Lymphocytic Arteritis in Epstein-Barr Virus Vulvar Ulceration (Lipschütz Disease): A Report of 7 Cases

Herpesvirus Infection of Endothelial Cells as a Systemic Pathological Axis in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome

Understanding the pathophysiology of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is critical for advancing treatment options. This review explores the novel hypothesis that a herpesvirus infection of endothelial cells (ECs) may underlie ME/CFS symptomatology. We review evidence linking herpesviruses to persistent EC infection and the implications for endothelial dysfunction, encompassing blood flow regulation, coagulation, and cognitive impairment-symptoms consistent with ME/CFS and Long COVID. This paper provides a synthesis of current research on herpesvirus latency and reactivation, detailing the impact on ECs and subsequent systemic complications, including latent modulation and long-term maladaptation. We suggest that the chronicity of ME/CFS symptoms and the multisystemic nature of the disease may be partly attributable to herpesvirus-induced endothelial maladaptation. Our conclusions underscore the necessity for further investigation into the prevalence and load of herpesvirus infection within the ECs of ME/CFS patients. This review offers conceptual advances by proposing an endothelial infection model as a systemic mechanism contributing to ME/CFS, steering future research toward potentially unexplored avenues in understanding and treating this complex syndrome.

Dysplastic changes secondary to cytomegalovirus-induced Lipschutz ulcer: Unraveling complexity

Lipschutz ulcer is a rare nonvenereal condition affecting predominantly young females who are not sexually exposed and can be triggered by various infectious agents, trauma, and drugs. It presents with single or multiple painful ulcers over labia minora, labia majora, vestibule, and lower part of the vagina and may be preceded by prodromal symptoms akin to influenza or mononucleosis. Diagnosis is based on specific criteria, which include age, ulcer characteristics, and absence of immunodeficiency. Management involves reassurance, supportive measures, and in severe cases, corticosteroids. This case highlights the importance of considering cytomegalovirus as a potential causative agent in Lipschutz ulcer and a cause for dysplasia.

Lipschütz Ulcer and SARS-CoV-2: What We Currently Know?

BACKGROUND

In recent years, several interesting case reports have been published which describe the possible role of SARS-CoV-2 infection or vaccination in the etiopathogenesis of Lipschütz ulcer. Our aim is to analyze this association and provide a rapid algorithm that is of support to gynecologists and dermatologists both in the diagnosis and in setting up the therapy. To do so, in this paper, we describe an interesting case of acute vulvar ulcer triggered by SARS-CoV-2 infection and review the related literature.

METHODS

We conducted a literature review including papers published between October 2021 and April 2023, and we described the case of a patient referred to our clinic with Lipschütz ulcer and SARS-CoV-2 infection.

RESULTS

In almost all cases analyzed, a correlation with SARS-CoV-2 infection or vaccination was found; ulcers usually manifest after 2 to 4 weeks and are associated with flu-like symptoms. A concordance in review papers, as well as in our case report, was also found about the treatment, which is mainly symptomatic.

CONCLUSIONS

Previous infection or vaccination for SARS-CoV-2 should be included as possible etiopathogenetic factors in the onset of Lipschütz ulcer.

Epstein-Barr Virus-positive Mucocutanous Ulcer of the Uterine Cervix: Report of a Rare and Evolving Entity

Epstein-Barr virus (EBV)-positive mucocutaneous ulcer (EBVMCU) is a newly described lymphoproliferative lesion characterized by the proliferation of EBV-positive atypical B cells in a variable inflammatory background associated with mucosal or cutaneous ulcers. Commonly involved sites include the oropharyngeal tract, skin, and gastrointestinal tract, with emerging reports describing EBVMCU of genitalia. To date, no lesions have been described of the uterine cervix. Herein, we report the first cervical EBVMCU incidentally discovered at large loop excision of the transformation zone performed for treating human papillomavirus induced high-grade squamous intraepithelial lesion. The patient was a 35-yr-old, human immunodeficiency virus-positive woman with a history of pulmonary tuberculosis. Histologic and immunohistochemical findings showed classic Hodgkin lymphoma-like features. Systemic lymphoproliferative disease was excluded by appropriate clinical and imaging modalities. This case report highlights the prototypical histologic features of cervical EBVMCU. We emphasize the importance of clinicopathologic correlation to avoid overtreatment of a lesion that can otherwise meet histologic criteria for a lymphoma. Clinicians and pathologists should familiarize themselves with this entity, as this indolent, pseudomaligant lesion typically occurs in immunocompromised patients and spontaneously regresses when the cause for the immunosuppression is addressed.

Acute Vulvar Aphthous Ulceration After COVID-19 Vaccination: 3 Cases

OBJECTIVE

We present a case series of acute vulvar aphthosis immediately following COVID-19 vaccination.

MATERIALS AND METHODS

We describe 3 cases of acute vulvar aphthosis following Pfizer Comirnaty BNT162b2 mRNA and AstraZeneca (Vaxzevria) ChAdOx1 nCoV-19 COVID-19 vaccination in adolescent girls.

RESULTS

All patients developed vulvar aphthosis within a few days after receiving COVID-19 vaccination. The onset of vulvar aphthosis was observed to correlate with the dosing schedule known to produce the highest likelihood of adverse effects, first dose in AstraZeneca (Vaxzevria) ChAdOx1 nCoV-19 and second dose in Pfizer Comirnaty BNT162b2 mRNA COVID-19 vaccine. Two patients required oral prednisolone and hospital admission for indwelling urinary catheterization due to urinary retention. Full disease resolution with no sequalae was achieved in all three patients.

CONCLUSIONS

Clinicians should be aware of the possible risk of vulvar aphthosis after COVID-19 vaccine administration. Nevertheless, its occurrence should not prevent affected patients from receiving future doses of COVID-19 vaccines, as the mortality and morbidity of COVID-19 infection significantly outweigh the risk of vulvar aphthosis recurrence.

EBV-positive Mucocutaneous Ulcer With Small Lymphocytic Infiltration Mimicking Nonspecific Ulceration

Epstein-Barr virus (EBV)-associated lymphoproliferative disorder may resemble nonspecific inflammation. We report 3 cases of immunosuppressed adult patients with small lymphocytic EBV ulcers in the skin and oral mucosa, characterized by a lack of atypical lymphocytic infiltration. All 3 cases were diagnosed in routine practice. For comparisons, cases of conventional Epstein-Barr virus-positive mucocutaneous ulcer (EBVMCU) were reviewed which were extracted from our pathology archives (n=11). The present patients were 2 females and 1 male, aged above 70 years. The primary disease was rheumatoid arthritis (n=2) and dermatitis herpetiformis (n=1). The main source of immunosuppression was prednisolone (n=2) and methotrexate (n=1). The ulcers were located in the oral cavity, buttock, and/or external genitalia. Histology evaluation revealed nonspecific lymphocytic infiltration. Epstein-Barr virus-encoded small RNA (EBER)-positive cells were small and coexpressed CD20. The number of EBER-positive cells ranged from 52 to 132/HPF, which was within the range of that observed in the reviewed conventional EBVMCUs (range, 48 to 1328; median, 121). All 3 cases regressed spontaneously or by the reduction of immunosuppressants. Although the present cases lacked cytologic atypia, those clinical course and loads of EBER-positive cells (>50/HPF) suggested EBV involvement. Current cases of EBVMCU with small lymphocytic infiltration underscore the need for EBER in situ hybridization when an etiology of ulcer with predominant lymphocytes in an immunosuppressed patient is unclear.

Acute Acalculous Cholecystitis Associated with Epstein-Barr Infection: A Case Report and Review of the Literature

The most common cause of acute cholecystitis (ACC) is cholelithiasis. Acute acalculous cholecystitis (AAC) is well documented in the literature related with critical illness, but viral causes such as cytomegalovirus (CMV) and Epstein-Barr virus (EBV) have also been reported. We present a rare manifestation of EBV infection, reporting a case of a 15-year-old female suffering from acute acalulous cholecystitis, and we review the relevant literature. Clinicians should be aware of this rare complication of EBV infection and properly exclude it in young patients with cholecystitis.

Acute genital ulcers: keep Lipschütz ulcer in mind

AIM

Lipschütz ulcers (LU) were first described as rare vulvar ulcerations that affect adolescents without previous history of sexual contact. However, more LU patients have been identified in acute genital ulcers (AGU) services in Europe.

PURPOSE

To review cases of AGU and analyze the occurrence of LU in the Ob/Gyn Emergency Department of a Brazilian private hospital, using the currently used diagnostic criteria.

METHODS

All female patients who sought our service with AGU complaints from January 2009 to July 2015 were selected and had their medical records reviewed, considering the clinical data and some diagnostic criteria, that included: < 20 years old, first AGU episode, sudden onset, absence of sexual contact 3 months before onset and the absence of immunodeficiency.

RESULTS

273 patients eligible for analysis were identified according to the criteria and 12 (4.39%) of them were identified with the possible diagnosis of LU. By applying less restrictive criteria that allowed the inclusion of patients of any age and sexual status, 98 were identified (35.89%).

CONCLUSIONS

Despite being described as a rare pathology, ours and previous results indicate a considerable number of AGU cases, suggesting that LU should be better known and considered for differential diagnosis.

Lipschütz Ulcers: A Rare Diagnosis in Women With Vulvar Ulceration

BACKGROUND

Lipschütz ulcers are characterized by painful vulvar ulceration, most commonly in young women. Because these lesions are so rarely seen, the diagnosis can be challenging.

CASE

An 18-year-old woman, without any prior sexual activity, developed painful blue vulval lesions. These became necrotizing ulcers, and she began antiviral therapy for presumptive herpes infection. Herpes cultures, however, were negative. Serology consistent with a recent Epstein-Barr virus infection resulted in a diagnosis of Lipschütz ulcers.

CONCLUSION

Lipschütz ulcers, associated with acute Epstein-Barr virus infection or other viral and bacterial infections, are a type of nonsexually transmitted vulvar ulceration. It is important to avoid selective attention to sexually transmitted infections as the etiology to avoid unnecessary antiviral therapy and immune suppressants. By considering other etiologies, the patient will be spared potentially embarrassing persistent questioning about her sexual history.