Hydroa Vacciniforme and Hydroa Vacciniforme-Like Lymphoproliferative Disorder: A Spectrum of Disease Phenotypes Associated with Ultraviolet Irradiation and Chronic Epstein-Barr Virus Infection

A Fatal Case of Severe Leg Edema and Necrotic Ulcers in a 14-Year-Old Boy

A 14-year-old boy presented with edema, ulcers, tenderness, and progressive functional limitation of both legs, first diagnosed as Henoch-Schonlein vasculitis. Then, he underwent one inguinal lymph node excision and two skin biopsies which reported an angiocentric lymphoproliferative process, EBER (Epstein-Barr virus-encoded small RNA) positive, consistent with hydroa vacciniforme-like lymphoproliferative disorder (HVLPD); after eight weeks, his face presented with edema and ulcers, characteristic of the original patients described with HVLPD. The patient's parents refused treatment and took him back home, and he died a few months later. Our case study highlights an atypical localization of the disease, as it initially presented in the lower extremities rather than the face, posing a diagnostic challenge that was ultimately resolved through biopsy.

Epstein-Barr virus-related lymphoproliferative disorders of the skin

Epstein Barr Virus (EBV) is associated both solid (nasopharyngeal carcinoma, non-nasopharyngeal lymphoepithelioma-like carcinoma, gastric carcinoma, leiomyosarcoma) and hematolymphoid malignancies, some of the latter, however, spanning over a spectrum ranging from reactive and self-limiting to severe and life-threatening conditions. This review will focus on the disorder most commonly involving the skin, namely: EBV-positive mucocutaneous ulcer; lymphomatoid granulomatosis; EBV-positive diffuse large B cell lymphoma; plasmablastic lymphoma; post-transplant lymphoproliferative disorder; extranodal NK/T cell lymphoma, nasal type; angoimmunoblastic T cell lymphoma; severe mosquito bite allergy; hydroa vacciniformelike lymphoproliferative disorder. Given the uncommon occurrence of all these infiltrates in the skin, multidisciplinary approach, as well as referral to tertiary care centers are always advisable.

An update on viral-induced cutaneous lymphoproliferative disorders. CME Part I

Viral-induced cutaneous T-cell lymphomas are an uncommon group of lymphoproliferative disorders characterized by a viral infection of T and natural killer (NK) cells. This group of cutaneous T-cell lymphomas is more commonly encountered in Asians and Native Americans from Central and South America compared with Western populations. Viral-associated lymphoproliferative disorders include a spectrum of entities that range from nonneoplastic lesions, such as chronic active Epstein-Barr virus infection and infective dermatitis to malignant diseases, such as extranodal NK/T-cell lymphoma, hydroa vacciniforme-like T-cell lymphoma, and adult T-cell leukemia/lymphoma. This review article will focus on hydroa vacciniforme-like lymphoproliferative disorder, extranodal NK/T-cell lymphoma, adult T-cell leukemia/lymphoma, lymphomatoid granulomatosis, and Epstein-Barr virus-positive mucocutaneous ulcers. We will review the pathogenesis of these conditions and the challenges of making a timely diagnosis in early-stage disease and discuss the common clinicopathologic manifestations, mutational landscape, and approaches to treat these highly aggressive and frequently lethal types of lymphoma.

Clinical and Pathological Features of Hydroa Vacciniforme-Like Lymphoproliferative Disorder Along with Risk Factors Indicating Poor Prognosis

Purpose

To examine the clinical and pathological features, laboratory markers, therapeutic options and risk factors indicating poor prognosis of hydroa vacciniforme-like lymphoproliferative disorder (HVLPD).

Patients and Methods

Seven patients with HVLPD had their clinical and pathological data collected. Immunohistochemical staining, Epstein-Barr virus-encoded RNA (EBER) in situ hybridization experiments, T-cell receptor (TCR) gene rearrangement, RT-PCR tests and the Elisa assay were carried out.

Results

The main clinical manifestations were papulovesicular lesions and ulcers on the face, neck, or trunk. Five cases had systemic symptoms. Three of the deceased patients had significant facial edema, deep body necrosis, and ulceration. The pathological results demonstrated that lymphocytes infiltrated blood vessels and sweat glands in addition to the dermis and subcutaneous tissues. All patients tested positive for CD3 and EBER. Six cases tested positive for TCRβF1, but none tested positive for TCRδ. TCRγ monoclonal rearrangement, strongly positive expression of TIA-1 and a Ki67 proliferation index of 40% occurred in 3 fatal cases. When compared to the survival group, the plasma EBV DNA in the deceased group was considerably higher (P<0.05). IFN-γ and TNF-α cytokine levels in patients were higher than in the control group, particularly in the deceased group (P<0.05). The skin lesions on all patients recovered quickly underwent conservative care. Nonetheless, 3 patients passed away as the disease progressed in its latter stages.

Conclusion

In our cases, the main infiltrating cells were T cells and the dominant lymphocyte subclass was αβT cells. A significant increase in lgE level, plasma EBV DNA, IFN-γ, and TNF-α cytokine levels, decreased hemoglobin level, strongly positive expression of TIA-1, high Ki67 proliferation index, and positive TCR gene rearrangement are all indicators of a poor prognosis.

Case report: Cellular therapy for hydroa vacciniforme-like lymphoproliferative disorder in pediatric common variable immunodeficiency with chronic active Epstein-Barr virus infection

Hydroa vacciniforme-like lymphoproliferative disorder (HV-LPD) is a cutaneous form of chronic active Epstein-Barrvirus (EBV) infection, which can develop into the extremely rare systemic lymphoma. Patients with Inborn errors of immunity (IEI), such as common variable immunodeficiency (CVID), are at higher risk of developing a severe course of infections especially viral and malignancies than the general population. The aim of the study was to present complex diagnostic and therapeutic management of HV-LPD. The clinical diagnosis was confirmed at the histological and molecular level with next generation sequencing. HV-LPD was diagnosed in a patient with CVID and chronic active Epstein–Barr virus (CAEBV) infection. The patient was refractory to CHOP chemotherapy and immunosuppressive treatment in combination with antiviral drugs (prednisone, bortezomib, gancyclovir). The third-party donor EBV-specific cytotoxic T cells (EBV-CTL, tabelecleucel) were used, which stabilised the disease course. Finally, matched unrelated donor hematopoietic cell transplantation (MUD-HCT) was performed followed by another cycle of EBV-CTL.

Hydroa vacciniforme-like lymphoproliferative disorder: A retrospective study on clinicopathological characteristics of 32 cases

The clinicopathological features of 32 patients (17 females and 15 males) with a median age of 8 years (range, 1.5-21 years) from Southwestern China diagnosed with hydroa vacciniforme-like lymphoproliferative disorder (HVLPD) were reviewed. At presentation, 6 patients showed only skin lesions, while 26 patients showed both skin lesions and systemic symptoms, including fever, lymphadenopathy and hepatosplenomegaly. As the disease progressed, systemic symptoms occurred in all patients. Follow-up data of 29 patients showed that 14 patients were still alive with disease with a median follow-up time of 22 months (range 3.6-71 months), and 15 patients died within a median follow-up of 6 months (range 0-60 months).

Hydroa vacciniforme-like lymphoproliferative disorder with eye involvement

Hydroa vacciniforme-like lymphoproliferative disorder (HVLPD) is characterized by vesiculopapular eruptions on sun-exposed and sometimes unexposed skin. Though ocular involvement in HVLPD is rare, it may present with conjunctivitis, corneal opacities, uveitis, and interstitial keratitis. We report a case of a 7-year-old boy with HVLPD, whose ophthalmic symptoms were neglected for over 2 years, who developed anterior uveitis and corneal nebulae without vision impairment. Awareness of eye involvement in patients with HVLPD may help to prevent severe complications.

Correlations Between Intestinal Microbial Community and Hematological Profile in Native Tibetans and Han Immigrants

Hematological features are one of the best-known aspects of high-altitude adaptation in Tibetans. However, it is still unclear whether the intestinal microbiota is associated with the hematology profile. In this study, routine blood tests and 16S rRNA gene sequencing were used to investigate the differences in the intestinal microbiota and hematological parameters of native Tibetan herders and Han immigrants sampled at 3,900 m. The blood test results suggested that the platelet counts (PLTs) were significantly higher in native Tibetans than the Han immigrants. The feces of the native Tibetans had significantly greater microbial diversity (more different species: Simpson’s and Shannon’s indices) than that of the Han immigrants. The native Tibetans also had a different fecal microbial community structure than the Han immigrants. A Bray–Curtis distance-based redundancy analysis and envfit function test showed that body mass index (BMI) and PLT were significant explanatory variables that correlated with the fecal microbial community structure in native Tibetans. Spearman’s correlation analysis showed that Megamonas correlated positively with BMI, whereas Bifidobacterium correlated negatively with BMI. Alistipes and Parabacteroides correlated positively with the PLT. Succinivibrio correlated positively with SpO₂. Intestinibacter correlated negatively with the red blood cell count, hemoglobin, and hematocrit (HCT). Romboutsia correlated negatively with HCT, whereas Phascolarctobacterium correlated positively with HCT. A functional analysis showed that the functional capacity of the gut microbial community in the native Tibetans was significantly related to carbohydrate metabolism. These findings suggest that the hematological profile is associated with the fecal microbial community, which may influence the high-altitude adaptation/acclimatization of Tibetans.