A case of epidermodysplasia verruciformis associated with squamous cell carcinoma and Bowen's disease: A therapeutic challenge

Epidermodysplasia verruciformis: three case reports and a brief review

Epidermodyplasia verruciformis (EV) is a rare heritable disease that is characterized by an increased susceptibility to infection with specific human papillomavirus (HPV) types due to a defect in cell-mediated immune response to HPV infection. Widespread infection with HPV is responsible for the development of wart-like lesions and pityriasis versicolor-like spots. These individuals have a lifelong risk of developing cutaneous malignancies, especially Bowen's disease and squamous cell carcinoma, mainly in sun-exposed parts. Being the first disease to correlate cancer and viral infection, EV serves as the cornerstone of the understanding of viral oncogenesis. We report three cases of EV, of which one patient subsequently developed Bowen's disease. The patients had multiple hypopigmented papules and plaques of varying sizes that started erupting in childhood and were mainly distributed over sun-exposed parts of the body. Histopathology of the skin biopsies was consistent with EV. One of these patients had started developing an ulcerated plaque over the left clavicle 2 years earlier. A biopsy from the clavicular region also showed histopathological features of Bowen's disease arising in EV. Hence, this clinical review discusses three cases of EV presenting in different age groups with detailed histopathological findings typical for EV.

Cytokine immunomodulation for the treatment of infectious diseases: lessons from primary immunodeficiencies

Traditionally, management of infectious diseases focuses on identification of the causative microbe and the use of pathogen-targeted therapy. With increasing antimicrobial resistance, novel approaches are required. One strategy is to modulate those natural host immune responses that critically mediate resistance to specific microbes. Clinically, this host-directed tactic could be used either alone or in combination with antimicrobial therapy. While conceptually attractive, there is potential concern that the pathways governing host resistance to pathogens in animal models may not extrapolate linearly to humans. Targeting these immune processes clinically may precipitate damaging, epiphenomenal responses. The field of Primary Immunodeficiencies focuses on the characterization of humans with inborn errors of immunity. These rare conditions permit the identification of those molecular and cellular processes that are central to human susceptibility to microbes. In efforts to compensate for defective host responses, this field has also provided a wealth of clinical experience in the effective use of cytokines to treat various active infections, while demonstrating their safety. In this review, we provide a historical perspective of the treatment of infectious diseases, evolving from a focus on the microbe, to an understanding of human immunity; we then outline the growing contribution of Primary Immunodeficiencies to the rational use of adjunctive cytokine immunotherapy in the management of infections.

Differential regulation of human papillomavirus type 8 by interferon regulatory factors 3 and 7

The genus β human papillomavirus (HPV) type 8 is associated with nonmelanoma skin cancer in patients with epidermodysplasia verruciformis, and evidence for its protumorigenic potential in the general population increases. To date, strategies to suppress genus β HPV infections are limited. Interferon regulatory factors IRF-3 and IRF-7 play key roles in the activation of the innate immune response to viral infections. In this study, we show for the first time that both IRF-3 and IRF-7 regulate transcription of a papillomavirus, but with opposing effects. IRF-7, expressed in the suprabasal layers of human epidermis, increased HPV8 late promoter activity via direct binding to viral DNA. UV-B light-induced activation of the HPV8 promoter involved IRF-7 as a downstream effector. In contrast, IRF-3, expressed in all layers of human epidermis, induced strong HPV8 suppression in primary keratinocytes. IRF-3-mediated suppression prevailed over IRF-7-induced HPV8 transcription. Unlike the E6 oncoprotein of the mucosal high-risk HPV16, the HPV8 E6 protein did not bind to IRF-3 and only weakly antagonized its activity. Strong antiviral activity was also observed, when keratinocytes were treated with potent IRF-3 activators, poly(I:C) or RNA bearing 5' phosphates. In conclusion, we show that IRF-3 activation induces a state of cell-autonomous immunity against HPV in primary human keratinocytes. Our study suggests that local application of IRF-3-activating compounds might constitute an attractive novel therapeutic strategy against HPV8-associated diseases, particularly in epidermodysplasia verruciformis patients.