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Abstract
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.
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Affiliation(s)
- Wei-Hsin Wu
- Department of Dermatology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chia-Yu Chu
- Department of Dermatology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
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2
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Shiraki K, Sato N, Sakai K, Matsumoto S, Kaszynski RH, Takemoto M. Antiviral therapy for COVID-19: Derivation of optimal strategy based on past antiviral and favipiravir experiences. Pharmacol Ther 2022; 235:108121. [PMID: 35121001 PMCID: PMC8806403 DOI: 10.1016/j.pharmthera.2022.108121] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 01/24/2022] [Indexed: 12/22/2022]
Abstract
Favipiravir, a broad-spectrum RNA-dependent RNA polymerase inhibitor, inhibits the replication of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) at significantly lower concentrations than the plasma trough levels achieved by the dosage adopted for influenza treatment and exhibits efficacy against coronavirus disease 2019 (COVID-19) pneumonia. Although high doses of favipiravir are required due to the molecule being a purine analog, its conversion into the active form in infected cells with active viral RNA synthesis enhances the antiviral specificity and selectivity as a chain terminator with lethal mutagenesis. Another characteristic feature is the lack of generation of favipiravir-resistant virus. COVID-19 pneumonia is caused by strong cell-mediated immunity against virus-infected cells, and the inflammatory response induced by adaptive immunity continues to peak for 3 to 5 days despite antiviral treatment. This has also been observed in herpes zoster (HZ) and cytomegalovirus (CMV) pneumonia. Inflammation due to an immune response may mask the effectiveness of favipiravir against COVID-19 pneumonia. Favipiravir significantly shortened the recovery time in patients with mild COVID-19 pneumonia by 3 days with the start of treatment by the 5th day of symptom onset. Since both CMV and COVID-19 pneumonia are caused by adaptive immunity and prevention of cytomegalovirus pneumonia is the standard treatment due to difficulties in treating refractory CMV pneumonia, COVID-19 pneumonia should be prevented with early treatment as well. In the present study, we have comprehensively reviewed the optimal antiviral therapy for COVID-19 based on clinical trials of favipiravir for the treatment of COVID-19 pneumonia and the concurrently established therapies for other viral infections, particularly HZ and CMV pneumonia. Optimally, antivirals should be administered immediately after COVID-19 diagnosis, similar to that after influenza diagnosis, to prevent COVID-19 pneumonia and complications resulting from microangiopathy.
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Affiliation(s)
| | - Noriaki Sato
- Department of Biomedical Data Intelligence, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kaoru Sakai
- Department of Nephrology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shirou Matsumoto
- Department of Pediatrics, Graduate School of Medical Sciences, Kumamoto University, Japan
| | - Richard H Kaszynski
- Stanford Solutions, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Masaya Takemoto
- Department of Microbiology, Faculty of Pharmaceutical Sciences, Hokuriku University, Kanazawa, Japan
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Paslin D, Perret J, Pennypacker C. Spatial mapping of long-term recrudescent herpes simplex labialis. JAAD Case Rep 2021; 18:45-48. [PMID: 34815992 PMCID: PMC8591339 DOI: 10.1016/j.jdcr.2021.09.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Affiliation(s)
- David Paslin
- Department of Dermatology, University of California, San Francisco, San Francisco, California
| | | | - Carlton Pennypacker
- Lawrence Berkeley National Laboratory, and University of California, Berkeley, Berkeley, California
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Amenamevir, a Helicase-Primase Inhibitor, for the Optimal Treatment of Herpes Zoster. Viruses 2021; 13:v13081547. [PMID: 34452412 PMCID: PMC8402822 DOI: 10.3390/v13081547] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 08/03/2021] [Accepted: 08/03/2021] [Indexed: 12/02/2022] Open
Abstract
Acyclovir, valacyclovir, and famciclovir are used for the treatment of herpes simplex virus (HSV) and varicella-zoster virus (VZV) infections. Helicase-primase inhibitors (HPIs) inhibit replication fork progression that separates double DNA strands into two single strands during DNA synthesis. The HPIs amenamevir and pritelivir have novel mechanisms of anti-herpetic action, and their once-daily administration has clinical efficacy for genital herpes. Among HPIs, amenamevir has anti-VZV activity. The concentrations of HSV-1 and VZV required for the 50% plaque reduction of amenamevir were 0.036 and 0.047 μM, respectively. We characterized the features of amenamevir regarding its mechanism, resistance, and synergism with acyclovir. Its antiviral activity was not influenced by the viral replication cycle, in contrast to acyclovir. A clinical trial of amenamevir for herpes zoster demonstrated its non-inferiority to valacyclovir. To date, amenamevir has been successfully used in over 1,240,000 patients with herpes zoster in Japan. Post-marketing surveillance of amenamevir in Japan reported side effects with significant potential risk identified by the Japanese Risk Management Plan, including thrombocytopenia, gingival bleeding, and palpitations, although none of these were serious. The clinical efficacy and safety profiles of amenamevir were established in patients with herpes zoster. Therefore, amenamevir as an HPI opens a new era of anti-herpes therapy.
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Hoyos-Samboní DF, Munar JV, López D, Vásquez-Arteaga LR. Síndrome de Stevens-Johnson con reactivación de herpes simple asociado a la ingestión de paracetamol. Reporte de caso. REVISTA DE LA FACULTAD DE MEDICINA 2021. [DOI: 10.15446/revfacmed.v69n4.85264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
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.
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Amode R, Ingen-Housz-Oro S, Ortonne N, Bounfour T, Pereyre S, Schlemmer F, Bequignon E, Royer G, Wolkenstein P, Chosidow O. Clinical and histologic features of Mycoplasma pneumoniae-related erythema multiforme: A single-center series of 33 cases compared with 100 cases induced by other causes. J Am Acad Dermatol 2018; 79:110-117. [PMID: 29559400 DOI: 10.1016/j.jaad.2018.03.013] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Revised: 03/03/2018] [Accepted: 03/09/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Mycoplasma pneumoniae infection has been documented in erythema multiforme (EM) and Stevens-Johnson syndrome-toxic epidermal necrosis (SJS-TEN). Clinical aspects of M pneumoniae-related EM have been poorly described in the literature. OBJECTIVE To highlight differences between M pneumoniae EM and non-M pneumoniae EM. METHODS This single-center, retrospective cohort study included all patients admitted to our dermatology department for EM during 2000-2015. We compared epidemiologic, clinical, and histologic data and follow-up for M pneumoniae EM and non-M pneumoniae EM cases. RESULTS Thirty-three patients with M pneumoniae EM were compared with 100 patients with non-M pneumoniae EM. Disease onset in winter was more frequent with M pneumoniae EM (P = .003). Acrally distributed lesions (32% vs 88%, P < .0001) and typical targets (45% vs 74%, P = .01) were less common in M pneumoniae EM than non-M pneumoniae EM. Multiple (≥2) mucousal membrane involvement was more frequent in M pneumoniae EM than non-M pneumoniae EM (97% vs 60%; P < .0001), as were mucosal and respiratory tract sequelae (P < .05). The mean hospital stay was longer with M pneumoniae EM patients: 9.5 days versus 5.1 days (P = .0002). A TEN-like pattern was observed in all 14 (100%) M pneumoniae EM skin biopsies versus 10 of 27 (48%) non-M pneumoniae EM biopsies (P < .001). LIMITATIONS The retrospective design. CONCLUSION M pneumoniae EM has a distinctive presentation compared with non-M pneumoniae EM, with more diffuse and atypical targets, more mucositis and respiratory tract sequelae. Histologic data show a TEN-like pattern in all M pneumoniae EM skin samples.
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Affiliation(s)
- Reyhan Amode
- Dermatology Department, Assistance Publique Hôpitaux de Paris (AP-HP), Henri Mondor Hospital, Créteil, France
| | - Saskia Ingen-Housz-Oro
- Dermatology Department, Assistance Publique Hôpitaux de Paris (AP-HP), Henri Mondor Hospital, Créteil, France; Epidémiologie en Dermatologie et Evaluation des Thérapeutiques, Université Paris-Est Créteil (UPEC) Val de Marne, Créteil, France; Referral Center for Toxic Bullous Diseases, AP-HP, Henri Mondor Hospital, Créteil, France.
| | - Nicolas Ortonne
- Pathology Department, AP-HP, Henri Mondor Hospital, Créteil, France; UPEC, Créteil, France
| | - Touda Bounfour
- Dermatology Department, Assistance Publique Hôpitaux de Paris (AP-HP), Henri Mondor Hospital, Créteil, France
| | - Sabine Pereyre
- Université Bordeaux, National Institute for Agricultural Research, Mycoplasmal and Chlamydial Infections in Humans, Bordeaux, France; Bacteriology Department, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Frédéric Schlemmer
- Pneumology Department, AP-HP, Henri Mondor Hospital, Créteil and Département Hospitalo-Universitaire A-TVB (Ageing-Thorax-Vessel-Blood), UPEC, Créteil, France
| | - Emilie Bequignon
- Ear-Nose-Throat - Head and Neck Surgery Department, AP-HP, Henri Mondor Hospital, Créteil, France
| | - Gérard Royer
- Ophthalmology Department, AP-HP, Henri Mondor Hospital, Créteil, France
| | - Pierre Wolkenstein
- Dermatology Department, Assistance Publique Hôpitaux de Paris (AP-HP), Henri Mondor Hospital, Créteil, France; Epidémiologie en Dermatologie et Evaluation des Thérapeutiques, Université Paris-Est Créteil (UPEC) Val de Marne, Créteil, France; Referral Center for Toxic Bullous Diseases, AP-HP, Henri Mondor Hospital, Créteil, France; UPEC, Créteil, France
| | - Olivier Chosidow
- Dermatology Department, Assistance Publique Hôpitaux de Paris (AP-HP), Henri Mondor Hospital, Créteil, France; Epidémiologie en Dermatologie et Evaluation des Thérapeutiques, Université Paris-Est Créteil (UPEC) Val de Marne, Créteil, France; Referral Center for Toxic Bullous Diseases, AP-HP, Henri Mondor Hospital, Créteil, France; UPEC, Créteil, France
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Heinze A, Tollefson M, Holland KE, Chiu YE. Characteristics of pediatric recurrent erythema multiforme. Pediatr Dermatol 2018; 35:97-103. [PMID: 29231254 DOI: 10.1111/pde.13357] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Erythema multiforme (EM) is an acute condition characterized by distinctive target lesions of the skin often accompanied by mucosal ulcers. A subset of individuals experience frequent episodes of recurrent EM, which is rare and poorly understood, especially in children. OBJECTIVE To characterize clinical features, laboratory findings, and treatment responses of pediatric recurrent EM. METHODS A retrospective chart review was conducted at the Children's Hospital of Wisconsin in Milwaukee, Wisconsin (2000-2015) and the Mayo Clinic in Rochester, Minnesota (1990-2015). Inclusion criterion was a diagnosis before age 18 years with recurrent EM, defined as a symmetrically distributed, fixed eruption, including target lesions, with or without mucous membrane involvement, occurring on at least three occasions. A literature review was conducted to include individuals who met the inclusion criterion. RESULTS Twenty-six patients were included, of whom 16 (62%) were male. The median age of onset was 9.1 years (range 0-15.7 years). Nine patients (35%) required hospitalization. Herpes simplex virus testing was positive in 9 of 17 (65%) patients. Remission was achieved in 5 of 16 (31%) patients while taking suppressive antivirals. Eight patients received continuous anti-inflammatory treatment, two (25%) of whom experienced remission. CONCLUSION This study of pediatric recurrent EM found a greater male predominance, more hospitalizations, fewer cases caused by herpes simplex virus, and a lower response to immunosuppression in children than in the general population.
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Affiliation(s)
- Adam Heinze
- Medical College of Wisconsin, Milwaukee, WI, USA
| | - Megha Tollefson
- Section of Pediatric Dermatology, Departments of Dermatology and Pediatrics, Mayo Clinic, Rochester, MN, USA
| | - Kristen E Holland
- Section of Pediatric Dermatology, Departments of Dermatology and Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Yvonne E Chiu
- Section of Pediatric Dermatology, Departments of Dermatology and Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
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Aurelian L, Burnett JW. Current understanding of herpes simplex virus-associated erythema multiforme. ACTA ACUST UNITED AC 2014. [DOI: 10.1586/17469872.3.4.491] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Akpek G, Joseph R, Günay C, Kessler II, Shvartsbeyn M, Bhatnagar B, Aurelian L. Frequent Detection of Herpes Simplex Virus Antigen in Skin and Peripheral Blood CD34+ Mononuclear Cells from Patients with Graft-versus-Host Disease. Biol Blood Marrow Transplant 2013; 19:529-37. [DOI: 10.1016/j.bbmt.2012.12.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2012] [Accepted: 12/28/2012] [Indexed: 10/27/2022]
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Makaron L, Smith K, Bailey C, Kaliyaperumal S, Miller A, Kramer J. Immune-mediated interface dermatitis in a rhesus macaque. J Med Primatol 2012; 41:332-5. [PMID: 22882754 DOI: 10.1111/j.1600-0684.2012.00558.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2012] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- L Makaron
- Harvard Medical School, New England Primate Research Center, Southborough, MA 01772, USA.
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Nguyen N, Burkhart CN, Burkhart CG. Identifying potential pitfalls in conventional herpes simplex virus management. Int J Dermatol 2010; 49:987-93. [PMID: 20883262 DOI: 10.1111/j.1365-4632.2010.04587.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
In recent years, it has become increasingly clear that genital ulcers from herpes simplex virus (HSV) are associated with HIV acquisition. In light of this evolving synergy in transmission and the availability of effective antiviral therapy, proper diagnosis and management of HSV becomes increasingly important. Unfortunately, conventional HSV management is founded on several popular misconceptions. Herein, we hope to dispel these common misconceptions and expand the current model of herpetic reactivation. By doing so, we aimed to unveil potential pitfalls in current herpetic management.
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Wetter DA, Davis MDP. Recurrent erythema multiforme: clinical characteristics, etiologic associations, and treatment in a series of 48 patients at Mayo Clinic, 2000 to 2007. J Am Acad Dermatol 2009; 62:45-53. [PMID: 19665257 DOI: 10.1016/j.jaad.2009.06.046] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2009] [Revised: 05/05/2009] [Accepted: 06/10/2009] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- David A Wetter
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota
| | - Mark D P Davis
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota.
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Bowman C, Delrieu O. Immunogenetics of drug-induced skin blistering disorders. Part I: Perspective. Pharmacogenomics 2009; 10:601-21. [PMID: 19374517 DOI: 10.2217/pgs.09.11] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
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.
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Affiliation(s)
- Clive Bowman
- School of Biological Sciences, The University of Reading, Whiteknights, Reading, RG6 6AH, UK.
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Burnett JW, Laing JM, Aurelian L. Acute skin eruptions that are positive for herpes simplex virus DNA polymerase in patients with stem cell transplantation: a new manifestation within the erythema multiforme reactive dermatoses. ACTA ACUST UNITED AC 2008; 144:902-7. [PMID: 18645142 DOI: 10.1001/archderm.144.7.902] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Patients with stem cell transplantation (SCT) develop erythematous eruptions (SCTE) that are often misdiagnosed and poorly treated. Latent herpes simplex virus (HSV) is likely to be reactivated by SCT-associated immunosuppression. Therefore, one of the differential diagnostic possibilities for SCTE is HSV-associated erythema multiforme (HAEM) in which HSV genetic fragments localize in stem cells that deliver them to the skin on differentiation. OBSERVATIONS Lesional skin from patients with SCTE, HAEM, HSV, or drug-induced erythema (DIEM) was stained with antibodies to the HSV antigen DNA polymerase (Pol) and the major capsid protein, virion protein 5 (VP5). The HSV DNA polymerase Pol was expressed in 79% of patients with SCTE and 75% of those with HAEM. The protein VP5 was not expressed in these patients, indicative of the absence of virus replication. Findings in patients with DIEM were negative for both antigens, and those with HSV lesions were positive for both antigens. CONCLUSIONS There is a growing problem with SCTE, related to the increasing numbers of performed SCT. The greater frequency of SCT-generated circulating stem cells in patients with hematological malignant neoplasms (who have latent HSV infection) may result in a widespread SCTE characterized by skin deposition of HSV DNA fragments, notably those expressing Pol antigen. This HAEM-like presentation should be considered in the differential diagnosis of SCTE. Prolonged high-dosage antiviral chemotherapy during and after hospitalization may be warranted.
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Affiliation(s)
- Joseph W Burnett
- Department of Dermatology, University of Maryland, 4401 Roland Ave, Baltimore, MD 21210, USA.
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Nahassf G, Penneys N, Leonardi C. Interface dermatitis in acute varicella-zoster virus infection: demonstration of varicella-zoster virus DNA in keratinocytes by in situ
polymerase chain reaction. Br J Dermatol 2008. [DOI: 10.1046/j.1365-2133.1996.d01-960.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Arduino PG, Porter SR. Herpes Simplex Virus Type 1 infection: overview on relevant clinico-pathological features. J Oral Pathol Med 2008; 37:107-21. [PMID: 18197856 DOI: 10.1111/j.1600-0714.2007.00586.x] [Citation(s) in RCA: 196] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Herpes Simplex Virus Type 1 (HSV-1) is a nuclear replicating enveloped virus, usually acquired through direct contact with infected lesions or body fluids (typically saliva). The prevalence of HSV-1 infection increases progressively from childhood, the seroprevalence being inversely related to socioeconomic background. Primary HSV-1 infections in children are either asymptomatic or following an incubation period of about 1 week gives rise to mucocutaneous vesicular eruptions. Herpetic gingivostomatitis typically affects the tongue, lips, gingival, buccal mucosa and the hard and soft palate. Most primary oro-facial HSV infection is caused by HSV-1, infection by HSV-2 is increasingly common. Recurrent infections, which occur at variable intervals, typically give rise to vesiculo-ulcerative lesions at mucocutaneous junctions particularly the lips (herpes labialis). Recurrent HSV-1 infection within the mouth is uncommon in otherwise healthy patients, although in immunocompromised patients, recurrent infection can be more extensive and/or aggressive. The diagnosis of common herpetic infection can usually be based upon the clinical history and presenting features. Confirmatory laboratory diagnosis is, however, required when patients are, or may be, immunocompromised.
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Affiliation(s)
- Paolo G Arduino
- Department of Biomedical Sciences and Human Oncology, Oral Medicine Section, University of Turin, Turin, Italy.
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Abstract
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.
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Gober MD, Laing JM, Burnett JW, Aurelian L. The Herpes simplex virus gene Pol expressed in herpes-associated erythema multiforme lesions upregulates/activates SP1 and inflammatory cytokines. Dermatology 2007; 215:97-106. [PMID: 17684370 DOI: 10.1159/000104259] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2006] [Accepted: 02/14/2007] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS Herpes-simplex-virus-associated erythema multiforme (HAEM) is characterized by lesional skin expression of the viral protein Pol and localized inflammation. The objective of this study is to examine the mechanism whereby Pol induces localized inflammation. METHODS A431 cells transfected with Pol or an empty vector and lesional skin from HAEM or drug-induced erythema multiforme patients were examined for expression of the transcription factor SP1 and SP1-regulated genes by immunoblotting, immunohistochemistry and immunofluorescence. RESULTS SP1, TGF-beta, p21(waf1) and Hsp27 were upregulated in A431 cells transfected with Pol but not the empty vector. Expression was further increased by exposure to IFN-gamma. Pol+ HAEM lesional skin expressed SP1, Hsp27, TGF-beta and p21(waf1). Normal skin and drug-induced erythema multiforme lesional skin were negative. CONCLUSION The data indicate that Pol activates SP1, causing upregulation of SP1 target genes (notably TGF-beta) involved in localized inflammation. Upregulation is potentiated by IFN-gamma.
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Affiliation(s)
- Michael D Gober
- Department of Pharmacology and Experimental Therapeutics, University of Maryland School of Medicine, Baltimore, MD 21201-1559, USA
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Schalock PC, Dinulos JGH, Pace N, Schwarzenberger K, Wenger JK. Erythema multiforme due to Mycoplasma pneumoniae infection in two children. Pediatr Dermatol 2006; 23:546-55. [PMID: 17155996 DOI: 10.1111/j.1525-1470.2006.00307.x] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Peter C Schalock
- Department of Dermatology, Harvard Medical School, Boston, Massachasetts, USA
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20
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Abstract
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.
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Affiliation(s)
- P Farthing
- Charles Clifford Dental School, University of Sheffield, UK
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21
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Ono F, Sharma BK, Smith CC, Burnett JW, Aurelian L. CD34+ cells in the peripheral blood transport herpes simplex virus DNA fragments to the skin of patients with erythema multiforme (HAEM). J Invest Dermatol 2005; 124:1215-24. [PMID: 15955097 DOI: 10.1111/j.0022-202x.2005.23712.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Herpes simplex virus (HSV)-associated erythema multiforme (HAEM) is a recurrent disease characterized by the presence and expression of HSV DNA fragments in lesional skin. Our studies examined the mechanism of viral DNA transport to the skin of HAEM patients. CD34+ cells were isolated from the blood of normal subjects and HSV and HAEM patients during acute lesions and at quiescence. They were cultured with cytokines that favor their differentiation into Langerhans cells (LC) precursors (CD1a+/CD14-) and examined for HSV replication, HSV-induced cellular alterations, viral DNA fragmentation, and clearance. CD34+ cells from all study groups were non-permissive for HSV replication but infection favored their differentiation into CD1a+/CD14- LC precursors and upregulated E-cadherin expression, thereby assisting LC targeting to the skin. Only HAEM patients had CD34+ cells that retained viral DNA fragments, notably polymerase DNA, for at least 7 d of in vitro culture. The percentages of circulating CD34+ (and CD34+/CLA+) cells were significantly higher in HAEM patients at the time of acute lesions. A similar increase was not seen for HSV patients. The data are the first report implicating CD34+ cells in HAEM pathogenesis, likely by transporting HSV DNA fragments to lesional skin.
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Affiliation(s)
- Fumitake Ono
- Department of Pharmacology and Experimental Therapeutics, The University of Maryland School of Medicine, Baltimore, Maryland 21201, USA
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22
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Ng PPL, Sun YJ, Tan HH, Tan SH. Detection of Herpes simplex Virus Genomic DNA in Various Subsets of Erythema multiforme by Polymerase Chain Reaction. Dermatology 2004; 207:349-53. [PMID: 14657624 DOI: 10.1159/000074112] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2002] [Accepted: 04/05/2003] [Indexed: 11/19/2022] Open
Abstract
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.
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25
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Sun Y, Chan RKW, Tan SH, Ng PPL. Detection and genotyping of human herpes simplex viruses in cutaneous lesions of erythema multiforme by nested PCR. J Med Virol 2003; 71:423-8. [PMID: 12966549 DOI: 10.1002/jmv.10502] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
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.
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Affiliation(s)
- Yongjiang Sun
- Infectious Disease Laboratory, Infectious Disease Research Centre, Level 2, TTSH Medical Centre, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433, Republic of Singapore.
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26
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Koelle DM, Corey L. Recent progress in herpes simplex virus immunobiology and vaccine research. Clin Microbiol Rev 2003; 16:96-113. [PMID: 12525427 PMCID: PMC145296 DOI: 10.1128/cmr.16.1.96-113.2003] [Citation(s) in RCA: 192] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
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.
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Affiliation(s)
- David M Koelle
- Department of Medicine, University of Washington, Seattle, Washington 98195, USA.
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27
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Burkhart CN. HIV-1 shedding in genital tract of infected women. Lancet 2002; 359:1526. [PMID: 11988284 DOI: 10.1016/s0140-6736(02)08453-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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28
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Abstract
Hypersensitivity reactions of the oral mucosa comprise an array of clinical manifestations. Some of the reactions are difficult to differentiate from toxic reactions. Hypersensitivity reactions of type I, type III, and type IV are well known, although, especially for types I and III, they are rarely encountered. Type-I reactions are most frequently seen related to application of polymers in the oral cavity, such as orthodontic bonding and fissure sealant materials. There may also be systemic manifestations such as urticaria. Type-IV reactions may be seen related to most dental materials used, from amalgam and gold to polymers. These reactions appear as chronic reddening and/or ulceration of the oral mucosa. Lichenoid reactions have histopathological characteristics compatible with type-IV hypersensitivity reactions and are the most prevalent material-adverse reactions seen in the oral cavity. A special variety inside the lips with multiple papules and/or diffuse redness has recently been identified. This lesion comprises a serious treatment challenge. Skin patch tests, applying a series of dental materials in non-toxic concentrations on the skin, have been used to identify sensitization. However, the value of those tests can be questioned. Exacerbation of geographic stomatitis may be another form of hypersensitivity to dental materials.
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Affiliation(s)
- T Axéll
- Institute of Clinical Dentistry, Faculty of Dentistry, University of Oslo, Norway.
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29
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Ayangco L, Sheridan PJ, Rogers RS. Erythema multiforme secondary to herpes simplex infection: a case report. J Periodontol 2001; 72:953-7. [PMID: 11495145 DOI: 10.1902/jop.2001.72.7.953] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
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.
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Affiliation(s)
- L Ayangco
- Department of Dental Specialties, Mayo Clinic, Rochester, MN 55905, USA
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30
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Larcher C, Gasser A, Hattmannstorfer R, Obexer P, Fürhapter C, Fritsch P, Sepp N. Interaction of HSV-1 infected peripheral blood mononuclear cells with cultured dermal microvascular endothelial cells: a potential model for the pathogenesis of HSV-1 induced erythema multiforme. J Invest Dermatol 2001; 116:150-6. [PMID: 11168811 DOI: 10.1046/j.1523-1747.2001.00235.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The effect of herpes virus infection on human dermal microvascular endothelial cells and herpes-virus-1-infected peripheral blood mononuclear cells on human dermal microvascular endothelial cells was studied as a model of herpes-associated erythema multiforme. After infection of human dermal microvascular endothelial cells with native herpes virus and overnight culture, 60%--90% of human dermal microvascular endothelial cells showed cytopathic effects. HLA class I molecules and CD31 (PECAM-1) surface expression in herpes-virus-infected endothelial cells were substantially downregulated, whereas CD54 (ICAM-1) remained unchanged. Cocultivation with herpes-virus-1-infected peripheral blood mononuclear cells left characteristic plaques on the human dermal microvascular endothelial cell monolayer; however, very few human dermal microvascular endothelial cells (1%--3%) were infected. Adhesion molecule expression of human dermal microvascular endothelial cells cocultivated with herpes-virus-infected peripheral blood mononuclear cells demonstrated a 5-fold increase in CD54 expression, a 2-fold increase in HLA class I expression, but no change of CD31 by fluorescence-activated cell sorter analysis. Incubation of human dermal microvascular endothelial cells with ultraviolet-C irradiated herpes-virus-infected peripheral blood mononuclear cells had no effect on morphology or adhesion molecule expression levels. Changes of adhesion molecule expression by direct infection or cocultivation with peripheral blood mononuclear cells (with native and ultraviolet-C inactivated herpes virus infection) were also documented at the mRNA level. Adhesion assays demonstrated an increased binding of herpes-virus-infected peripheral blood mononuclear cells versus noninfected peripheral blood mononuclear cells to noninfected human dermal microvascular endothelial cells. Our results suggest that incubation of herpes-virus-infected peripheral blood mononuclear cells with human dermal microvascular endothelial cells induces significant upregulation of CD54 and major histocompatibility complex class I molecules in the surrounding noninfected human dermal microvascular endothelial cells, which is associated with an increased binding of peripheral blood mononuclear cells. Our in vitro findings may serve as a model for herpes-associated erythema multiforme possibly explaining the dermal inflammatory reaction seen in that condition.
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Affiliation(s)
- C Larcher
- Institute of Hygiene, University of Innsbruck, Innsbruck, Austria
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31
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Aurelian L, Kokuba H, Burnett JW. Understanding the pathogenesis of HSV-associated erythema multiforme. Dermatology 2000; 197:219-22. [PMID: 9812024 DOI: 10.1159/000018000] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Erythema multiforme (EM) is a polymorphic, often recurring eruption caused by exposure to medication or various infections, notably herpes simplex virus (HSV). Understanding the pathogenesis of HSV-associated EM (HAEM) is essential for patient management. We suggest that HAEM results from the combination of viropathic effects mediated by HSV proteins, notably DNA polymerase (Pol), and an immunological reaction to viral antigens. Presumably, viral DNA and proteins ingested by macrophages at HSV lesion sites undergo fragmentation and processing for presentation to T cells with HSV memory. HSV DNA is deposited on the skin, where it is expressed. Activated T cells are recruited to the skin site of Pol expression, directly or indirectly resulting in the generation of an inflammatory cascade. Factors potentially involved in the incidence of recurrences, lesion severity and anatomical localization include the identity of the deposited HSV genes, cutaneous capillary size, degree of vasoconstriction and ambient temperature. Evidence in support of this interpretation is reviewed.
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Affiliation(s)
- L Aurelian
- Virology/Immunology Laboratories, Department of Pharmacology & Experimental Therapeutics, University of Maryland, School of Medicine, Baltimore, Md., USA.
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32
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Katta R. Taking aim at erythema multiforme. How to spot target lesions and less typical presentations. Postgrad Med 2000; 107:87-90. [PMID: 10649667 DOI: 10.3810/pgm.2000.01.826] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Erythema multiforme is a distinct cutaneous condition characterized by target lesions. Most cases are associated with HSV infection, which may be subclinical. When the classic target lesions are absent, skin biopsy may be necessary to confirm the diagnosis. Treatment is directed at suppressing outbreaks of HSV infection and controlling symptoms during acute episodes.
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Affiliation(s)
- R Katta
- Department of Dermatology, Baylor College of Medicine, Houston, TX 77030, USA
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33
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Kokuba H, Aurelian L, Burnett J. Herpes simplex virus associated erythema multiforme (HAEM) is mechanistically distinct from drug-induced erythema multiforme: interferon-gamma is expressed in HAEM lesions and tumor necrosis factor-alpha in drug-induced erythema multiforme lesions. J Invest Dermatol 1999; 113:808-15. [PMID: 10571738 DOI: 10.1046/j.1523-1747.1999.00754.x] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Erythema multiforme follows administration of several drugs or infection with various agents, including herpes simplex virus, a syndrome designated herpes simplex virus associated erythema multiforme. Lesional skin from 21 of 26 (81%) herpes simplex virus associated erythema multiforme patients was positive for herpes simplex virus gene expression as evidenced by reverse transcriptase-polymerase chain reaction with primers for DNA polymerase and/or immunohistochemistry with DNA polymerase antibody. Reverse transcriptase-polymerase chain reaction and immunohistochemistry studies indicated that herpes simplex virus associated erythema multiforme lesional skin from 16 of 21 (76%) DNA polymerase positive herpes simplex virus associated erythema multiforme patients was also positive for interferon-gamma, a product of T cells involved in delayed-type hypersensitivity (p < 0. 0001 by Pearson correlation coefficient). Interferon-gamma signals were in infiltrating mononuclear cells and in intercellular spaces within inflammatory sites in the epidermis and at the epidermis/dermis junction. Herpes simplex virus lesional skin was also positive for DNA polymerase [five of five (100%)] and interferon-gamma [four of five (80%)], but lesional skin from drug-induced erythema multiforme patients was negative. Lesional herpes simplex virus associated erythema multiforme keratinocytes also stained with antibody to transforming growth factor-beta [14 of 23 (61%)] and cyclin-dependent kinase inhibitor waf [12 of 18 (67%)]. Staining was also seen in keratinocytes from herpes simplex virus lesions [five of five (100%)], but not in normal skin. By contrast, staining with antibody to tumor necrosis factor-alpha, another pro-inflammatory cytokine, was seen in seven of 11 (64%) drug-induced erythema multiforme patients, but not in herpes simplex virus or herpes simplex virus associated erythema multiforme patients, and lesional keratinocytes from drug-induced erythema multiforme patients were negative for transforming growth factor-beta and cyclin-dependent kinase inhibitor waf. We interpret the data to indicate that herpes simplex virus associated erythema multiforme pathology includes a delayed-type hypersensitivity component and is mechanistically distinct from drug-induced erythema multiforme.
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Affiliation(s)
- H Kokuba
- Department of Dermatology, The University of Maryland School of Medicine, Baltimore 21201, USA
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34
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Kokuba H, Imafuku S, Burnett JW, Aurelian L. Longitudinal study of a patient with herpes-simplex-virus-associated erythema multiforme: viral gene expression and T cell repertoire usage. Dermatology 1999; 198:233-42. [PMID: 10393444 DOI: 10.1159/000018121] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Erythema multiforme is a polymorphous self-limited, often recurrent eruption that can follow herpes simplex virus (HSV) infection, hereby designated HAEM. Studies of relatively large groups of patients during one recurrent episode indicated that HAEM pathogenesis is associated with HSV gene expression, Vbeta2 T cell infiltration of lesional skin and altered T cell receptor (TCR) repertoire usage by HSV-stimulated peripheral blood mononuclear cells (PBMC). However, HAEM recurrences are not always preceded by overt HSV eruptions and virus cannot be isolated from HAEM lesional skin. Therefore, it is unknown whether all HAEM recurrences experienced by a given patient are HSV related. OBJECTIVE The studies described in this report were designed to examine whether all HAEM recurrences experienced by a given patient are HSV related. METHODS We describe one patient who was studied longitudinally during 6 HAEM recurrences and in the intervening lesion-free periods. Lesional skin from all HAEM episodes was studied for HSV gene expression and infiltration by Vbeta2 and Vbeta3 T cells. PBMC obtained at these times were assayed for TCR repertoire usage upon HSV stimulation. RESULTS Lesional skin from all HAEM episodes was positive for HSV gene expression (RNA and protein) as well as Vbeta2 T cell infiltration. HSV-stimulated PBMC obtained at these times had an altered TCR repertoire characterized by a predominance of Vbeta2 cells. The duration of viral gene expression, Vbeta2 cell infiltration and altered TCR repertoire usage correlated with the duration of clinical symptoms. CONCLUSION The data suggest that HSV and a virus-specific immunopathology component are involved in the causation of all HAEM episodes experienced by the patient.
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MESH Headings
- Adult
- Erythema Multiforme/etiology
- Erythema Multiforme/immunology
- Erythema Multiforme/virology
- Gene Expression Regulation, Viral
- Genes, pol/genetics
- Herpes Simplex/complications
- Herpes Simplex/genetics
- Humans
- Leukocytes, Mononuclear/cytology
- Leukocytes, Mononuclear/immunology
- Leukocytes, Mononuclear/metabolism
- Longitudinal Studies
- Male
- Receptors, Antigen, T-Cell/genetics
- Receptors, Antigen, T-Cell/metabolism
- Simplexvirus/genetics
- Simplexvirus/immunology
- Skin Diseases, Viral/etiology
- T-Lymphocytes/cytology
- T-Lymphocytes/immunology
- T-Lymphocytes/metabolism
- Time Factors
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Affiliation(s)
- H Kokuba
- Virology/Immunology Laboratories, Department of Pharmacology and Experimental Therapeutics, University of Maryland School of Medicine, Baltimore, MD 21201, USA
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35
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Maggs DJ, Chang E, Nasisse MP, Mitchell WJ. Persistence of herpes simplex virus type 1 DNA in chronic conjunctival and eyelid lesions of mice. J Virol 1998; 72:9166-72. [PMID: 9765463 PMCID: PMC110335 DOI: 10.1128/jvi.72.11.9166-9172.1998] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Herpes simplex virus type 1 (HSV-1) causes chronic blepharitis and conjunctivitis as well as keratitis in humans. The pathogenesis of these inflammatory ocular and dermal lesions is not well understood. We have examined the persistence of HSV-1 DNA and its relationship to inflammatory lesions in the conjunctiva and eyelid skin of mice which were inoculated with HSV-1 by the corneal route. Viral DNA was detected by in situ PCR in the conjunctiva and eyelid tissue of infected mice at 5, 11, 23, and 37 days postinfection (p.i.). This DNA was localized in the epithelial cells of the conjunctiva and hair follicles and in the epidermal cells of the eyelid skin. Viral proteins were not detected in the conjunctiva or the eyelid skin after 5 days p.i., even though histopathological lesions were found at 23 and 37 days p.i. in both tissues. The DNA-containing cells were adjacent to sites of inflammation in the chronic lesions in both the conjunctiva and the eyelid skin. A similar temporal and spatial relationship between HSV-1 DNA and inflammatory lesions has been previously reported for the cornea. Our data suggest that the lesions in the cornea, conjunctiva, and eyelid skin progress similarly. Further studies are required to determine whether the long-term presence of HSV-1 is involved in the mechanism by which these chronic inflammatory lesions develop. The presence of HSV-1 DNA in these extraocular tissues for extended periods may constitute persistent viral infection of nonneuronal cells.
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MESH Headings
- Animals
- Antigens, Viral/isolation & purification
- Base Sequence
- Blepharitis/etiology
- Blepharitis/pathology
- Blepharitis/virology
- Chronic Disease
- Conjunctivitis, Viral/etiology
- Conjunctivitis, Viral/pathology
- Conjunctivitis, Viral/virology
- DNA Primers/genetics
- DNA, Viral/genetics
- DNA, Viral/isolation & purification
- Disease Models, Animal
- Female
- Herpesvirus 1, Human/genetics
- Herpesvirus 1, Human/isolation & purification
- Herpesvirus 1, Human/pathogenicity
- Keratitis, Herpetic/etiology
- Keratitis, Herpetic/virology
- Mice
- Mice, Inbred BALB C
- Polymerase Chain Reaction
- Time Factors
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Affiliation(s)
- D J Maggs
- Departments of Veterinary Medicine and Surgery, College of Veterinary Medicine, University of Missouri, Columbia, Missouri 65211, USA
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Weisman K, Petersen CS, Blichmann CW, Nielsen NH, Hultberg BM. Bullous erythema multiforme following herpes zoster and varicella-zoster virus infection. J Eur Acad Dermatol Venereol 1998; 11:147-50. [PMID: 9784041 DOI: 10.1111/j.1468-3083.1998.tb00768.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Four cases of herpes zoster-induced bullous erythema multiforme (EM) are reported. Three patients presented with widespread skin lesions 10 to 14 days after an episode of thoracic herpes zoster. In these patients a high increase in varicella-zoster virus (VZV) antibody titer was detected, indicating secondary VZV infection. Histologic examinations of skin biopsy from a patient with widespread lesions (case 4) revealed a mixture of EM, toxic epidermal necrolysis and herpetic virus infection. VZV should be included in the list of infectious agents able to trigger EM and Stevens-Johnson syndrome.
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Affiliation(s)
- K Weisman
- Department of Dermato-Venereology, Bispebjerg Hospital, Copenhagen NV, Denmark
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37
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Affiliation(s)
- T Brown
- Department of Dermatology, University of Texas Medical Branch at Galveston, USA
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38
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Kokuba H, Imafuku S, Huang S, Aurelian L, Burnett JW. Erythema multiforme lesions are associated with expression of a herpes simplex virus (HSV) gene and qualitative alterations in the HSV-specific T-cell response. Br J Dermatol 1998; 138:952-64. [PMID: 9747355 DOI: 10.1046/j.1365-2133.1998.02260.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
A common form of erythema multiforme, herpes-associated erythema multiforme (HAEM), occurs following infection with herpes simplex virus (HSV). Here we report that HSV gene expression and the qualitative nature of the virus-specific T-cell responses are related to HAEM lesion development. Skin from HAEM lesions and 1-3 months healed HAEM lesional skin were positive for the viral DNA polymerase gene (Pol) by polymerase chain reaction. However, gene expression as determined by immunohistochemistry with Pol-specific antibody was seen only in HAEM lesions, suggesting that lesion development is associated with Pol gene expression. Similar HSV-specific T-cell lymphoproliferative responses were seen in peripheral blood mononuclear cells (PBMCs) from patients with acute or healed HAEM lesions or HSV lesions and from HSV-seropositive patients with unrelated inflammatory diseases. However, the T-cell receptor variable (V beta) chain repertoire of HSV-stimulated PBMCs obtained from HAEM lesions was altered; the prevalence of some families of variable chain (namely V beta 16 and V beta 19) was reduced, whereas the prevalence of others was increased (namely V beta 2 and V beta 7). V beta 2 cells were found in HAEM lesional skin positive for Pol antigen, suggesting that these cells home to viral antigen-positive skin.
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Affiliation(s)
- H Kokuba
- Virology/Immunology Laboratories, University of Maryland School of Medicine, Baltimore 21201, USA
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39
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Differential Diagnosis and Treatment of Ulcerative, Erosive, and Vesiculobullous Lesions of the Oral Mucosa. Oral Maxillofac Surg Clin North Am 1998. [DOI: 10.1016/s1042-3699(20)30930-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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40
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Abstract
Herpes simplex virus type 1 (HSV-1) and, to a lesser extent, type 2 (HSV-2) are the aetiological agents of recrudescent herpes labialis (RHL). The available literature on patterns of HSV-1 shedding into the oral cavity at the prodromal stage of disease, during recrudescences and also during asymptomatic periods, is reviewed, as are the potential sources of virus and the known trigger factors leading to viral reactivation. Attention is given to the methodologies in use for the detection of HSV-1 and the relevance to the risk of cross-infection in surgery. This review also discusses the increase in incidence of HSV-1 genital infections and the significance of salivary inhibitors of the herpes simplex type 1 virus.
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Affiliation(s)
- D A Scott
- School of Clinical Dentistry, Queen's University of Belfast, N. Ireland
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41
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Imafuku S, Kokuba H, Aurelian L, Burnett J. Expression of herpes simplex virus DNA fragments located in epidermal keratinocytes and germinative cells is associated with the development of erythema multiforme lesions. J Invest Dermatol 1997; 109:550-6. [PMID: 9326389 DOI: 10.1111/1523-1747.ep12336800] [Citation(s) in RCA: 47] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Skin from acute and healed herpes simplex virus or herpes simplex virus-associated erythema multiforme (HAEM) lesions was examined by polymerase chain reaction with primers for DNA polymerase, ICP8, thymidine kinase (5' end of herpes simplex virus genome), and ICP27 (3' end of herpes simplex virus genome). The primers were herpes simplex virus specific and equally sensitive. The four herpes simplex virus genes were seen in acute herpes simplex virus lesions, but except for one patient, only polymerase (or polymerase and ICP8) were seen in 7-d healed lesional skin. Herpes simplex virus DNA was not seen 1-1.5 mo after healing. HAEM skins from 18 of 24 patients (75%) were positive for polymerase DNA and four of 24 (17%) were also positive for ICP8 or thymidine kinase DNA. Only one tissue (4%) was positive for polymerase, ICP8, and ICP27 DNA. Skin from healed HAEM lesions was still polymerase DNA positive 1-3 mo after lesion resolution. The polymerase DNA signal was in the basal and spinous cell layers of the epidermis and in the outer root sheath of the hair follicle. Polymerase RNA was identified by reverse transcriptase polymerase chain reaction in skin from acute, but not healed polymerase DNA positive HAEM lesions, suggesting that polymerase expression is associated with HAEM lesion development.
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Affiliation(s)
- S Imafuku
- Department of Dermatology, The University of Maryland School of Medicine, Baltimore 21201, U.S.A
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42
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Scott DA, Coulter WA, Biagioni PA, O'Neill HO, Lamey PJ. Detection of herpes simplex virus type 1 shedding in the oral cavity by polymerase chain reaction and enzyme-linked immunosorbent assay at the prodromal stage of recrudescent herpes labialis. J Oral Pathol Med 1997; 26:305-9. [PMID: 9250929 DOI: 10.1111/j.1600-0714.1997.tb00220.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Recrudescent herpes labialis (RHL) is a disease caused by herpes simplex virus (HSV), predominantly type 1 (HSV-1). We have monitored HSV-1 shedding in the oral cavity by polymerase chain reaction (PCR) and enzyme-linked immunosorbent assays (ELISA) using digoxigenin-labeled primers designed to amplify a 278 bp segment of the HSV-1 UL 42 region. Prodromal RHL was confirmed by thermographic imaging in 22 patients. Infectious virus was not detected using tissue culture for virus isolation (0/22). Using PCR and agarose gel electrophoresis, we could detect HSV-1 DNA in 8/22 patients. Using a biotinylated-probe internal to the predicted sequence of the PCR product, HSV-1 DNA was detected in 10/22 patients by ELISA. We conclude that HSV-1 DNA is shed into the oral cavity of patients presenting with sub-clinical RHL and that the PCR-ELISA technique represents a more sensitive method to monitor HSV-1 shedding than conventional tissue culturing or PCR-electrophoresis alone.
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Affiliation(s)
- D A Scott
- School of Clinical Dentistry, Queen's University of Belfast, Northern Ireland
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43
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Nahassf G, Penneys N, Leonardi C. Interface dermatitis in acute varicella-zoster virus infection: demonstration of varicella-zoster virus DNA in keratinocytes by in situ polymerase chain reaction. Br J Dermatol 1996. [DOI: 10.1111/j.1365-2133.1996.tb03636.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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44
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Backman KS, Patterson R. An erythematous rash preceding ulcerative oral lesions in a 41-year-old woman. Ann Allergy Asthma Immunol 1996; 76:500-6. [PMID: 8673683 DOI: 10.1016/s1081-1206(10)63268-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- K S Backman
- Department of Medicine, Northwestern Memorial Hospital, Chicago, Illinois, USA
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45
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Scully C. New aspects of oral viral diseases. CURRENT TOPICS IN PATHOLOGY. ERGEBNISSE DER PATHOLOGIE 1996; 90:29-96. [PMID: 8791748 DOI: 10.1007/978-3-642-80169-3_2] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- C Scully
- Eastman Dental Institute for Oral HealthCare Sciences, University of London, England
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46
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Williams DM. Mucocutaneous conditions affecting the mouth. CURRENT TOPICS IN PATHOLOGY. ERGEBNISSE DER PATHOLOGIE 1996; 90:1-28. [PMID: 8791747 DOI: 10.1007/978-3-642-80169-3_1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- D M Williams
- Department of Oral Pathology, Faculty of Clinical Dentistry, St. Bartholomew's and The Royal London School of Medicine and Dentistry, London, England
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47
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Farthing PM, Maragou P, Coates M, Tatnall F, Leigh IM, Williams DM. Characteristics of the oral lesions in patients with cutaneous recurrent erythema multiforme. J Oral Pathol Med 1995; 24:9-13. [PMID: 7722922 DOI: 10.1111/j.1600-0714.1995.tb01122.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Erythema multiforme may be recurrent and the oral cavity is often affected. A series of 82 patients with unequivocal recurrent cutaneous erythema multiforme were examined to determine the incidence and nature of oral lesions. Seventy per cent of patients had oral lesions, comprising multiple, large, shallow, extremely painful and debilitating ulcers, which affected the entire oral mucosa in over 20%. The buccal mucosa and tongue were the most frequently affected sites in the remainder and the lips were affected in 13% of patients. Lesions generally lasted for 1-3 weeks. In over 60% of cases these attacks followed an episode of herpes simplex virus infection during the preceding fortnight. Recurrent attacks showed a different site distribution from the initial attacks, with a greater proportion having genital as well as skin and oral mucosal involvement. Detailed case histories of five patients are presented to illustrate the role of azathioprine in treating oral lesions and to document a familial case of recurrent erythema multiforme, with severe mucosal involvement.
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Affiliation(s)
- P M Farthing
- Joint Department of Oral Pathology, London Hospital Medical College, England
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48
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Brice SL, Leahy MA, Ong L, Krecji S, Stockert SS, Huff JC, Weston WL. Examination of non-involved skin, previously involved skin, and peripheral blood for herpes simplex virus DNA in patients with recurrent herpes-associated erythema multiforme. J Cutan Pathol 1994; 21:408-12. [PMID: 7868752 DOI: 10.1111/j.1600-0560.1994.tb00281.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The association between infection with HSV and the subsequent development of erythema multiforme is well established, although the role that the virus plays in the pathogenesis of this disorder is not known. HSV DNA has been detected in cutaneous lesions of herpes-associated erythema multiforme (HAEM), and it has been suggested that the tissue damage seen in these lesions is virus-specific. In the current, prospective study, we examined biopsies of lesional, non-involved, and previously involved but healed skin, in addition to specimens of peripheral blood, from patients with HAEM, for HSV DNA by using the polymerase chain reaction. HSV DNA was detected in lesional skin of 10 of 11 patients compared to 2 of 11 non-involved skin biopsies obtained at the same time. HSV was present in 4 of 6 blood specimens obtained during the acute episode. Five patients returned 3 months after the acute episode resolved for biopsies of previously involved skin. HSV was detected in 4 of these 5 biopsies. Thus, the presence of HSV DNA in the skin of patients with HAEM appears to be predominantly in areas of clinical involvement; the virus remains in those cutaneous sites for up to 3 months without evidence of clinical disease; and HSV DNA may be detected in the peripheral blood cells during acute HAEM. Based on these findings, we suggest that the virus plays a role in lesion development, that the skin may function as a site of viral persistence, and that hematogenous spread of viral DNA may be an important factor in the development of HAEM.
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Affiliation(s)
- S L Brice
- University of Colorado Health Sciences Center, Department of Dermatology, Denver 80262
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49
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Affiliation(s)
- A Win
- Department of Medicine, St. Francis Medical Center, Trenton, New Jersey 08629
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50
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Eversole LR. Immunopathology of oral mucosal ulcerative, desquamative, and bullous diseases. Selective review of the literature. ORAL SURGERY, ORAL MEDICINE, AND ORAL PATHOLOGY 1994; 77:555-71. [PMID: 8065717 DOI: 10.1016/0030-4220(94)90312-3] [Citation(s) in RCA: 102] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Cell/cell and cell/matrix adhesion proteins are responsible for maintaining the integrity of the mucosal lining of the oral cavity. Disease processes that destroy keratinocytes or adversely affect their adhesion to one another or to the subjacent basement membrane will result in erosions, ulcerations, and desquamations. Immunologic processes that have a deleterious effect on the integrity of the epithelial/basement membrane/submucosa complex are reviewed, and current research findings with respect to pathogenesis are discussed. In particular, T-cell-mediated hypersensitivity is involved in recurrent aphthous stomatitis and lichen planus; humoral-mediated immunity to cadherin intercellular adhesion molecules is important in the process of acantholysis in pemphigus vulgaris, and genetic defects and antibody-mediated processes give rise to junctional separation in epidermolysis bullosa and mucous membrane pemphigoid, respectively. An immune complex mechanism appears to underlie the pathogenesis of erythema multiforme.
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Affiliation(s)
- L R Eversole
- Section of Diagnostic Sciences, UCLA School of Dentistry
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