Human papilloma virus (HPV) infection in children and adolescents

Oral and periodontal manifestation related during human papilloma virus infections: Update on early prognostic factors

Human Papilloma Virus (HPV) is considered one of the most common sexually transmitted infections and has been shown to play an important role in the pathogenesis of squamous cell carcinomas (SCC) of the cervix and head and neck. Manifestations of HPV infections can be manifold, ranging from asymptomatic infections to benign or potentially malignant lesions to intraepithelial neoplasms and invasive carcinomas. The heterogeneity of clinical manifestations from HPV infection depends on the interactions between the viral agent and the host, a direct consequence of the ability on the part of HPV is to remain silent and to evade and convey the action of the host immune system. The oral mucosa represents one of the tissues for which HPV has a distinct tropism and is frequently affected by infection. While much information is available on the role that HPV infection plays in the development of SCC in the oral cavity, there is less information on asymptomatic infections and benign HPV-induced oral lesions. Therefore, the purpose of this review is to analyze, in light of current knowledge, the early clinical and bio-humoral prognostic features related to the risk of HPV malignant transformation, focusing on subclinical conditions, benign lesions, and the correlation between oral infection and infection in other districts. The data show that the main risk associated with HPV infection is related to malignant transformation of lesions. Although HPV-driven OPSCC is associated with a better prognosis than non-HPV-driven OPSCC, primary prevention and early detection of the infection and affected genotype are essential to reduce the risk of malignant neoplastic complications and improve the prognosis.

Comparison of HPV neutralizing and IgG antibodies in unvaccinated female adolescents

Aims: To analyze the consistency between HPV neutralizing antibodies and specific total IgG antibodies in unvaccinated females. Materials & methods: Serum samples from 978 unvaccinated Chinese females aged 9-26 years were measured for antibodies against HPV-16 and HPV-18 using simultaneous pseudovirus-based neutralization assay and ELISA. Results: There was a moderate level of consistency between HPV neutralizing antibodies and specific IgG in females aged 18-26 years (Cohen's κ coefficient for HPV-16 and HPV-18: 0.52 and 0.38) and poor consistency in those aged 9-17 years (Cohen's κ coefficient <0.05). However, Cohen's κ coefficient remained almost unchanged in sensitivity analysis when the IgG antibody cut-off value was raised. Conclusion: HPV neutralizing antibodies are a more specific indicator for the evaluation of HPV natural humoral immunity.

Reduced NK Cell Cytotoxicity by Papillomatosis-Derived TGF-β Contributing to Low-Risk HPV Persistence in JORRP Patients

The role of natural killer (NK) cells in juvenile-onset recurrent respiratory papillomatosis (JORRP) patients remains elusive. In this study, we find increased NK cell percentage, particularly CD11b-CD27- (DN) subsets in peripheral blood of JORRP patients and associated with disease activity. RNA sequencing shows a downregulated "natural killer cell-mediated cytotoxicity" feature in JORRP tumors. We also find impaired cytotoxic capacity and lower expression of NK cell-activating receptors including NKp30 and NKp46. Higher transforming growth factor-beta 1 (TGF-β1) is found both in plasma and tumor tissues of JORRP, and anti-TGF-β1 antibody could restore NK cell cytolytic activity and upregulate NKp30 and NKG2D expression. Also, we find a significantly higher Chemokine receptor type 6 (CXCR6) on NK cells in tumors compared with that in peripheral blood. Finally, RT-PCR analysis show that both HPV6-E6-E7 and HPV11-E6-E7 overexpression leads to higher TGFB1 expression compared with control SNU-1076 cell line, and higher CXCR6 expression is detected on NK coculture with HPV11-E6-E7-overexpressing cells. In conclusion, we demonstrate that TGF-β1 by papillomatosis leads to decreased NK cell cytotoxicity through downregulating NK cell-activating receptors in JORRP patients.

Human papillomavirus (HPV) in pregnancy - An update

Human papilloma viruses (HPV) are small epitheliotropic DNA viruses, of which there are 200 genotypes, 40 of which are known to cause genital infections and are also oncogenic. HPV is the most common sexually transmitted infection. Clinical features vary from asymptomatic (identified at routine cervical cancer screening) to large lesions on the vulva, vagina, cervix and some extragenital sites. Its prevalence in pregnancy varies from 5.5% to 65% depending on age, geography and gestational age (increasing with gestational age). Infection in pregnancy has been associated with adverse outcomes such as spontaneous miscarriage, preterm birth, placental abnormalities and fetal growth restriction. However, the evidence for these adverse outcomes is varied. Besides being oncogenic (and thus associated with cancer of the cervix in pregnancy), vertical transmission to the fetus/neonate can cause neonatal infections, especially juvenile-onset recurrent oral and respiratory papillomatosis (JORRP). Where there are very large lesions on the vulva, delivery may be obstructed. Diagnosis in pregnancy is mainly by viral PCR or from the clinical appearance of the characteristic lesions on the vulva. Treatment is local by either surgical or laser excision or application of trichloroacetic acid. Podophyllin/podophyllotoxin is contraindicated in pregnancy. HPV Infection is not an indication for caesarean delivery as this has not been shown to prevent vertical transmission. For those diagnosed at routine cervical cancer screening, management should follow guidelines for cervical cancer screening in pregnancy. Vaccination is currently not recommended for pregnant women, although studies on those inadvertently vaccinated in pregnancy have not shown any adverse effects on either the fetus or mother.

Paediatric Virology and innovation in medical education: An interview with Dr Ioannis N. Mammas, Consultant Paediatrician on the island of Euboea (Greece) and Coordinator of the Paediatric Virology Study Group

Born in Chalkida in Greece, Dr Ioannis N. Mammas, Consultant Paediatrician on the island of Euboea, studied Medicine at the University of Crete School of Medicine, where he received his MD in 2002 and his PhD in Clinical Virology in 2006. He was trained in Paediatrics and Neonatology in Merseyside (UK), attending the 'Alder Hey' Children's Hospital's specialty training (ST) rotation programme and in Athens (Greece) at the 'Penteli' Children's Hospital and the 'MAKKA' Paediatric Infectious Diseases (PID) Unit of the 'Aghia Sophia' Children's Hospital. On October 10th, 2015, he presented the Paediatric Virology subspecialty's proposal, which up-to-date has attracted the critical interest of several international experts in the scientific fields of Neonatology, Paediatrics, PID and Virology and has been evaluated as a unique project of innovation in medical education. According to Dr Mammas, Paediatrics is the specialty, which daily provides the opportunity to support with responsibility the children's smile, the hope of life and future. He highlights the significant role of the Paediatric Virology Study Group (PVSG), a paediatric think tank, which was established by a group of paediatric trainees and young paediatricians in 2007 and since then has been involved with enthusiasm in the perspectives of Paediatric Virology in medical education. Dr Mammas strongly believes that in the future, Paediatric Virology subspecialists will have a strategically principal role, both clinical and academic, at the fight against viral infections in childhood. This aim will be supported by the newly founded Institute of Paediatric Virology (IPV), the first scientific initiative in the world committed to medical education on neonatal and paediatric viral infections.

Clinical Virology research and medical education in Greece: An interview with Demetrios A. Spandidos, Professor of Clinical Virology at the University of Crete in Greece

Professor Demetrios A. Spandidos, Professor Emeritus of Clinical Virology at the University of Crete School of Medicine in Crete, Greece, is a pioneer in world research in Virology, Oncology and medical education. He has been the first Professor of Clinical Virology at the University of Crete School of Medicine, the only School of Medicine with a separate Department of Clinical Virology in Greece. According to Professor Spandidos, the understanding of the interactions of viruses with human host cells is what enables the development of new vaccines and new therapies against a wide range of diseases in humans, including cancer. Over the past two decades, the expansion of new knowledge, treatments, prevention and management options and the emerging needs on neonatal and paediatric viral infections have made the role of future paediatric virologists more than necessary. For this reason, he strongly believes that Paediatric Virology should be recognized as a new paediatric subspecialty. Professor Spandidos declares that medical education is a continuous sequence from undergraduate to postgraduate/specialty/subspecialty medical training and continuing learning. He also supports the concept that the future of medical education represents the future of Medicine.

Paediatric virology and human papillomaviruses: An update

Almost 10 years ago, in October, 2008, the scientist who reported for the first time the association between human papillomaviruses (HPV) and cervical cancer, was awarded with the Nobel prize. In the years that followed, Professor Harald zur Hausen actively supported the value of the HPV vaccination in the prevention of different types of cancer and highlighted the necessity of its introduction in both girls and boys. However, to date, in the majority of countries, HPV vaccination among male adolescents has not been implemented into the national vaccination schemes, while in several countries, including Greece, the participation rate to HPV vaccination among female adolescents still remains low. Recent data indicate that catch-up HPV vaccination among young women has been extremely useful and has exhibited a significant effect in decreasing the prevalence of HPV. While the marketed current HPV vaccines prevent anogenital HPV infection, their impact on the natural history of oral HPV and their efficacy in preventing HPV-related head and neck carcinomas need to be further investigated. Juvenile onset recurrent respiratory papillomatosis, as well as HPV-associated conjunctival papillomas continue to be observed in childhood and their clinical management involves different therapeutic approaches with controversial outcomes. This review article provides an overview of recent views and advances on HPV infections and prevention in childhood that were presented at the '4th Workshop on Paediatric Virology' on Saturday September 22, 2018 in Athens, Greece.

Prevalence and factors associated with warts in primary school children in Tema District, Sohag Governorate, Egypt

BACKGROUND

Warts are one of the most common, persistent, and frustrating cutaneous problems encountered in dermatology clinical practice especially in younger generations.

OBJECTIVE

To determine the prevalence of warts in primary school children in Tema District, Sohag, Egypt, and to determine possible factors associated with transmission.

PARTICIPANTS AND METHODS

A school-based cross-sectional (prevalence) study was carried out during the academic year 2015-2016 in six primary schools in Tema District, Sohag Governorate, Egypt. A total of 1045 students were examined. Data was collected using a self-administered semi-structured questionnaire which was taken home by the student to be completed by his/her caregiver.

RESULTS

Among 1045 examined school students, 108 students were diagnosed as having warts with a prevalence rate of 10.3%. Common wart was the most common type among students (49.0%) followed by plantar and plane warts (24.1%, each) while genital wart was the least one (2.8%). There was no significant sex or age difference. The prevalence of warts was significantly higher among students from public schools, rural areas, and big families; students with lower paternal education level; and students who were sharing shoes, walking barefoot, having contact with house pets, or exposed to water channels.

CONCLUSION

Warts, especially the common variant, are highly prevalent in primary school children. The significant factors associated with the development of warts in these children were big family size and sharing shoes. Other significant associated factors included living in rural areas, attending public schools, illiterate parents, fathers with manual work, and swimming in water canals.

HPV-Related Papillary Lesions of the Oral Mucosa: A Review

Human papillomaviruses (HPVs) are causative of a group of clinically papillary lesions. The HPV-related lesions of the oral cavity include squamous papilloma, condyloma acuminatum, verruca vulgaris, and multifocal epithelial hyperplasia. Benign entities, such as verruciform xanthoma or giant cell fibroma, as well as malignancies, such as papillary squamous cell carcinoma and verrucous carcinoma, may be considered in the clinical and/or histologic differential diagnoses of these lesions. Mechanisms of infection, epidemiology, clinical presentations, histologic features, and differential diagnoses of the HPV-related oral pathologies are discussed. Current concepts of viral transmission, especially as pertaining to lesions in pediatric patients, and the impacts of HPV vaccination are reviewed.

Paediatric Virology and its interaction between basic science and clinical practice (Review)

The 3rd Workshop on Paediatric Virology, which took place on October 7th, 2017 in Athens, Greece, highlighted the role of breast feeding in the prevention of viral infections during the first years of life. Moreover, it focused on the long-term outcomes of respiratory syncytial virus and rhinovirus infections in prematurely born infants and emphasised the necessity for the development of relevant preventative strategies. Other topics that were covered included the vaccination policy in relation to the migration crisis, mother‑to‑child transmission of hepatitis B and C viruses, vaccination against human papilloma viruses in boys and advances on intranasal live‑attenuated vaccination against influenza. Emphasis was also given to the role of probiotics in the management of viral infections in childhood, the potential association between viral infections and the pathogenesis of asthma, fetal and neonatal brain imaging and the paediatric intensive care of children with central nervous system viral infections. Moreover, an interesting overview of the viral causes of perinatal mortality in ancient Greece was given, where recent archaeological findings from the Athenian Agora's bone well were presented. Finally, different continuing medical educational options in Paediatric Virology were analysed and evaluated. The present review provides an update of the key topics discussed during the workshop.

Paediatric Virology: A rapidly increasing educational challenge

The '2nd Workshop on Paediatric Virology', which took place on Saturday the 8th of October 2016 in Athens, Greece, provided an overview on recent views and advances on Paediatric Virology. Emphasis was given to HIV-1 management in Greece, a country under continuous financial crisis, hepatitis B vaccination in Africa, treatment options for hepatitis C virus in childhood, Zika virus in pregnancy and infancy, the burden of influenza on childhood, hand-foot-mouth disease and myocarditis associated with Coxsackie viruses. Other general topics covered included a critical evaluation of Paediatric Accident and Emergency viral infections, multimodality imaging of viral infections in children, surgical approaches of otolaryngologists to complex viral infections, new advances in the diagnosis and treatment of viral conjunctivitis and novel molecular diagnostic methods for HPV in childhood. A brief historical overview of the anti-vaccination movement was also provided, as well as presentations on the educational challenge of Paediatric Virology as a new subspecialty of Paediatrics. This review highlights selected lectures and discussions of the workshop.

Vaccination against Human Papillomavirus in relation to Financial Crisis: The "Evaluation and Education of Greek Female Adolescents on Human Papillomaviruses' Prevention Strategies" ELEFTHERIA Study

STUDY OBJECTIVE

In this study we aimed to explore financial and other sociodemographic factors that affect nonvaccination against the human papillomavirus (HPV) in Greece, one of the first European Union countries to introduce the vaccination against HPV into its National Immunization Programme in 2008. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: Six hundred thirty-two female adolescents (aged 11-16 years) from Greece completed a pilot cross-sectional questionnaire-based survey (ELEFTHERIA study) from 2008 to 2014.

RESULTS

Overall, only 8.9% (56 of 632) of the female adolescents reported that they had received all 3 doses of the HPV vaccination. The HPV vaccination uptake rates increased gradually from 3.2% (3 of 95) in 2008 to 17.1% (14 of 82) in 2011. However, it abruptly decreased to 2.1% (2 of 95) in 2012 and it reached 9.2% (8 of 87) in 2013 and 11.5% (11 of 96) in 2014. The most common factors for nonvaccination included fear of side effects, which decreased (Spearman ρ = -0.860; P = .024) and financial issues, which increased statistically significantly (Spearman ρ = 0.890; P = .012) during the years 2008 to 2014.

CONCLUSION

In our study we addressed the novel topic of the association of financial issues with HPV vaccination compliance and highlighted the urgent need to provide and maintain health insurance coverage to children in Greece, a country in financial crisis.

Genital HPV in Children and Adolescents: Does Sexual Activity Make a Difference?

STUDY OBJECTIVE

To compare the prevalence of human papillomavirus (HPV) genital infection among prepubertal children, sexually active and not sexually active adolescents, and assess potential risk factors for transmission.

DESIGN

Prospective study.

SETTING

Outpatient adolescent health clinic.

PARTICIPANTS

Ninety-five girls aged 2-21 years; 38 sexually active adolescents (group A), 28 not sexually active adolescents (group B), and 29 prepubertal children (group C).

INTERVENTIONS

Participants' vaginal or cervical specimens were tested for HPV with the CLART HPV 2 assay (Clinical Array Technology, Genomica, Madrid, Spain) and for cytological abnormalities with liquid-based cytology.

MAIN OUTCOME MEASURES

Differences in prevalence of low- and high-risk HPV infections among the 3 groups.

RESULTS

Genital HPV was detected in 37.9% (36/95) of all participants; 47.4% (18/38) of group A, 28.6% (8/28) of group B, and 34.5% (10/29)of group C (P = .27). Multiple HPV infection was detected in 26.3% (10/38), 10.7% (3/28), and 13.8% (4/29) of groups A, B, and C, respectively (P = .21). High-risk genotypes were detected in 47.4% (18/38), 28.6% (8/28), and 24.1% (7/29) of groups A, B, and C, respectively (P = .10). Main high-risk genotypes were HPV 16 (27%, 10/37), HPV 31 (21.6%, 8/37 ), HPV 35 (13.5%, 5/37), HPV 53 (13.5%, 5/37), and low-risk HPV 6 (18.9%, 7/37). Sexual activity was associated with increased risk for genital high-risk HPV infection (odds ratio = 3.41; 95% confidence interval, 1.19-9.78); specifically with HPV 33 and HPV 51. Forty percent of sexually active adolescents with normal cervical cytology were infected with high-risk HPV types. Family history of skin HPV was positively associated with genital HPV in the sexually active group (odds ratio = 2.01; 95% confidence interval, 1.17-3.46).

CONCLUSION

Timeline and target population for HPV vaccination might need to be reappraised, in view of significant nonsexual transmission of genital HPV so early in childhood.

Effect of mode of delivery on vertical human papillomavirus transmission - A meta-analysis

A systematic review of the literature has been conducted (last update March 2014) for clinical studies reporting the prevalence of human papillomavirus (HPV) in the offspring of HPV-infected women in association to their mode of delivery. A meta-analysis was carried out according to the identification of concordant neonatal to maternal HPV types. Overall eight studies were included in the meta-analysis. Our pooled results, showed that caesarean section is associated with significantly lower rates of HPV transmission than vaginal birth (14.9% vs. 28.2%, risk ratio or RR: 0.515, 95% confidence interval or CI: 0.34-0.78). The number of caesarean sections needed to prevent one case of perinatal infection (number needed to treat or NNT) would be 7.5. As a conclusion it should be noted that caesarean section decreases the risk for perinatal HPV transmission by approximately 46%. Perinatal transmission still occurs in approximately 15% of the children born by caesarean section.

Elevated glucose-6-phosphate dehydrogenase expression in the cervical cancer cases is associated with the cancerigenic event of high-risk human papillomaviruses

The most important etiologic agent in the pathogenesis of cervical cancers (CCs) is human papillomavirus (HPV), while the mechanisms underlying are still not well known. Glucose-6-phosphate dehydrogenase (G6PD) is reported to elevate in various tumor cells. However, no available references elucidated the correlation between the levels of G6PD and HPV-infected CC until now. In the present study, we explored the possible role of G6PD in the pathology of CC induced by HPV infection. Totally 48 patients with HPV + CC and another 63 healthy women enrolled in the clinical were employed in the present study. Overall, prevalence of cervical infection with high-risk-HPV (HR-HPV) type examined was HPV-16, followed by HPV-18. The expressions of G6PD in CC samples were also detected by immunohistochemistry (IHC), qRT-PCR, and Western blot. Regression analysis showed elevated G6PD level was positively correlated with the CC development in 30-40 aged patients with HR-HPV-16/18 infection. The HPV16 + Siha, HPV18 + Hela, and HPV-C33A cell lines were employed and transfected with G6PD deficient vectors developed in vitro. MTT and flow cytometry were also employed to determine the survival and apoptosis of CC cells after G6PD expressional inhibition. Our data revealed that G6PD down-regulation induced poor proliferation and more apoptosis of HPV18 + Hela cells, when compared with that of HPV16 + Siha and HPV-C33A cells. These findings suggest that G6PD expressions in the HR-HPV + human CC tissues and cell lines play an important role in tumor growth and proliferation.

Examining the efficacy and safety of squaric acid therapy for treatment of recalcitrant warts in children

The objective of the study was to determine the safety and efficacy of squaric acid dibutyl ester (SADBE) therapy on the treatment of recalcitrant warts in children. This retrospective chart review examined 72 patients treated using SADBE from July 2002 to December 2012. Patients were followed for 6 months to 11 years. Patients were treated at a pediatric dermatology outpatient clinic at the University of North Carolina at Chapel Hill. Seventy-two children with verrucae who failed initial treatment for warts were selected for the study. Full long-term follow-up was obtained in 48 patients. Four patients discontinued the use of SADBE because of adverse effects. The primary study outcome was efficacy of SADBE treatment. Adverse effects, dosages administered, type of wart, other cutaneous disease present, and level of immunosuppression were measured. Forty of 48 (83%) patients in whom treatment outcomes could be obtained reported complete resolution of their warts. Seventy percent of patients used a maximum concentration of 0.4% SADBE and 60% of patients reported no adverse effects. The majority of patients treated with SADBE reported complete resolution of warts. Most patients reported no adverse effects even while receiving doses as high as 2% daily. This study shows that SADBE is a safe and effective treatment for recalcitrant warts in children.

Clinical efficiency of quadrivalent HPV (types 6/11/16/18) vaccine in patients with recurrent respiratory papillomatosis

The aim of the study was to assess the clinical efficiency of quadrivalent HPV (types 6/11/16/18) vaccine in patients with recurrent respiratory papillomatosis (RRP). This was a prospective study of patients with RRP treated from January 2009 to July 2012 at the Ear, Nose and Throat Department of the Emergency County Hospital of Cluj-Napoca, Romania. Demographic characteristics, onset of RRP, HPV typing, use and number of cidofovir injections, number of surgeries for RRP per year, and use of human papillomavirus vaccine (types 6, 11, 16, 18) (recombinant, adsorbed)/Silgard® were considered from all the patients included in the study. Charts were reviewed for follow-up after diagnosis, after cidofovir, and after Silgard; all the statistical tests were applied at a significance level of 5%. The recurrences were observed within 27.53 ± 11.24 days after intralesional cidofovir injection. Thirteen patients with recurrence after cidofovir agreed and received Silgard® vaccine. 85% [54.44–99.41] of patients had no recurrences during 1-year follow-up. The recurrence of papillomas was observed in two patients (15%, 95% CI [0.59–45.56]), one with adult-onset RRP and one with juvenile-onset RRP. Both recurrences appeared after the first Silgard dose; one month after the third vaccine dose each patient underwent a new surgery for remaining papillomas with no recurrences at 1-year follow-up visit. Silgard® vaccination had a good effect and proved to be efficient in the treatment of our patients with RRR without appearance of recurrence in 85% of the patients during 1-year follow-up.

The paediatric story of human papillomavirus (Review)

Human papillomavirus (HPV) is composed of a particularly heterogeneous family of DNA viruses, which has gained much attention in recent years due to the discoveries of Professor Harald zur Hausen, who first identified a connection between HPV and cervical cancer. Professor Harald zur Hausen, the 'Father of HPV Virology', was the recipient of the 2008 Nobel Prize. HPV can be transmitted through physical contact via autoinoculation or fomites, sexual contact, as well as vertically from the HPV-positive mother to her newborn, causing subclinical or clinical infections. In infancy and childhood, HPV-associated clinical infections include skin warts, genital warts and juvenile recurrent respiratory papillomatosis, while cervical squamous intraepithelial lesions have also been reported among adolescent girls. To date, several research teams, worldwide, have extensively investigated HPV from the paediatric point of view. This primitive effort has been performed before the recent great expansion of paediatric HPV research due to the vaccination programmes against HPV, which were introduced into clinical practice in 2006. In this review article, we present a brief overview of paediatric HPV research after the first report in 1978 involving children in the research of HPV until the time point of this great expansion. In the future, it is expected that further unresolved issues will be addressed and clarified, as the paediatric story of HPV remains a challenging research target.

Genomic diversity of human papillomaviruses (HPV) and clinical implications: an overview in adulthood and childhood

During the last years, several researchers have highlighted the importance of characterizing more than one genomic region in order to detect recombination and classify variants of human papillomaviruses (HPVs) properly. HPVs variants differ in their biological, molecular and chemical properties. Therefore, this genomic diversity can present differences in the natural history and pathogenicity of HPVs. Different 'high-risk' HPVs variants of the genotypes HPV 16 and 18 can confer varied risks of viral persistence in the human cervix and influence HPVs progression to cervical cancer. Moreover, different 'low-risk' HPVs variants of the genotypes HPV 6 and 11 can play a unique role in the development of anogenital and cutaneous warts, recurrent respiratory papillomatosis (RRP) and ophthalmic pterygium. In future, the precise impact of genomic HPVs diversity to the clinical course of HPVs-associated diseases as well as to the efficacy of the current HPVs vaccines remains to be elucidated.

Suppression of respiratory papillomatosis with malignant transformation by erlotinib in a kidney transplant recipient

A 52-year-old non-smoker and renal transplant recipient developed an incessant cough. A CT scan of the thorax revealed ill-defined hazy opacities in the right upper lung. He was diagnosed with non-tuberculosis Mycobacterium chelonae/abscessus infection based on sputum culture results. A trial of antibiotics initially resulted in some clinical improvement. A subsequent CT of the thorax documented worsening of the lesions in the right lung and new lesions on the left. An intratracheal growth was noted. Bronchoscopy with biopsy of the tracheal lesions documented respiratory papillomatosis with transformation to squamous cell cancer. Test for high-risk human papilloma virus was positive. Video-assisted thoracoscopic surgery biopsy with wedge resection of the left lower lobe revealed metastatic squamous cell lung cancer. He was treated with one ablation followed by four cycles of chemotherapy. He has been maintained on erlotinib ever since. There has been no recurrence of the cough or papillomas.

The ‘Trojan horse’ oncogenic strategy of HPVs in childhood

HPVs are considered to be the principal cause of cervical cancer worldwide. During the last decade, their possible oncogenic involvement has also been proposed in a substantial proportion of nongenital cancers, such as breast and lung cancer. The presence of high-risk HPVs in the neonatal oral mucosa supports the transmission of HPVs from the mother to her newborn. This review presents current evidence that supports the perinatal transmission of high-risk HPVs and suggests that this may be the initial step of the oncogenic strategy of high-risk HPVs in humans. The hypothesis that children are a unique reservoir of silent high-risk HPVs, analogously to the Trojan horse, should be investigated further.

Prevalence of the human papillomavirus (HPV) expression of the inner prepuce in asymptomatic boys and men

OBJECTIVE

To investigate the prevalence of high-risk (HR) and low-risk (LR) human papillomavirus (HPV) in prepuces of boys and men without any HPV related lesions.

PATIENTS AND METHODS

Between 2009 and 2011, a total collective of 250 boys and men were investigated in this prospective study. The samples were subdivided into 3 groups regarding their age, consisting of 125 (50%) children (0-10 years), 38 (15.2%) adolescents (11-20 years) and 87 (34.8%) adults (>20 years). In situ hybridization (ISH) was performed to detect HR and LR virus types within the epithelium, followed by microscopic interpretation and determination between episomal and integrative signal pattern.

RESULTS

Our results revealed high levels of HPV concentration (HR and LR) in all age groups: HR versus LR positivity was seen in 45.5 versus 35% (children), 60.6 versus 63.6% (adolescents) and 58.3 versus 48.6% (adults). The topmost rate of HR (59.8%)- and LR (50.6%)-positive probes was found in the group with high estimated sexual activity (>14 years).

CONCLUSION

Concerning the high prevalence of male HPV infection even in children, indicating non-sexual transmission pathways, inclusion of boys in the vaccination program seems to be required reducing their burden of HPV related disease.

Imiquimod 5% cream treatment for rapidly progressive genital condyloma in a 3-year-old girl

BACKGROUND

The incidence of genital warts in children has increased in the last 50 years. Although pediatric genital warts may resolve spontaneously, the treatment of extensive perianal genital warts in children can be challenging. Imiquimod, although not approved in the pediatric population, may avoid the pain or extensive scarring associated with other treatment modalities.

CASE

A 3-year-old female was scheduled for surgical resection of genital warts. At surgery, she had extensive condylomas that had progressed rapidly from initial presentation. They were not amenable to surgical treatment due to concerns of incomplete resection, post-operative pain, and genital scarring. After 6 weeks of imiquimod treatment, the condylomatous lesions had completely resolved with minimal side effects.

SUMMARY AND CONCLUSION

Imiquimod 5% cream is an effective treatment option for children with extensive and rapidly progressive perianal warts and is associated with minimal side effects. Its use should be considered in children with extensive condyloma in order to avoid the pain and possible scarring associated with other approved treatment modalities.

Laboratory and clinical aspects of human papillomavirus testing

Human papillomavirus (HPV) infection is associated with a wide spectrum of disease that ranges from self-limited skin warts to life-threatening cancers. Since HPV plays a necessary etiological role in cervical cancer, it is logical to use HPV as a marker for early detection of cervical cancer and precancer. Recent advances in technology enable the development of high-throughput HPV assays of different formats, including DNA-based, mRNA-based, high-risk group-specific and type-specific methods. The ultimate goal of these assays is to improve the accuracy and cost-effectiveness of cervical screening programs. HPV testing has several potential advantages compared to cytology-based screening. However, since the cancer to transient infection ratio is always low in the general population, HPV test results are bound to have a low positive predictive value that may subject women to unnecessary follow-up investigations. The wide-spread administration of prophylactic HPV vaccine will substantially decrease the incidence of cancer and precancer. This poses a number of challenges to cytology-based screening, and the role of HPV testing is expected to increase. Finally, apart from technical and cost-effectiveness considerations, one should also keep in mind the psycho-social impact of using sexually-transmitted agents as a marker for cancer screening.

Human papillomavirus genotypes present in the oral mucosa of newborns and their concordance with maternal cervical human papillomavirus genotypes

OBJECTIVES

To elucidate the concordance of human papillomavirus (HPV) genotypes between the mother and her newborn and to identify risk factors for the vertical transmission of HPV.

STUDY DESIGN

HPV genotypes present in 329 pregnant women, their newborns, cord blood, and placenta samples were determined by molecular techniques, including using pure DNA for nested polymerase chain reaction. HPV antibodies were tested using multiplex HPV serology. Kappa statistics and the Wilcoxon test were used to assess concordance, and regression analysis was used to calculate ORs and 95% CIs.

RESULTS

HPV DNA was detected in 17.9% of oral samples from newborns and in 16.4% of the cervical samples of the mothers. At delivery, mother-newborn pairs had similar HPV-genotype profiles, but this concordance disappeared in 2 months. Oral HPV carriage in newborns was most significantly associated with the detection of HPV in the placenta (OR=14.0; 95% CI, 3.7-52.2; P=.0001). The association between status of the cord blood and oral HPV was also significant at delivery (OR=4.7; 95% CI, 1.4-15.9; P=.015) but disappeared within 1 month. HPV antibodies in infants were of maternal origin (OR=68; 95% CI, 20.1-230.9; P=.0001).

CONCLUSIONS

HPV is prevalent in oral samples from newborns. The genotype profile of newborns was more restricted than that of the maternal cervical samples. The close maternal-newborn concordance could indicate that an infected mother transmits HPV to her newborn via the placenta or cord blood.

Anogenital Warts in Childhood - Always a Marker for Sexual Abuse?

Human papilloma viruses (HPV) are common pathogens associated with a wide range of cutaneous and mucosal infections in childhood. Different HPV types can cause common warts and anogenital warts. Condylomata acuminata in children may be, but are not necessarily, an indicator of sexual abuse. Each individual case therefore requires careful examination, with consideration of other possible means of transmission. Diagnosis of anogenital warts is generally by means of clinical examination. Additional histological, serological or molecular genetic investigation may be indicated occasionally. The high rate of spontaneous remission and the rate of recurrence after treatment should be considered. The available topical and surgical treatment options are discussed.

InterSCOPE study: Associations between esophageal squamous cell carcinoma and human papillomavirus serological markers

BACKGROUND

The role of human papillomavirus (HPV) in the causation of esophageal squamous cell carcinoma is unclear. We examined the associations between esophageal squamous cell carcinoma and 28 centrally measured HPV serological markers in serum from six existing case-control studies conducted in regions with differing background risks of esophageal cancer.

METHODS

We used centralized multiplex serology to test serum samples from 1561 case subjects and 2502 control subjects from six case-control studies for antibodies to the major HPV capsid protein (L1) and/or the early proteins E6 and/or E7 of eight high-risk, two low-risk, and four cutaneous HPV types. Study-specific odds ratios (ORs) and corresponding 95% confidence intervals (CIs) were estimated using conditional logistic regression with adjustment for smoking, alcohol consumption, and other potential confounders. Pooled odds ratios and 95% confidence intervals were calculated using either a linear mixed-effects approach or a joint fixed-effects approach. All statistical tests were two-sided.

RESULTS

We found statistically significant associations between esophageal squamous cell carcinoma and antibodies to E6 for HPV16 (OR = 1.89, 95% CI = 1.09 to 3.29, P = .023) and HPV6 (OR = 2.53, 95% CI = 1.51 to 4.25, P < .001) but not for other tested HPV types. There were no statistically significant associations between esophageal squamous cell carcinoma and antibodies to E7 for any of the tested HPV types. Simultaneous seropositivity for HPV16 E6 and E7 was rare (four case subjects, two control subjects; OR = 5.57, 95% CI = 0.90 to 34.35; P = .064). We also found statistically significant associations between esophageal squamous cell carcinoma and capsid antibodies for the high-risk mucosal type HPV33 L1 (OR = 1.30, 95% CI = 1.00 to 1.69; P = .047) and the low-risk mucosal types HPV6 (OR = 1.22, 95% CI = 1.05 to 1.42; P = .010) and HPV11 (OR = 1.30, 95% CI = 1.09 to 1.56, P = .0036).

CONCLUSIONS

We found limited serological evidence of an association between esophageal squamous cell carcinoma and HPV in the populations studied. Although HPV does not appear to be an important risk factor for esophageal squamous cell carcinoma, we cannot exclude the possibility that certain HPV types may be involved in a small subset of cancers.

HPV genotypes in the oral cavity/oropharynx of children and adolescents: cross-sectional survey in Poland

Human papillomaviruses (HPVs) are a very complex group of pathogenic viruses, with more than 80 types, causing human infection. Given the prevalence of HPV infection and its relationship with the development of cervical and many other cancers, HPV vaccine development has been a major public health initiative worldwide in the last decade. The aim of the presented study was to identify HPV DNA by MY-PCR in 4,150 school children and adolescents, aged 10-18 years in the Wielkopolska region, Poland. All individuals were asked to fill in extensive questionnaires; further normal, oral squamous cells were collected from each pupil. Cellular DNA was isolated and used as a MY-PCR template to estimate the incidence of HPV-active infection. Forty five subjects (1.08% of the sample) were carriers of oropharyngeal HPVs. HPV status and variables of interest, such as age, gender, socioeconomical status, and risk factors (smoking and sexual intercourse history, alcohol consumption) were not correlated. The presence of HPVs in the oral cavity was cumulated in several schools of the region. DNA sequencing of MY-PCR products revealed only four HPV genotypes. The most frequent genotype was HPV11 (38/45 HPV-positive cases), while other more rare genotypes were HPV6 (3/45), HPV12 (3/45), and HPV57 (1/45).

CONCLUSION

Our findings presented herein, reveal a relatively low prevalance of oropharyngeal HPVs in Polish adolescents and fill an important gap in the knowledge of oral HPV infections of children above 10 years and adolescents.

Detection of human papillomavirus in bronchoalveolar lavage samples in immunocompetent children

BACKGROUND

Human papillomavirus (HPV) has been detected in lungs of adults and has been proposed to play a role in lung carcinogenesis. However, no data are currently available on the incidence of HPV in the lower respiratory tract of children.

PURPOSE

To determine the prevalence of HPV deoxyribonucleic acid (DNA) in bronchoalveolar lavage (BAL) samples were obtained from asymptomatic immunocompetent children.

METHODS

A total of 71 children between 2 and 12 years of age were prospectively enrolled. Detection of HPV DNA and HPV typing were performed using polymerase chain reaction-based techniques.

RESULTS

Of the 71 BAL samples, HPV DNA was detected in 6 children. Coinfection with HPV 16, 18, and 31 was detected in 2 children, while 4 children were positive for non-"high-risk" HPVs.

CONCLUSIONS

This preliminary case-control study indicates the presence of HPV DNA in BAL samples in children. The possible presence of HPV in the lower respiratory tract of children requires further investigation to elucidate the actual epidemiologic condition, the potential modes of its transmission, and its possible causative relationship in lung carcinogenesis in adulthood.

Can 'high-risk' human papillomaviruses (HPVs) be detected in human breast milk?

AIM

Human papillomavirus (HPV) transmission via nonsexual modes in childhood has been proposed by several researchers. The aim of our study was to determine the presence of 'high-risk' HPV DNA in human breast milk.

METHODS

Using polymerase chain reaction techniques, we evaluated the presence of HPV infection in human breast milk collected from 21 HPV-positive and 11 HPV-negative mothers.

RESULTS

Of the 32 studied human milk specimens, no 'high-risk' HPV 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58 or 58 DNA was detected.

CONCLUSION

This preliminary case-control study indicates the absence of mucosal 'high-risk' HPV types in human breast milk.

Factors affecting transmission of mucosal human papillomavirus

Human papillomavirus (HPV) is the most common sexually transmitted infection. The effect of HPV on public health is especially related to the burden of anogenital cancers, most notably cervical cancer. Determinants of exposure to HPV are similar to those for most sexually transmitted infections, but determinants of susceptibility and infectivity are much less well established. Gaps exist in understanding of interactions between HPV, HIV, and other sexually transmitted infections. The roles of mucosal immunology, human microbiota at mucosal surfaces, host genetic factors and hormonal concentrations on HPV susceptibility and infectivity are poorly understood, as are the level of effectiveness of some primary or secondary preventive measures other than HPV vaccination (such as condoms, male circumcision, and combination antiretroviral therapy for HIV). Prospective couples studies, studies focusing on mucosal immunology, and in-vitro raft culture studies mimicking HPV infection might increase understanding of the dynamics of HPV transmission.

Novel human papilloma virus (HPV) genotypes in children with recurrent respiratory papillomatosis

INTRODUCTION

Recurrent respiratory papillomatosis (RRP) is characterized by the presence of benign virally induced tumors of the larynx and respiratory epithelium that may obstruct the airway and tend to recur frequently. RRP is caused by the human papilloma virus (HPV), most frequently by HPV types 6 and 11. In this study, we present four cases of children with RRP in whom HPVs other than HPV-6 or HPV-11 were found.

MATERIAL AND METHODS

In all four cases, HPV typing was performed by polymerase chain reaction (PCR) followed by restriction digestion (RFLP) in biopsy samples collected during surgery.

RESULTS

In the first case, simultaneous HPV infection with types 13 and 39 was detected, while in the second case HPV-40 and HPV-56 were found. In cases 3 and 4, the biopsy samples were positive for unidentified 'low-risk' HPVs.

CONCLUSIONS

The presence of novel HPV genotypes in children with RRP emphasizes the need for further investigation of the implication of these genotypes in the disease.

Vaccination against human papilloma virus (HPV): epidemiological evidence of HPV in non-genital cancers

Recently, the vaccine against human papillomavirus (HPV) was introduced in the national vaccination programmes of several countries worldwide. The established association between HPV and the progression of cervical neoplasia provides evidence of the expected protection of the vaccine against cervical cancer. During the last two decades several studies have also examined the possible involvement of HPV in non-genital cancers and have proposed the presence of HPV in oesophageal, laryngeal, oropharyngeal, lung, urothelial, breast and colon cancers. The possible involvement of HPV in these types of cancer would necessitate the introduction of the vaccine in both boys and girls. However, the role of HPV in the pathogenesis of these types of cancer has yet to be proven. Moreover, the controversial evidence of the possible impact of the vaccination against HPV in the prevention of non-genital cancers needs to be further evaluated. In this review, we present an overview of the existing epidemiological evidence regarding the detection of HPV in non-genital cancers.

Current concepts on human papillomavirus infections in children

Current evidence is strong enough to conclude that human papillomavirus (HPV) can be transmitted both sexually and non-sexually. The debate on HPV infections in children still continues but it is more focused on HPV prevalence than on transmission modes. HPV DNA detection in amniotic fluid, foetal membranes, cord blood and placental trophoblastic cells all suggest HPV infection in utero, i.e. prenatal transmission. Based on recent meta-analysis, vertical transmission occurs in approximately 20% of cases. Most of the mucosal HPV infections in infants are incident, persistent infections in oral and genital mucosa being found in less than 10% and 2% respectively. The mother seems to be the main transmitter of HPV to her newborn, but subsequent HPV infections are acquired horizontally via saliva or other contacts. Bimodal peak prevalence is seen for skin warts, oral papillomas and recurrent respiratory papillomatosis (RRP) in younger and older age groups, suggesting similar epidemiology. Of the clinical HPV diseases, juvenile-onset-RRP and genital condylomata are problematic; the former because of its life-threatening potential and the latter because of possible sexual abuse. HPV6 and 11 are the most common genotypes in both the lesions. Early in life, infections by the high-risk HPV genotypes may also remain persistent for a considerable period, and should be of considerable importance for HPV vaccination strategies.

High-risk human papillomavirus in the oral cavity of women with cervical cancer, and their children

BACKGROUND

Association of High-risk Human Papillomavirus (HR-HPV) with oral cancer has been established recently. Detecting these viruses in oral cavity is important to prevent oral lesions related to them. The purpose of this study was to evaluate the prevalence of HR-HPV in the oral cavity of women with cervical cancer, and their children. A total of 70 women, previously diagnosed with cervical cancer, and 46 children of these women, born by vaginal delivery only, were selected for this study. Buccal swabs were collected from their oral cavity and HPV detection was carried out using Hybrid Capture 2 high-risk HPV (HC2 HR-HPV) detection system.

RESULTS

Out of 70 women with cervical cancer, four (5.71%) were found to be positive for HR-HPV in their oral cavity. No association of HR-HPV was found with sociodemographic profile, marital status, reproductive history, tobacco and alcohol usage, contraceptive pills usage, and presence of oral lesions (p>0.05). Among children, HR-HPV in the oral cavity was detected in only 1 of the 46 subjects examined (2.17%). Clinically healthy oral mucosa, without any oral lesions, was observed in all the HR-HPV positive subjects.

CONCLUSION

The result of this study showed that there is low, if any, risk of HR-HPV infection in the oral cavity of women with cervical cancer. Further, our study suggests that there is very low risk for children of women with cervical cancer, to acquire and sustain HR-HPV in their oral cavity until childhood or adolescence.

High-risk human papilloma virus infection, tumor pathophenotypes, and BRCA1/2 and TP53 status in juvenile breast cancer

Juvenile breast cancer is rare and poorly known. We studied a series of five breast cancer patients diagnosed within 25 years of age that included two adolescents, 12- and 15-years-old, and 3 young women, 21-, 21-, and 25-years-old, respectively. All cases were scanned for germline mutations along the entire BRCA1/2 coding sequences and TP53 exons 4-10, using protein truncation test, denaturing high performance liquid chromatography and direct sequencing. Paraffin-embedded primary tumors (available for 4/5 cases), and a distant metastasis (from the 15-years-old) were characterized for histological and molecular tumor subtype, human papilloma virus (HPV) types 16/18 E6 sequences and tumor-associated mutations in TP53 exons 5-8. A BRCA2 germline mutation (p.Ile2490Thr), previously reported in breast cancer and, as compound heterozygote, in Fanconi anemia, was identified in the 21-year-old patient diagnosed after pregnancy, negative for cancer family history. The tumor was not available for study. Only germline polymorphisms in BRCA1/2 and/or TP53 were detected in the other cases. The tumors of the 15- and 12-years-old were, respectively, classified as glycogen-rich carcinoma with triple negative subtype and as secretory carcinoma with basal subtype. The tumors of the 25-year-old and of the other 21-year-old were, respectively, diagnosed as infiltrating ductal carcinoma with luminal A subtype and as lobular carcinoma with luminal B subtype. No somatic TP53 mutations were found, but tumor-associated HPV 16 E6 sequences were retrieved from the 12- and 25-year-old, while both HPV 16 and HPV 18 E6 sequences were found in the tumor of the 15-year-old and in its associated metastasis. Blood from the 15- and 25-year-old, diagnosed with high-stage disease, resulted positive for HPV 16 E6. All the HPV-positive cases were homozygous for arginine at TP53 codon 72, a genotype associated with HPV-related cancer risk, and the tumors showed p16(INK4A) immunostaining, a marker of HPV-associated cancers. Notably menarche at 11 years was reported for the two adolescents, while the 25-year-old was diagnosed after pregnancy and breast-feeding. Our data suggest that high-risk HPV infection is involved in a subset of histopathologically heterogeneous juvenile breast carcinomas associated with menarche or pregnancy and breast-feeding. Furthermore we implicate BRCA2 in a juvenile breast carcinoma diagnosed at 21 years of age, 4 years after an early full-term pregnancy, in absence of cancer family history.