Detection of herpes simplex virus DNA in cutaneous lesions of erythema multiforme

Human Orf with Immune-Mediated Reactions: A Systematic Review

Background: Orf is a highly contagious zoonosis caused by Orf virus (ORFV), which is endemic in sheep and goats worldwide. Human Orf is usually a self-limiting disease, but potential complications, including immune-mediated reactions, may occur. Methods: We included all articles regarding Orf-associated immunological complications published in peer-reviewed medical journals. We conducted a literature search of the United States National Library of Medicine, PubMed, MEDLINE, PubMed Central, PMC, and the Cochrane Controlled Trials. Results: A total of 16 articles and 44 patients were included, prevalently Caucasian (22, 95.7%) and female (22, 57.9%). The prevailing immunological reaction was erythema multiforme (26, 59.1%), followed by bullous pemphigoid (7, 15.9%). In most cases, the diagnosis was made on the basis of clinical and epidemiological history (29, 65.9%), while a biopsy of secondary lesions was performed in 15 patients (34.1%). A total of 12 (27.3%) patients received a local or systemic treatment for primary lesions. Surgical removal of primary lesion was described in two cases (4.5%). Orf-immune-mediated reactions were treated in 22 cases (50.0%), mostly with topical corticosteroids (12, 70.6%). Clinical improvement was reported for all cases. Conclusions: Orf-related immune reactions can have a varied clinical presentation, and it is important for clinicians to be aware of this in order to make a prompt diagnosis. The main highlight of our work is the presentation of complicated Orf from an infectious diseases specialist's point of view. A better understanding of the disease and its complications is essential to achieve the correct management of cases.

Annular infectious dermatoses

Annular configuration is conspicuous in the clinical manifestation of many skin diseases and can be helpful for the diagnosis and differential diagnosis. Variations may include arciform, ring-form, annular, circinate, serpiginous, gyrated, polycyclic, targeted or figurate forms, in different colors, sizes, and numbers, with various textures and surfaces. In infectious dermatoses, the annular reactions can be specific or nonspecific, while the underlying mechanisms remain largely unknown. In the specific reactions caused by direct invasion of the pathogens, the contest between the centrifugal outspread of the infectious agents and the centripetal impedance of the host immune response is supposed to determine the final conformation. Examples include erythema infectiosum, orf, erythema multiforme, and pityriasis rosea of viral origin. Bacterial infections that may display annular lesions include erythrasma, erythema (chronicum) migrans of Lyme borreliosis, secondary syphilis, cutaneous tuberculosis, and leprosy. Superficial mycosis, such as dermatophytosis, candida intertrigo, tinea imbricata, and subcutaneous mycosis, such as chromoblastomycosis, and algae infection protothecosis, are characterized by annular progression of the skin lesions. The creeping serpiginous extension is an alarming sign for the diagnosis of cutaneous larva migrans. A better understanding of the virulence and pathogenicity of the pathogens and the way and type of immune response will help to clarify the pathogenesis.

Annular drug eruptions

Cutaneous adverse drug reactions are undesirable cutaneous changes caused by medications. Drug eruptions can mimic a wide range of dermatoses that include exanthematous (morbilliform), urticarial, pustular, bullous, papulosquamous, or granulomatous lesions, and sometimes these eruptions may present with annular, polycyclic, or polymorphous configurations. The correct identification of a cutaneous drug eruption depends on a high index of suspicion, detailed medication exposure history, chronologic evaluation of the causal relationships between drug exposures and eruptions, and the exclusion of other infectious or idiopathic diseases. Most drug eruptions are annoying but self-limited, usually resolving after the withdrawal of the causative agents. Rarely, patients have severe cutaneous adverse reactions, such as Stevens-Johnson syndrome, toxic epidermal necrolysis, and drug reaction with eosinophilia and systemic symptoms (DRESS), which are potentially lethal adverse drug reactions that involve the skin and mucous membranes and may also damage internal organs. Prompt recognition of the alarming signs of severe cutaneous adverse reactions and providing adequate treatment may thus be life-saving. We present the main clinical presentations, histopathology, possible implicated medications, and treatment of cutaneous adverse drug reactions that can present in annular configurations.

Erythema multiforme associated with anti-plakin antibodies: a multicentric retrospective case series

BACKGROUND

Erythema multiforme (EM) is a muco-cutaneous inflammatory disease mainly triggered by herpes simplex virus (HSV) recurrences. Association of EM and circulating auto-antibodies against plakins (anti-PLK-Abs [EM-PLK+]) has been reported. However, little is known about this subset of EM.

OBJECTIVES

We aimed to describe the clinical and immunological features and response to treatment of EM-PLK+.

METHODS

We conducted a retrospective multicentric study of EM-PLK+ selected from the database of the immunological laboratory of Bichat hospital, Paris, France, from January 2009 to December 2020. Anti-PLK-Abs were detected in ≥1 immunological tests: immunofluorescence assay, immunoblotting and/or ELISA. Patients with alternative diagnoses were excluded.

RESULTS

We included 29 patients (16 women, median age 25 [range 2-58] years). EM-PLK+ were mostly major (EM with ≥2 mucosal involvements; n = 24, 83%) and relapsing (≥2 flares; n = 23, 79%). Cutaneous lesions were target (n = 13, 54%) and target-like lesions (n = 9, 38%) with usual topography (acral, n = 19, 79%; limbs, n = 21, 88%). Mucosal lesions affected the mouth (n = 27, 96%) and genitalia (n = 19, 68%), with a median of 2 [range 0-5] mucous membranes. EM-PLK+ were suspected as certain or possible postherpetic (EM-HSV) in 19 cases (65.5%); no triggering factors were detected in 9 (31%) patients. Desmoplakin-I/II Abs were the most frequent anti-PLK-Abs (n = 20, 69%); envoplakin and periplakin Abs were detected in 11 and 9 cases. Relapsing EM-PLK+ (n = 23) were still active (≥1 flare within 6 months) in 13 (57%) patients despite immunosuppressive therapy (n = 8, 62%). Antiviral drugs were ineffective in preventing relapse in 15/16 (94%) EM-HSV.

CONCLUSION

The rationale for anti-PLK-Ab detection in EM is not elucidated. More systematic research of anti-PLK-Abs is warranted to better understand whether this association reflects humoral immune activity in a subset of EM or is fortuitous, related to an epitope spreading process. However, EM-PLK+ seems to be associated with major and relapsing subtypes, and difficult-to-treat cases.

Differential Diagnosis of Lesions

There have been many uncertainties during the coronavirus pandemic. New studies emerge about new symptoms associated with the virus that include dermatological disorders. Lesions with an unknown cause can be a challenge to diagnose and treat. Some lesions have nonspecific symptoms associated with viral infections, immune-mediated reactions, autoimmune disease, malignancy, radiation, immunizations, and sarcoidosis. These lesions may be associated with erosions and bullae that can involve the mucosa. Nurse practitioners must be aware of the clinical manifestations of various lesions and need to determine when patients should be hospitalized or managed in the outpatient setting.

Herpes Simplex Associated Erythema Multiforme: A Case Report and Review of the Literature

Erythema multiforme (EM) is an acute immune-mediated disease with multifactor etiology, which presents with symmetric target-like lesions on the skin. Probably the most common etiological factor of EM is viral infections, particularly herpes simplex virus (HSV). Herpes-associated erythema multiforme (HAEM) is an acute exudative dermatosis, caused mostly by HSV-1 and much rarely by HSV-2. A 44-year-old female patient with herpes associated erythema multiforme was consulted with initial appearance of typical target lesions on the dorsal surface of both hands, after long history of labial herpes episodes. The diagnostic algorithm included routine laboratory tests, histological examination and serologic test for HSV-1 and 2. Our first choice of treatment was acyclovir 5 x 200 mg/24 h and dexamethasone 4 mg/24 h, however due to increased anxiety and tachycardia reported by patient the corticosteroid therapy was discontinued and promethazine was initiated. The patient responded well to the therapeutic regimen and at the follow-up visit was in clinical remission. In conclusion, the diagnosis of HAEM is mainly clinical, when the patient develops target lesions and coexisting HSV infection is detected.

Síndrome de Stevens-Johnson con reactivación de herpes simple asociado a la ingestión de paracetamol. Reporte de caso

Introducción. El síndrome de Stevens-Johnson (SJS) es una enfermedad poco común que afecta la piel y las mucosas oral, ocular y urogenital; además, en más del 50% de los casos es producida por reacciones a medicamentos. Presentación del caso. Hombre de 20 años quien asistió al servicio de urgencias de hospital de tercer nivel de Popayán por un cuadro clínico de 10 días de evolución consistente en astenia, adinamia, fiebre no cuantificada, tos con escasa expectoración blanquecina y cefalea, sintomatología que mejoraba con el uso de paracetamol; sin embargo, la condición del paciente empeoró en los últimos dos días, presentando hiporexia, prurito en faringe, vesículas y ampollas en comisuras labiales, mucosa oral, tronco y extremidades, y dificultad respiratoria y odinofagia, razón por la cual acudió al servicio. En principio de sospechó de herpes simple diseminado, lupus eritematoso sistémico, y SJS; sin embargo, con base en los hallazgos clínicos y de laboratorio se confirmó el diagnóstico de SJS con reactivación de herpes simple asociado a la ingesta de paracetamol, por lo que se suspendió este medicamento y se inició manejo con aciclovir y metilprednisolona. El paciente tuvo una evolución satisfactoria y fue dado de alta a los 10 días del inicio del nuevo tratamiento y en las citas de control su condición general era óptima. Conclusión. El desarrollo de SJS puede estar asociado al consumo de paracetamol; sin embargo, su uso no se desaconseja gracias a sus grandes bondades y beneficios generales. En este sentido, dado que el paracetamol es un medicamento venta libre y uso extenso en Colombia, es indispensable reconocer las manifestaciones clínicas del SJS para poder dar un manejo adecuado y evitar complicaciones en casos como el aquí reportado.

Illuminating, through immunohistochemistry, the link between SARS‐CoV‐2 and pernio (chilblains)

Linked Article:  Colmenero et al. Br J Dermatol 2020; 183:729–737.

A 65-Year-Old Male with Primary Central Nervous System Diffuse Large B-Cell Lymphoma on Nivolumab with Oral Mucositis and Targetoid Plaques

Background/Aims

The development of programmed cell death-1 (PD-1) inhibitors has greatly improved patient outcomes in the treatment of a variety of advanced malignancies. These novel immunotherapies are not without adverse effects, the most common of which are dermatologic.

Methods

We report our experience with an atypical erythema multiforme-like eruption in a patient with primary central nervous system diffuse large B-cell lymphoma treated with nivolumab.

Results

The patient presented with oral mucositis and scattered erythematous papules which progressed to targetoid purpuric plaques with hyperkeratotic centers. Histopathology demonstrated interface dermatitis with dyskeratotic keratinocytes and pigment incontinence. The patient experienced improvement of the eruption with discontinuation of nivolumab and on systemic and topical glucocorticoids.

Conclusion

As PD-1 inhibitors become more widely used in the treatment of advanced malignancies, the early recognition and treatment of rare dermatologic toxicities remain of great importance.

Lichenoid and interface dermatoses

The terms 'lichenoid' and 'interface' dermatitis are often used interchangeably to describe an inflammatory pattern characterized histologically by damage to the basal keratinocytes in the epidermis. The mechanism of cell damage of such cells is now best understood as apoptosis, or programmed cell death. This inflammatory pattern of dermatoses, is also accompanied frequently by a band of lymphocytes and histiocytes in the superficial dermis, that often obscures the dermal-epidermal junction, hence the term 'lichenoid'. A discussion of the more common lichenoid/interface dermatitides encountered in the routine clinical practice encompasses the following entities: lichen planus, lupus erythematosus, dermatomyositis, erythema multiforme, graft versus host disease, fixed drug reactions, and multiple others.

A retrospective review of hyperaesthetic leucotrichia in horses in the USA

BACKGROUND

Hyperaesthetic leucotrichia (HL) rarely affects horses and causes painful lesions on the dorsum that result in leucotrichia. This may be a variant of erythema multiforme (EM), but there are no studies investigating this condition.

OBJECTIVES

Describe the clinical and histological features of HL and compare them to the histological features of EM.

METHODS

A retrospective review of medical records from 1985 to 2015 identified 15 horses with HL. Thirteen biopsies of HL and five of EM were evaluated and compared.

RESULTS

Arabian horses and their crosses (χ(2) (1)  = 8.56, P < 0.01) and American paint horses (χ(2) (1)  = 6.64, P < 0.05) were over represented. The onset of clinical signs was between April and September (14 of 15). The most common clinical signs were pain (15 of 15), leucotrichia (11 of 15), crusting (10 of 15) and alopecia (8 of 15) limited to darkly pigmented skin. The lesions recurred seasonally in 6 of 12 horses and unpredictably in 1 of 12 horse. The most common histological features were the presence of large stellate cells (13 of 13) and oedema (12 of 13) in the superficial dermis, perivascular to diffuse lymphocytic inflammation (13 of 13), pigmentary incontinence (12 of 13), apoptotic keratinocytes (9 of 13) and vesicle formation (8 of 13). Horses with EM (n = 5) had significantly more acanthosis (z = -2.40, P < 0.02) and lymphocytic exocytosis (z = -3.1, P < 0.004), satellitosis (Fisher's exact P = 0.02) and inflammation (z = -2.91, P < 0.004). Horses with HL had significantly more pigmentary incontinence (z = 2.13, P < 0.04) and superficial dermal oedema (z = 2.56, P < 0.002).

CONCLUSIONS

HL affects primarily Arabian horses and American paint horses. It occurs mainly in summer and may recur. Histologically HL shares features with EM, but there are significant differences between them.

Erythema multiforme, Stevens-Johnson syndrome and toxic epidermal necrolysis: a comparative review

BACKGROUND

Human erythema multiforme (EM) and Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) are separate conditions. There is no consensus on classification criteria for the eponymous diseases in animals.

RESULTS

Animal EM is very different from 90% of human EM, which is herpes virus associated (HAEM). Animals lack acrally distributed, typical raised targets. Unlike canine parvovirus 'EM', HAEM is not an active infection. Animal EM is often attributed to drugs, but this is rarely proved. Conversely, human and animal SJS/TEN are almost identical, life-threatening disorders of epidermal necrosis and detachment, typically triggered by drugs (occasionally by infectious agents). Both EM and SJS/TEN are mediated by cytotoxic lymphocyte responses against altered keratinocytes (infectious agents or drugs). Apoptosis results from direct cytotoxicity or through soluble mediators, namely Fas ligand, granzymes, perforin and granulysin. Diagnosis in humans is clinicopathological, with emphasis on clinical lesions; histopathology confirms the pathological process as interface (cytotoxic) dermatitis. Human EM is self-limiting; only recurrent and rare persistent cases require antiviral/immunosuppressive therapies. Drug-induced EM responds to drug withdrawal. Idiopathic canine EM (>40%) is usually chronic, refractory to treatment and may represent heterogeneous conditions. Early identification and removal of the causative drug and high-quality supportive care are critical in SJS/TEN. Mortality rate is nevertheless high.

CONCLUSIONS AND CLINICAL IMPORTANCE

(1) Histopathological lesions do not reliably differentiate EM, SJS and TEN. (2) A multicentre study to develop a consensus set of clinical criteria for EM and SJS/TEN in animals is overdue. (3) No adjunctive therapies, including intravenous immunoglobulin and ciclosporin, have met evidence-based standards.

Immunopathogenic Role of Herpes Simplex Virus in Behçet's Disease

The role of viral infections, such as herpes simplex virus (HSV) infection, in the pathogenesis of Behçet's disease (BD) has been investigated for many years. HSV has been detected in peripheral blood leukocytes, saliva, and genital ulcers of patients with BD. Various cell adhesion molecules on cultured endothelial cells have been induced by HSV in a TNF- α dependent manner. In addition, a BD-like animal model was developed by inoculating ICR mouse earlobes with HSV, and antiviral treatment was effective in improving BD-like symptoms in this model. Still, there are several incompletely characterized proteins that possess antiviral properties and are being investigated as mediators of viral infection-related chronic inflammatory reactions. Although the role of HSV in the pathogenesis of BD remains to be fully established, recent research findings regarding HSV in BD have expanded our understanding of the disease and will hopefully lead to the development of more effective therapeutic agents in the near future.

Immune-mediated interface dermatitis in a rhesus macaque

BACKGROUND

Autoimmune dermatitis, specifically interface dermatitis, is rarely reported in nonhuman primates.

RESULTS AND CONCLUSIONS

This report describes a case of idiopathic immune-mediated dermatitis clinically manifesting as palmoplantar hyperkeratosis in a rhesus macaque, successfully controlled with the use of long-term oral corticosteroid therapy.

A case of erythema multiforme associated with primary Epstein-Barr virus infection

We present a case of primary Epstein-Barr virus (EBV) infection with erythema multiforme. A 1-year-old Japanese boy presented with skin eruptions, including typical target lesions and a low-grade fever. Just before the skin biopsy, 95 copies/μg DNA of EBV genome was detected in peripheral blood mononuclear cells, which subsequently increased to 6,834 copies/μg DNA. Skin tissue collected from the skin lesion showed the typical pathologic findings of erythema multiforme. EBV-encoded small nuclear RNA signals were not detected in the skin tissue by in situ hybridization.

Recurrent erythema multiforme: clinical characteristics, etiologic associations, and treatment in a series of 48 patients at Mayo Clinic, 2000 to 2007

BACKGROUND

Recurrent erythema multiforme (EM) is a condition of substantial morbidity. Our efforts toward the etiologic attribution and treatment of recurrent EM have been less fruitful than those previously described.

OBJECTIVE

We sought to further characterize clinical characteristics, etiologic associations, and treatment of recurrent EM.

METHODS

We conducted a retrospective review of patients with recurrent EM seen between 2000 and 2007.

RESULTS

Of 48 patients (mean age at disease onset, 36.4 years), 28 (58%) were female (mean duration of recurrent EM, 6 years). Thirty (63%) patients had oral involvement. Herpes simplex virus caused recurrent EM in 11 (23%) patients, and the cause remained unknown in 28 (58%). In all, 37 (77%) patients received systemic corticosteroids, 33 (69%) received continuous antiviral treatment, and 23 (48%) used immunosuppressive or anti-inflammatory agents. Sixteen of 33 patients receiving continuous antiviral treatment had either partial or complete disease suppression. Patients had varied responses to immunosuppressants, with mycophenolate mofetil providing partial or complete response in 6 of 8 patients. Features of recalcitrant cases included clinicians' inability to identify a specific cause, lack of improvement with continuous antiviral therapy, severe oral involvement, extensive corticosteroid therapy, and immunosuppressive therapy (two or more agents).

LIMITATION

This study is retrospective.

CONCLUSIONS

More than half of patients in this study did not have an identifiable cause for recurrent EM, and herpes simplex virus was found less frequently than reported in previous studies. Response to systemic treatments, including continuous antivirals and immunosuppressants, was varied and often times suboptimal.

Immunogenetics of drug-induced skin blistering disorders. Part I: Perspective

The overall immunopathogenesis relevant to a large series of disorders caused by a drug or its associated hyperimmune condition is discussed based upon the examination of the genetics of severe drug-induced bullous skin problems (sporadic idiosyncratic adverse events, including Stevens-Johnson syndrome and toxic epidermal necrolysis). An overarching pharmacogenetic schema is proposed. Immune cognition and early-effector processes are focused upon and a challenging synthesis around systems evolution is explained by a variety of projective analogies. Etiology, human leukocyte antigen-B, immune stability, dysregulation, pharmacomimicry, viruses and an aggressive ethnically differentiated 'karmic' response are discussed.

Oral mucosal diseases: Erythema multiforme

Erythema multiforme (EM) is a rare acute mucocutaneous condition caused by a hypersensitivity reaction with the appearance of cytotoxic T lymphocytes in the epithelium that induce apoptosis in keratinocytes, which leads to satellite cell necrosis. EM can be triggered by a range of factors, but the best documented association is with preceding infection with herpes simplex virus (HSV). Most other cases are initiated by drugs. EM has been classified into a number of variants, mainly minor and major forms, as it may involve the mouth alone, or present as a skin eruption with or without oral or other lesions of the mucous membrane. EM minor typically affects only one mucosa, and may be associated with symmetrical target skin lesions on the extremities. EM major typically involves two or more mucous membranes with more variable skin involvement. A severe variant of EM major is Stevens-Johnson syndrome, which typically extensively involves the skin. Both EM major and Stevens-Johnson syndrome can involve internal organs and produce systemic symptoms. Treatment of EM is controversial, as there is no reliable evidence. Precipitants should be avoided or treated and, in severe cases, corticosteroids may be needed. Toxic epidermal necrolysis may be similar to Stevens-Johnson syndrome, but many experts regard it as a discrete disease, and therefore it is not discussed here.

Human herpes simplex virus infections: epidemiology, pathogenesis, symptomatology, diagnosis, and management

Eight of the more than 80 known herpesviruses are human pathogens. Human herpes simplex virus (HSV) is a contagious infection with a large reservoir in the general population. It has a potential for significant complications in the immunocompromised host. In addition, psychological distress caused by the negative stigma associated with genital herpes and visible facial lesions in those experiencing frequent outbreaks renders it a challenging clinical dilemma. This article reviews the epidemiology, pathogenesis, and diagnostic features of HSV infections, providing the clinician with an up-to-date understanding of the available management strategies for mucocutaneous HSV-induced disease.

Erythema multiforme due to Mycoplasma pneumoniae infection in two children

Mycoplasma pneumoniae is an important and highly relevant cause of bullous erythema multiforme, isolated mucositis, and Stevens-Johnson syndrome in children. In this article, we present two children with respiratory Mycoplasma pneumoniae infection and associated cutaneous findings within the spectrum of erythema multiforme. We review the literature associating these three entities with Mycoplasma pneumoniae infection and discuss controversies regarding the classification of erythema multiforme, as well as update reported infectious causes of the bullous form. Many understand the erythema multiforme spectrum to include bullous erythema multiforme, mucositis, and Stevens-Johnson syndrome in the order of increasing severity. We feel that this relationship should be reconsidered to help better understand the prognosis and outcomes. It is our opinion that bullous erythema multiforme is a separate, yet related condition that can occur in the context of Mycoplasma pneumoniae infection. With many similarities to mucositis and Stevens-Johnson syndrome, bullous erythema multiforme can be considered part of a spectrum of disease that includes Stevens-Johnson syndrome. Unlike mucositis and Stevens-Johnson syndrome, bullous erythema multiforme caused by Mycoplasma pneumoniae infection has low morbidity for the child. Mycoplasma pneumoniae-associated mucositis and Stevens-Johnson syndrome seem to occur along a spectrum with separate prognosis and potential pathogenesis compared with bullous erythema multiforme. Making the distinction between these conditions is valuable for predicting the child's prognosis. Patients who develop symptoms consistent with these conditions should be appropriately evaluated for Mycoplasma pneumoniae infection and closely monitored.

The cost to health services of human immunodeficiency virus (HIV) co-infection among tuberculosis patients in Sudan

OBJECTIVE

To compare the cost of managing HIV-positive and HIV-negative tuberculosis (TB) patients in Sudan.

METHODS

A prospective cohort of 1797 consecutive TB patients referred to the chest clinics within the general health services from March 1998 to March 2000 were included in this study. Patients were tested blindly for HIV; 1724 were HIV-negative and 73 were HIV-positive.

FINDINGS

The total cost associated with management of tuberculosis was significantly higher for HIV-positive, as compared with HIV-negative TB patients (105.08 US dollars versus 73.92, p=0.003). This difference was due mainly to greater costs for hospitalization of those HIV-positive, as compared with those HIV-negative (190.80 versus 141.00, p=0.001). The differences in cost for diagnostic tests, for drugs, for management of adverse reactions and for intercurrent symptoms were not significant (p>0.05) between HIV-positive TB patients and HIV-negative TB patients. Side effects of treatment were slightly more common among persons without HIV infection than among HIV-positive patients (14 and 9.6%, respectively). The total cost of management of HIV-positive patients in this series of patients was 6% of all costs for TB case management and the marginal cost attributable to HIV-positivity was 0.9% of the total cost.

CONCLUSION

The management of the HIV-positive TB case was more costly than that of the HIV-negative case in this stage of the HIV/AIDS epidemic in Sudan.

Number IV Erythema multiforme

Erythema multiforme (EM) is an acute mucocutaneous hypersensitivity reaction characterised by a skin eruption, with or without oral or other mucous membrane lesions. Occasionally EM may involve the mouth alone. EM has been classified into a number of different variants based on the degree of mucosal involvement and the nature and distribution of the skin lesions. EM minor typically affects no more than one mucosa, is the most common form and may be associated with symmetrical target lesions on the extremities. EM major is more severe, typically involving two or more mucous membranes with more variable skin involvement - which is used to distinguish it from Stevens-Johnson syndrome (SJS), where there is extensive skin involvement and significant morbidity and a mortality rate of 5-15%. Both EM major and SJS can involve internal organs and typically are associated with systemic symptoms. Toxic epidermal necrolysis (TEN) may be a severe manifestation of EM, but some experts regard it as a discrete disease. EM can be triggered by a number of factors, but the best documented is preceding infection with herpes simplex virus (HSV), the lesions resulting from a cell mediated immune reaction triggered by HSV-DNA. SJS and TEN are usually initiated by drugs, and the tissue damage is mediated by soluble factors including Fas and FasL.

Detection of Herpes simplex Virus Genomic DNA in Various Subsets of Erythema multiforme by Polymerase Chain Reaction

BACKGROUND

The wide variation in the detection of herpes simplex virus (HSV) DNA (36-75%) by polymerase chain reaction (PCR) in erythema multiforme (EM) may be partly attributed to differences in case selection in terms of subsets of EM studied.

OBJECTIVE

To determine the frequencies of detection of HSV DNA in specific subsets of EM.

METHODS

Nested PCR was used to detect HSV DNA in skin biopsies with histologically proven EM.

RESULTS

PCR was performed on skin biopsies from 63 patients with EM. HSV DNA was detected in 3/11 (27.2%) of single-episode HSV-associated EM (HAEM), 6/10 (60%) of recurrent HAEM, 1/4 (25%) of single-episode idiopathic EM and 6/12 (50%) of recurrent idiopathic EM. HSV DNA was not detected in atypical EM (0/11), suspected drug-induced EM (0/9) or Stevens-Johnson syndrome (0/6).

CONCLUSION

The overall PCR positive rates of HAEM (42.9%) and idiopathic EM (43.8%) were comparable suggesting that idiopathic EM is likely to be related to a subclinical HSV infection.

Detection and genotyping of human herpes simplex viruses in cutaneous lesions of erythema multiforme by nested PCR

A subset of erythema multiforme (erythema multiforme) is associated with herpes simplex virus (HSV) infection; viral cultures of erythema multiforme lesions are, however, usually negative and viral antigens difficult to identify. Polymerase chain reaction (PCR) has been used to demonstrate the association, hence, is currently the only available sensitive diagnostic means for HSV-associated erythema multiforme. A nested PCR, which could simultaneously detect and genotype HSV in erythema multiforme lesions and in clinical swab specimen was developed using the DNA polymerase gene of HSV as target gene because it is the only detectable HSV gene in a high proportion of erythema multiforme lesions. The PCR has demonstrated its robust sensitivity on swab samples by being able to detect further 45.3% HSV cases in comparison with virus isolation with 100% specificity in both detection and genotyping confirmed by virus isolation and DNA sequencing. This study represents the first investigation of typing HSV virus in HSV-associated erythema multiforme patients, and the finding that 66.7% of the patients was attributed to HSV1, 27.8% to HSV2, and 5.6% to HSV1 and 2 co-infection may reflect the distribution of HSV1 and 2 in local general population.

Recent progress in herpes simplex virus immunobiology and vaccine research

Herpes simplex virus types 1 and 2 (HSV-1 and HSV-2) cause prevalent, chronic infections that have serious outcomes in some individuals. Neonatal herpes may occur when the infant traverses the cervix during maternal genital herpes. Genital herpes is a major risk factor for human immunodeficiency virus type 1 transmission. Considerable efforts have been made to design and test vaccines for HSV, focusing on genital infection with HSV-2. Several protein subunit vaccines based on HSV-2 envelope glycoproteins have reached advanced-phase clinical trials. These antigens were chosen because they are the targets of neutralizing-antibody responses and because they elicit cellular immunity. Encouraging results have been reported in studies of treatment of HSV-seronegative women with a vaccine consisting of truncated glycoprotein D of HSV-2 and a novel adjuvant. Because most sexual HSV transmission occurs during asymptomatic shedding, it is important to evaluate the impact of vaccination on HSV-2 infection, clinically apparent genital herpes, and HSV shedding among vaccine recipients who acquire infection. There are several other attractive formats, including subunit vaccines that target cellular immune responses, live attenuated virus strains, and mutant strains that undergo incomplete lytic replication. HSV vaccines have also been evaluated for the immunotherapy of established HSV infection.

Herpes simplex viruses 1 and 2

An increased understanding of the pathogenesis and transmission of HSV infections and the development of sensitive type-specific diagnostic tests have helped develop effective prophylactic and therapeutic antiviral drug regimens. Effective medications have been available for quite some time, but the most optimal regimens are still under investigation. Advances in the treatment of atypical presentations of HSV infection (such as the use of cidofovir gel for the treatment of acyclovir-resistant HSV) are promising. Newer treatments, such as resiquimod, actually may alter the course of HSV infection, reducing the severity and frequency of recurrences. Vaccines are being explored as preventive and therapeutic measures against HSV.

Erythema multiforme secondary to herpes simplex infection: a case report

BACKGROUND

Erythema multiforme (EM) is a complex disease that may have cutaneous and/or mucosal involvement. The severity may range from mild to severe and potentially life threatening. The literature cites many factors including viruses, infections, and medications as causes. This report documents a patient who developed EM secondary to a herpes simplex viral (HSV) infection.

METHODS

Two weeks following an eruption of herpes labialis, a 20-year-old white female patient developed acutely painful oral and labial ulcers accompanied by target skin lesions. A diagnosis of erythema multiforme (EM) was made. The patient was treated with antivirals, analgesics, and symptomatic therapy.

RESULTS

Nine days after the onset of symptoms, the oral and cutaneous lesions had started to heal and the patient no longer required pain medication.

CONCLUSIONS

Although the etiology of EM is still often unknown, infections with herpes simplex virus have been implicated as a possible precipitating factor. This case illustrates the association of the occurrence of EM with an HSV infection.

High-dose intravenous immunoglobulins: An approach to treat severe immune-mediated and autoimmune diseases of the skin

Adjuvant high-dose intravenous immunoglobulins (IVIgs) are being used increasingly in a range of immune-mediated and autoimmune diseases. Although numerous immunomodulatory mechanisms have been suggested, the exact mechanisms of action are poorly understood. The efficacy of IVIg in certain diseases has been proven in clinical trials, insofar as IVIg is approved as the therapy of choice for Kawasaki syndrome or idiopathic thrombocytopenic purpura. IVIg treatment has been shown to be safe, without the many drug-related adverse effects, including systemic immunosuppression, that are related to corticosteroids and other immunosuppressive agents. Current dermatologic uses of IVIg are increasing, which calls for adequately controlled clinical trials. This review focuses on experiences with IVIg therapy for skin diseases and discusses current opinion concerning its potential immunomodulating mechanisms.

Unusual leukoderma after erythema multiforme: a case report

Erythema multiforme is an inflammatory disorder of the skin that usually fades without sequelae. It is well known that after inflammatory events, hyper- or hypochromic spots can remain, especially in skin types III-VI, but achromia is very rare. We report a case of residual leukoderma after erythema multiforme.

Detection of herpes simplex virus (HSV) in aborted material using the polymerase chain reaction technique

OBJECTIVE

To investigate the contribution of HSV to the aetiopathogenesis of spontaneous abortion.

DESIGN

A hospital-based, case-control study.

SETTING

Department of Obstetrics and Gynecology, University Hospital and Laboratory of Clinical Virology, Medical School, University of Crete, Heraklion, Crete, Greece.

POPULATION AND METHODS

Abortion material from 102 cases of women with spontaneous abortion was analysed for the presence of HSV DNA applying the PCR technique. Serological assays were used for the detection of specific IgM and IgG antibodies in the maternal sera of 90 pregnant women with successful outcome of their pregnancy while 70 non-pregnant women at reproductive age were also examined as control.

RESULTS

The HSV genome was detected by PCR amplification in 3 cases of spontaneous abortion, 2 of them exhibited serological markers of virus reactivation while the 3rd showed a past infection. There were no obvious clinical manifestations indicating a current herpes infection. Both groups of pregnant women, either with spontaneous abortion or with a successful outcome of pregnancy, displayed serological markers of HSV reactivation at higher rates compared with non-pregnant women (chi2, p < 0.05).

CONCLUSIONS

Using the PCR technique we were able to detect the HSV genome in gestational tissues of spontaneous abortions, even in cases without any clinical symptoms or seropositivity for a primary infection. Serological assays were not very useful for the elucidation of the role of HSV in inducing spontaneous abortions, although they indicate that the state of pregnancy predisposes to HSV reactivation. However, the detection of HSV in 3 out of a total number of 102 cases does not support HSV infection as a major abortion-related factor.

Scrotal temperature is increased in disposable plastic lined nappies

OBJECTIVES

Male reproductive health has deteriorated in recent decades. It is proposed that increased testicular temperature in early childhood, due to the use of modern disposable plastic lined nappies (diapers), could be an important factor contributing to this decline.

STUDY DESIGN

Scrotal skin temperature was measured non-invasively in 48 healthy children aged 0-55 months (three age groups) for two 24 hour periods in randomised order (either cotton or disposable plastic lined nappies) using a portable, miniature recorder.

RESULTS

Mean 24 hour scrotal temperature (2880 measurements) was significantly higher in all age groups during the periods of plastic nappy use than with cotton nappies (p < 0.001). The rectoscrotal temperature difference was significantly higher with cotton than with plastic nappy use (p < 0.01).

CONCLUSIONS

Scrotal hypothermia is an important factor for normal spermatogenesis. This study shows that scrotal temperature, which closely reflects testicular temperature, is increased in boys wearing disposable plastic lined nappies. The physiological testicular cooling mechanism is blunted and often completely abolished during plastic nappy use. The present results establish the basis for further research on the impact of increased testicular temperature in infancy on later spermatogenesis.