immunocompromised patients, benign HPV-induced lesions are characterized by atypical morphology and the simultaneous detection of multiple HPV types. Oral benign HPV lesions are mostly asymptomatic, and may persist or regress spontaneously.

Mucosally-derived HPV-40 can infect both human genital foreskin and cutaneous hand skin tissues grafted into athymic mice

HPV-40 is a rare HPV type that has been detected only in genital mucosal tissues. This HPV type is very closely related to HPV-7, which has a predominantly cutaneous tissue tropism. We have shown, previously, that an isolate of HPV-40 (described here as HPV-40(Hershey) or HPV-40(H)) productively infected genital tissues. In this study, HPV-40(H) was tested for productive infection of cutaneous tissue. Fetal hand skin fragments were incubated with infectious HPV-40(H) and implanted subrenally into athymic mice. After 120 days, xenografts showed morphological changes consistent with HPV-40(H) infection and were HPV-40 DNA in situ positive and capsid antigen positive. The results demonstrated that hand skin can support HPV-40(H) infection thereby indicating that this viral type has the capacity to infect both genital mucosal and cutaneous tissues.

Human papillomavirus-associated digital squamous cell carcinoma: literature review and report of 21 new cases

OBJECTIVE

Our aim was to review the clinical behavior of human papillomavirus (HPV)-associated digital squamous cell carcinoma (SCC). Specifically, we examined evidence for the tumor's (1) infectious origin and spread, (2) response to therapy, and (3) prognosis and metastatic risk.

DESIGN

We reviewed and performed data tabulation of all 51 reported cases in the English-language literature and a case series of 23 cases (21 of them not previously reported). We present 2 of the cases in depth.

SETTING

We used previously reported cases from MEDLINE and a case series from a single dermatologic operation practice from 1985 to 1999.

RESULTS

(1) Of all cases, 10% (7/72) had an antecedent genital dysplasia or carcinoma containing the same HPV subtype as the digital SCC. (2) The rate of recurrence after general surgical therapy was 43% (6/14). After Mohs micrographic surgery the recurrence rate was 13% (2/16) for the cases in the literature, and 26% (6/23) for our case series. (3) Of tumors, 3% (2/72) have been observed to metastasize.

CONCLUSIONS

(1) This suggests the possibility of genital-digital spread as a mechanism of tumor genesis. (2) HPV-associated digital SCC is more likely to recur after surgical treatment than previously reported. This rate of recurrence greatly exceeds that for cutaneous SCCs in general and may be caused by residual postsurgical HPV. (3) The rate of metastasis, however, appears to be low.

Viral diseases of the oral mucosa

A wide variety of both DNA and RNA viruses affect the oral cavity. When considered in conjunction with cutaneous features, careful examination of the oral mucosa and oropharynx aids the clinician in making a diagnosis. Examination of the oral cavity should be incorporated as a regular component of the dermatologic examination because diagnostic clues are readily available to assist in the evaluation of infectious processes.

Mechanisms of expression of HHV8, EBV and HPV in selected HIV-associated oral lesions

Opportunistic DNA viruses, particularly members of the herpesvirus family, are frequently the aetiological agents of HIV-associated oral lesions. Oral lesions common to the early phase of the AIDS epidemic, including Kaposi's sarcoma (KS), oral aphthous ulceration, AIDS-associated oral lymphoma, and oral hairy leukoplakia (OHL), have been tested for the prevalence of Epstein-Barr virus (EBV) and Kaposi's sarcoma-associated herpesvirus (KSHV). While EBV DNA is detected by PCR in all of these lesions, abundant viral replication can only be detected in OHL. In OHL, a novel state of EBV infection has been discovered with concurrent expression of replicative and transforming proteins, with all of these proteins contributing to the development of the lesion. Activation of signalling pathways and up-regulation of the viral receptor, proliferative and antiapoptotic genes by these proteins induce several of the histological features common to OHL, such as acanthosis and hyperproliferation. In contrast to other permissive herpesvirus infections, expression of EBV transforming proteins within the permissively infected OHL tissue enables epithelial cell survival and may enhance viral replication. Detection of KSHV in these HIV-infected individuals has been localized only to their saliva. Replicative and latent KSHV gene products have been detected in association with the development of oral KS lesions. EBV, but not human cytomegalovirus (HCMV), has been detected by PCR in minor salivary gland biopsies of HIV-associated salivary gland disease. Human papillomaviruses (HPV) are associated with oral warts in HIV-positive individuals; a diagnosis that appears to be increasing in frequency in the era of highly active antiretroviral therapy. To date, there appears to be little increase in the incidence of HPV-associated oral cancer. The mechanisms of interaction between HIV and HPV are not fully understood. Expression of viral gene products is clearly important and necessary for the development of multiple AIDS-associated oral lesions.

External genital warts: diagnosis, treatment, and prevention

External genital warts (EGWs) are visible warts that occur in the perigenital and perianal regions. They are due primarily to non-oncogenic human papillomavirus (HPV) types, usually types 6 and 11. Physical examination assisted by bright light and magnification is the recommended approach for primary diagnosis. Biopsy is indicated when EGWs are fixed to underlying structures or discolored or when standard therapies are not effective. Recurrences are common, and there is no single treatment that is superior to others. Among women with atypical squamous cells, molecular HPV testing may be useful in determining who should be referred for colposcopy. Condoms may provide some protection against HPV-related diseases and thus are recommended in new sexual relationships and when partnerships are not mutually monogamous. Because the efficacy of cesarean section in preventing vertical transmission of HPV infection from women with EGWs to their progeny has not been proved, it is not recommended.

Human papillomavirus type 38 infection in oral squamous cell carcinomas

In this study, 53 paraffin-embedded oral squamous cell carcinoma (OSCC) biopsy specimens were used. Human papillomavirus type 38 (HPV-38) infection was demonstrated in OSCCs using the PCR technique, DNA sequencing analysis, in situ hybridization, and immunohistochemical techniques. Additionally, the correlation between HPV-38 infection and expressions of proliferating cell nuclear antigens (PCNA) or p53 protein was analyzed immunohistochemically. Using consensus primers for the L1 region (L1-PCR), we identified 35 of 53 specimens (66%) as positive for HPV-38 DNA. Furthermore, specimens from patients over 60 years of age revealed a lower prevalence for the HPV-38 (56.7%) than did those below that age (78.3%). Immunohistochemically, positive stainings for PCNA and p53 protein were more frequently detected in HPV-38 positive OSCCs than HPV negative ones. These results indicate that HPV-38 positive OSCCs were higher in proliferative cellular activity than HPV negative ones. Moreover, the findings suggest that HPV-38 infection may cause malignant transformation of the oral mucosal epithelium.

The use of nested polymerase chain reaction and restriction fragment length polymorphism for the detection and typing of mucosal human papillomaviruses in samples containing low copy numbers of viral DNA

Mucosal human papillomaviruses (HPVs) that infect the genital area have also been shown to infect the oral cavity. In this study a restriction fragment length polymorphism (RFLP) method was developed on a nested polymerase chain reaction (PCR) product to identify ten high risk HPV types 16, 18, 31, 33, 35, 45, 51, 52, 58 and 59 as well as the low risk HPV 11. HPV DNA was detected in 23/31 (74%) of buccal specimens using a sensitive nested PCR employing degenerate consensus primers (Williamson and Rybicki, 1991). Consensus PCR using the PGMy09/11 primers. was able to detect HPV in only 29% of the specimens that had tested positive using the nested HPV PCR primers. HPV 11 type specific primers detected HPV 11 DNA in only 66% of the specimens showing HPV 11 DNA by means of nested PCR and RFLP. A Genbank search revealed that the PCR primers could detect a wide range of mucosal HPV types including types HPV 70, 72 and 73 which have all been isolated from immunocompromised patients. Of the 23 buccal specimens that were positive for HPV DNA, 13 were single infections, five were dual infections and three were triple infections. The HPV types identified by RFLP were: HPV 11 (18/23), HPV 18 (8/23), HPV 16 (3/23), and HPV 33 (1/23). HPV 13 (2/23) was identified by direct sequencing of the inner amplicon of the PCR product.

Synergism between HIV and other viruses in the mouth

The HIV family replicate in and are shed from the mouth. Oral sexual practices potentially contribute to the overall extent of HIV transmission, particularly if high-risk practices are not restricted. Herpesviruses and papillomaviruses that appear in the oral cavity can determine oral HIV replication. The mechanisms probably include heterologous transactivation, enhanced expression of HIV receptors and co-receptors in target cells, release of cytokines and chemokines, and production of superantigens. Oral diseases peculiar to, or more common in, the HIV-infected patient further predispose to heightened oral HIV replication and trafficking. Defining the mechanisms by which oral viruses interact with HIV in the co-infected host should permit intervention measures against oral HIV transmission to be more precisely targeted.

Human papillomavirus-associated oral warts among human immunodeficiency virus-seropositive patients in the era of highly active antiretroviral therapy: an emerging infection

Oral warts are a manifestation of human papillomavirus infection that have been noted infrequently in persons with human immunodeficiency virus (HIV). A nested case-control study was conducted to assess rates of and risk factors for oral warts among a cohort of HIV-seropositive patients. From 1997 through 1999, 56 patients with oral warts were identified among 2194 HIV-positive patients attending an urban oral health center (prevalence, 2.6%). Incident cases of oral warts were significantly more likely to have been diagnosed in 1999 than they were in 1997-1998 (P=.001). Multivariate analysis indicated that the risk of oral warts was associated with a >/=1-log(10) decrease in HIV RNA level in the 6 months before diagnosis of oral warts (odds ratio [OR], 2.35; 95% confidence interval [CI], 1.08-5.11) and with serologic evidence of chronic or previous infection with hepatitis B virus (OR, 2.66; 95% CI, 1.31-5.41). The incidence of oral warts in HIV-seropositive patients appears to be increasing in the era of highly active antiretroviral therapy. Oral warts were associated with reductions in virus load, which suggests that this may in part be related to immune reconstitution.

Identification of six putative novel human papillomaviruses (HPV) and characterization of candidate HPV type 87

Six putative novel human papillomavirus (HPV) types were detected by using general primers for a conserved L1 HPV region in patients examined in gynecologic centers. One of the isolates, detected in samples from 4 patients with koilocytic atypia at cervical cytology (3 of whom were also infected with human immunodeficiency virus type 1), was completely sequenced, identified as a new HPV genotype, and designated candidate HPV87 (candHPV87) by the Reference Center for Human Papillomavirus. candHPV87 shows the classic HPV genome organization and the absence of a functional E5 coding region. Phylogenetic analysis documented that the candHPV87 genome clusters within the A3 group of HPVs, together with HPV61, HPV72, HPV83, HPV84 and candHPV86, which have been completely sequenced, and a number of other putative novel genotypes (two of which are described in this work), which have been partially characterized. To address the growth-enhancing potential of candHPV87, the E6 and E7 putative coding regions were cloned and expressed in tissue cultures. The data indicate that both proteins stimulate cell division in tissue cultures more than those of low-risk HPVs, though not as much as those of HPV16. Taken together, the clinical, molecular, and biological data suggest that the novel papillomavirus characterized in the present study is a low- to intermediate-risk HPV.

High prevalence of oncogenic human papillomavirus in the genital tract of women with human immunodeficiency virus

OBJECTIVE

The goal of this study was to determine the prevalence of human papillomavirus (HPV) and squamous intraepithelial lesions (SILs) in women infected with human immunodeficiency virus (HIV) in Mexico.

METHODS

Cases included women who were positive for human immunodeficiency virus (HIV) and accepted to participate. There were two control groups in this study: group A, heterosexual partners of HIV+ men; group B, commercial sex workers. Gynecologic examination was performed in all participants. Also, a cervical smear with colposcopy and a sample for detection of HPV DNA by polymerase chain reaction (PCR) were obtained in all subjects, as were CD4+ counts. Relative risks (RR) and 95% confidence interval were calculated.

RESULTS

Eighty-five HIV+ women agreed to participate in this study; the route of HIV infection was heterosexual in 78.8%; transfusion in 8.2%; paid donors in 3.5%; and 9.4% unknown. A total of 9 controls were included: 4 from group A and 5 from group B. HPV DNA was detected by PCR in 57 (69%) cases and in 26 (29%) controls from both groups (P < 0.0001). The RR of HPV infection was 5.5 (2.7-11.5). Also, a significant difference in the prevalence of high-risk HPV types was observed between cases and controls, RR = 12.8 (4.07-42.9). These associations were independent of CD4+ counts and antiretroviral therapy. No association was observed between HIV infection and the risk for high-grade SIL.

CONCLUSIONS

We observed a high prevalence of oncogenic HPV types in HIV-positive women. These women should be screened regularly for early diagnosis of premalignant lesions and prevention of cervical cancer.