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Difficulty in the treatment of patients with recurrent genital herpes and its clinical repercussion
P6685
P6826
Cutaneous parvovirus B19 infection associated with bowel disease Marta Gonzalez-Sabın, MD, Complejo Hospitalario Universitario A Coru~ na, A Coru~ na, Spain; Ana De-Andres-Del-Rosario, MD, Complejo Hospitalario Universitario A Coru~ na, A Coru~ na, Spain; Carlos Garcıa-Martın, PhD, Complejo Hospitalario Universitario a Coru~ na, A Coru~ na, Spain; Laura Rosende-Maceiras, MD, Complejo Hospitalario Universitario A Coru~ na, A Coru~ na, Spain; Manuel Almagro-Sanchez, PhD, Complejo Hospitalario Universitario A Coru~ na, A Coru~ na, Spain; Raquel Iglesias-Conde, MD, Complejo Hospitalario Universitario A Coru~ na, A Coru~ na, Spain; Victoria Nespereira-Jato, MD, Complejo Hospitalario Universitario A Coru~ na, A Coru~ na, Spain
Etiology of ‘‘recurrent herpes zoster’’: A site-specific cohort Hung Doan, PhD, School of Medicine, The University of Texas Medical Branch at Galveston, Galveston, TX, United States; Farhan Khan, MD, MBA, Center for Clinical Studies, Houston, TX, United States; Marigdalia Ramirez-Fort, MD, Center for Clinical Studies, Houston, TX, United States; Rachel Gordon, MD, Center for Clinical Studies, Houston, TX, United States; Stephen Tyring, MD, PhD, Center for Clinical Studies, Houston, TX, United States
Background: Parvovirus B19 infection, is responsible for multiple clinical manifestations, the most common being: general syndrome, skin lesions, sore throat, arthralgia and arthritis. We report a case with an extremely rare abdominal manifestation. Methods: We report a 21-year-old man who was admitted in dermatology for evaluation of arthralgias and skin lesions. Two weeks before, he started with general malaise and odynophagia, followed by pruritus, myalgia and sensation of fever. In addition, 48 hours before admission, an exanthema appeared on the lower half of the legs, arms and pelvis, as well as swelling of the ankles. 36 hours after hospital admission, he started with the acute onset of right iliac fossa pain, so we requested an urgent abdominal ultrasound that was consistent with ileitis. Furthermore the diagnosis was confirmed with a CT scan and a colonoscopy. An intestinal biopsy revealed reactive follicular hyperplasia. Laboratory studies demonstrated positivity for IgM and IgG against parvovirus B19, with negative IgM at 2 months. The clinical manifestations were resolved in a few days with supportive therapy and the patient remained asymptomatic after 1 year of follow-up. Discussion: Infection by human parvovirus B19 is widespread and can be associated with a wide range of different pathologies and clinical manifestations. Cases of HenocheSch€ onlein syndrome, hepatitis or hepatic dysfunction in adults and bowel infarction associated with human parvovirus B19 primary infection have been described. Pironi et al reported the first evidence of localization of an active parvovirus B19 infection in the intestinal mucosa and its association with a severe inflammatory bowel disease, characterized by duodenal villous atrophy with increased intraepithelial lymphocytes and inflammatory infiltrates in the colonic mucosa. Conclusion: To our knowledge, this is the second reported case of inflammatory bowel disease accompanying the usual manifestations of parvovirus B19 infection and the first reported case of cutaneous parvovirus B19 infection associated with bowel disease. Commercial support: None identified.
P6904
Background: Recurrent herpes zoster (HZ) is thought to be a rare occurrence in the immunocompetent host, with an estimated lifetime prevalence between 1% and 5%. One study recently documented that recurrent HZ occurs with a prevalence of 5.2% in immunocompetent patients with a mean follow-up of 8 years; these findings challenge the prevailing thought that HZ and recurrent HZ is a disease of the immunocompromised. Female gender has been documented as an independent risk factor for HZ; we have noticed this trend in our 30 years of experience with patients presenting with suspected recurrence of HZ. Objective: To estimate the recurrence rate of HZ in our institute from September 21, 2009 to July 6, 2012. Our secondary aim is to determine the gender-specific recurrence rate of HZ. Methods: We performed a retrospective analysis of 25 medical records from immunocompetent patients who self-reported recurrent HZ, or who were referred to our clinic with suspected recurrent HZ between September 21, 2009 and July 6, 2012. If vesicles were clinically evident, cultures or biopsies were obtained for analysis as definitive evidence. If no active lesions were present, HSV serology was performed for presumptive evidence. Results: A total of 25 patients were evaluated; age ranged from 29 to 83 years of age. A female predominance was noted in our cohort (80%, 20/25). Of the 25 patients, 12 (52%) were clinically ruled out as recurrent HZ with other diagnoses including seborrheic dermatitis (8.3%, 1/12), clinical herpes simplex (16.7%, 2/12), post herpetic neuralgia (41.7%, 5/12), or other. Of the remaining 13 cases of suspected recurrent HZ, serologies, biopsies, or cultures were analyzed for herpes simplex virus 1 (HSV1), HSV2, or varicella zoster virus (VZV). Of the 13 laboratory analyzed cases, 7 (54%) were verified as HSV1 infections and 6 (46%) were verified as HSV2 infections. One case (7.7%) was negative for all three viral entities. None were identified as VZV positive. Conclusion: Our results suggest recurrent HZ as a rare occurrence in the immunocompetent host. No patients were identified with true recurrent HZ. The most common diagnosis was active HSV1 or HSV2 infection. We recommend confirmatory laboratory testing for presentations of recurrent HZ to optimize diagnostic certainty. The majority of patients presenting to our clinic with suspected recurrence HZ were female. A larger cohort will be necessary to evaluate the genderspecific recurrence rate of HZ and to estimate the odds ratio. Commercial support: None identified.
Difficulty in the treatment of patients with recurrent genital herpes and its clinical repercussion Fred Bernardes Filho, MD, Instituto de Dermatologia Prof. Rubem David Azulay da Santa Casa da Miseric ordia do Rio de Janeiro (IDPRDA/SCMRJ), Rio de Janeiro, Brazil; Carla Val eria Rocha Ramos, Instituto de Dermatologia Prof. Rubem David Azulay da Santa Casa da Miseric ordia do Rio de Janeiro (IDPRDA/SCMRJ), Rio de Janeiro, Brazil; Gisele Reis Cunha Silva, Instituto de Dermatologia Prof. Rubem David Azulay da Santa Casa da Miseric ordia do Rio de Janeiro (IDPRDA/SCMRJ), Rio de Janeiro, Brazil; Lorena Branco de Azevedo Cariello, Instituto de Dermatologia Prof. Rubem David Azulay da Santa Casa da Miseric ordia do Rio de Janeiro (IDPRDA/SCMRJ), Rio de Janeiro, Brazil; Olga Milena Zarco Suarez, MD, Instituto de Dermatologia Prof. Rubem David Azulay da Santa Casa da Miseric ordia do Rio de Janeiro (IDPRDA/SCMRJ), Rio de Janeiro, Brazil; Thaıs de Barros Castro Alves, Instituto de Dermatologia Prof. Rubem David Azulay da Santa Casa da Miseric ordia do Rio de Janeiro (IDPRDA/SCMRJ), Rio de Janeiro, Brazil; Ver^ onica Vilas-B^ oas Ferrari, Instituto de Dermatologia Prof. Rubem David Azulay da Santa Casa da Miseric ordia do Rio de Janeiro (IDPRDA/SCMRJ), Rio de Janeiro, Brazil Background: Genital herpes is an infectocontagious disease, subject to relapses, caused by different types of HSV, HSV-1 and HSV-2, being the majority caused by HSV-2. HSV determines manifestations of variable intensity depending on the host’s immunologic system. Its clinical manifestation could be primary or recurrent, the last one happening through viral reactivation, via the migration of the virus by periferic nerves to the skin or mucosae. The diagnosis is made by clinical assessment associated to lab confirmation. Despite the fact that there’s no treatment leading to cure, some antiviral drugs are capable of reducing the duration of the disease and prevent lesions, and in specific cases prophylactic treatment with chronic suppression is recommended. Nowadays, great efforts aim to fight genital herpes infection with the development of vaccines. Case report: A 38-year-old man from Paraıba - Brazil, arrived in outpatient facility in 2008 with a group of painful vesicular lesions with an erythematous base that ulcerated in the penis area 6 months earlier, with no other complaints associated. The patient denied having a steady partner and claimed having promiscuous behavior. Negative results for sexually transmitted diseases. He was treated with antiviral drugs for genital herpes. In 2012, the patient returns with the same complaints, although with intermittent episodes. A treatment with acyclovir 400 mg/day was indicated and he was requested to test the vaccine against HSV in an attempt to reduce the severity of the symptoms.
P7112 Gloves and socks syndrome caused by parvovirus B19 infection Susana Vilac¸a, MD, Centro Hospitalar do Porto, Porto, Portugal; Aristoteles Rosmaninho, MD, Centro Hospitalar do Porto, Porto, Portugal; Madalena Sanches, MD, Centro Hospitalar do Porto, Porto, Portugal; Manuela Selores, MD, Centro Hospitalar do Porto, Porto, Portugal
Discussion: There are few studies about the best strategy to be adopted, so we conclude that the individualization of the treatment is essential. The doctorepatient dialogue should be clear about different therapeutic measures, and that the patient’s opinion is crucial for a better prognosis. It is expected that the physician be prepared to attend the patients’ perspectives, as well as psychosocial aspects and the emotional feelings that might appear when the patient is aware of the infection.
The papular purpuric gloves and socks syndrome (PPGSS) is an uncommon dermatosis described for the first time by Harms et al in 1990. It is characterized by the presence of pruritus, edema and symmetric erythema, well defined at the wrists and ankles with a gloves-and-socks distribution. We described a case of a 64year-old man seen in our department with symmetric erythema and edema of the hands and feet, with gradual progression to petechiae and purpura with a sharp demarcation located exclusively on the wrists and ankles. Edema, itching, and pain were also present. This eruption was preceded by fever, anorexia, and asthenia. Diagnosis of this syndrome was made by the clinical dermatologic characteristics and confirmed by specific serology for parvovirus B19. Neither oral lesions nor lymphadenopathies were present. Serology for, hepatitis B and C, EpsteineBarr virus, HIV, cytomegalovirus, and herpes simplex virus were negative. The eruption resolves spontaneously in 2 weeks and does not result in residual scarring. PPGSS is a rare, but clearly defined clinical entity with distinctive characteristics which permit its rapid recognition and diagnosis. The syndrome is generally self-limited, as in our case, but some patients may occasionally need hospitalization for supportive therapy. Diverse acral dermatitis and disorders associated with acral petechiae have to be considered in the differential diagnosis, such as GianottieCrosti syndrome, atypical measles, rickettsial diseases, Kawasaki disease and meningococcemia.
Commercial support: None identified.
Commercial support: None identified.
APRIL 2013
J AM ACAD DERMATOL
AB133
P6826
Cutaneous parvovirus B19 infection associated with bowel disease Marta Gonzalez-Sabın, MD, Complejo Hospitalario Universitario A Coru~ na, A Coru~ na, Spain; Ana De-Andres-Del-Rosario, MD, Complejo Hospitalario Universitario A Coru~ na, A Coru~ na, Spain; Carlos Garcıa-Martın, PhD, Complejo Hospitalario Universitario a Coru~ na, A Coru~ na, Spain; Laura Rosende-Maceiras, MD, Complejo Hospitalario Universitario A Coru~ na, A Coru~ na, Spain; Manuel Almagro-Sanchez, PhD, Complejo Hospitalario Universitario A Coru~ na, A Coru~ na, Spain; Raquel Iglesias-Conde, MD, Complejo Hospitalario Universitario A Coru~ na, A Coru~ na, Spain; Victoria Nespereira-Jato, MD, Complejo Hospitalario Universitario A Coru~ na, A Coru~ na, Spain
Etiology of ‘‘recurrent herpes zoster’’: A site-specific cohort Hung Doan, PhD, School of Medicine, The University of Texas Medical Branch at Galveston, Galveston, TX, United States; Farhan Khan, MD, MBA, Center for Clinical Studies, Houston, TX, United States; Marigdalia Ramirez-Fort, MD, Center for Clinical Studies, Houston, TX, United States; Rachel Gordon, MD, Center for Clinical Studies, Houston, TX, United States; Stephen Tyring, MD, PhD, Center for Clinical Studies, Houston, TX, United States
Background: Parvovirus B19 infection, is responsible for multiple clinical manifestations, the most common being: general syndrome, skin lesions, sore throat, arthralgia and arthritis. We report a case with an extremely rare abdominal manifestation. Methods: We report a 21-year-old man who was admitted in dermatology for evaluation of arthralgias and skin lesions. Two weeks before, he started with general malaise and odynophagia, followed by pruritus, myalgia and sensation of fever. In addition, 48 hours before admission, an exanthema appeared on the lower half of the legs, arms and pelvis, as well as swelling of the ankles. 36 hours after hospital admission, he started with the acute onset of right iliac fossa pain, so we requested an urgent abdominal ultrasound that was consistent with ileitis. Furthermore the diagnosis was confirmed with a CT scan and a colonoscopy. An intestinal biopsy revealed reactive follicular hyperplasia. Laboratory studies demonstrated positivity for IgM and IgG against parvovirus B19, with negative IgM at 2 months. The clinical manifestations were resolved in a few days with supportive therapy and the patient remained asymptomatic after 1 year of follow-up. Discussion: Infection by human parvovirus B19 is widespread and can be associated with a wide range of different pathologies and clinical manifestations. Cases of HenocheSch€ onlein syndrome, hepatitis or hepatic dysfunction in adults and bowel infarction associated with human parvovirus B19 primary infection have been described. Pironi et al reported the first evidence of localization of an active parvovirus B19 infection in the intestinal mucosa and its association with a severe inflammatory bowel disease, characterized by duodenal villous atrophy with increased intraepithelial lymphocytes and inflammatory infiltrates in the colonic mucosa. Conclusion: To our knowledge, this is the second reported case of inflammatory bowel disease accompanying the usual manifestations of parvovirus B19 infection and the first reported case of cutaneous parvovirus B19 infection associated with bowel disease. Commercial support: None identified.
P6904
Background: Recurrent herpes zoster (HZ) is thought to be a rare occurrence in the immunocompetent host, with an estimated lifetime prevalence between 1% and 5%. One study recently documented that recurrent HZ occurs with a prevalence of 5.2% in immunocompetent patients with a mean follow-up of 8 years; these findings challenge the prevailing thought that HZ and recurrent HZ is a disease of the immunocompromised. Female gender has been documented as an independent risk factor for HZ; we have noticed this trend in our 30 years of experience with patients presenting with suspected recurrence of HZ. Objective: To estimate the recurrence rate of HZ in our institute from September 21, 2009 to July 6, 2012. Our secondary aim is to determine the gender-specific recurrence rate of HZ. Methods: We performed a retrospective analysis of 25 medical records from immunocompetent patients who self-reported recurrent HZ, or who were referred to our clinic with suspected recurrent HZ between September 21, 2009 and July 6, 2012. If vesicles were clinically evident, cultures or biopsies were obtained for analysis as definitive evidence. If no active lesions were present, HSV serology was performed for presumptive evidence. Results: A total of 25 patients were evaluated; age ranged from 29 to 83 years of age. A female predominance was noted in our cohort (80%, 20/25). Of the 25 patients, 12 (52%) were clinically ruled out as recurrent HZ with other diagnoses including seborrheic dermatitis (8.3%, 1/12), clinical herpes simplex (16.7%, 2/12), post herpetic neuralgia (41.7%, 5/12), or other. Of the remaining 13 cases of suspected recurrent HZ, serologies, biopsies, or cultures were analyzed for herpes simplex virus 1 (HSV1), HSV2, or varicella zoster virus (VZV). Of the 13 laboratory analyzed cases, 7 (54%) were verified as HSV1 infections and 6 (46%) were verified as HSV2 infections. One case (7.7%) was negative for all three viral entities. None were identified as VZV positive. Conclusion: Our results suggest recurrent HZ as a rare occurrence in the immunocompetent host. No patients were identified with true recurrent HZ. The most common diagnosis was active HSV1 or HSV2 infection. We recommend confirmatory laboratory testing for presentations of recurrent HZ to optimize diagnostic certainty. The majority of patients presenting to our clinic with suspected recurrence HZ were female. A larger cohort will be necessary to evaluate the genderspecific recurrence rate of HZ and to estimate the odds ratio. Commercial support: None identified.
Difficulty in the treatment of patients with recurrent genital herpes and its clinical repercussion Fred Bernardes Filho, MD, Instituto de Dermatologia Prof. Rubem David Azulay da Santa Casa da Miseric ordia do Rio de Janeiro (IDPRDA/SCMRJ), Rio de Janeiro, Brazil; Carla Val eria Rocha Ramos, Instituto de Dermatologia Prof. Rubem David Azulay da Santa Casa da Miseric ordia do Rio de Janeiro (IDPRDA/SCMRJ), Rio de Janeiro, Brazil; Gisele Reis Cunha Silva, Instituto de Dermatologia Prof. Rubem David Azulay da Santa Casa da Miseric ordia do Rio de Janeiro (IDPRDA/SCMRJ), Rio de Janeiro, Brazil; Lorena Branco de Azevedo Cariello, Instituto de Dermatologia Prof. Rubem David Azulay da Santa Casa da Miseric ordia do Rio de Janeiro (IDPRDA/SCMRJ), Rio de Janeiro, Brazil; Olga Milena Zarco Suarez, MD, Instituto de Dermatologia Prof. Rubem David Azulay da Santa Casa da Miseric ordia do Rio de Janeiro (IDPRDA/SCMRJ), Rio de Janeiro, Brazil; Thaıs de Barros Castro Alves, Instituto de Dermatologia Prof. Rubem David Azulay da Santa Casa da Miseric ordia do Rio de Janeiro (IDPRDA/SCMRJ), Rio de Janeiro, Brazil; Ver^ onica Vilas-B^ oas Ferrari, Instituto de Dermatologia Prof. Rubem David Azulay da Santa Casa da Miseric ordia do Rio de Janeiro (IDPRDA/SCMRJ), Rio de Janeiro, Brazil Background: Genital herpes is an infectocontagious disease, subject to relapses, caused by different types of HSV, HSV-1 and HSV-2, being the majority caused by HSV-2. HSV determines manifestations of variable intensity depending on the host’s immunologic system. Its clinical manifestation could be primary or recurrent, the last one happening through viral reactivation, via the migration of the virus by periferic nerves to the skin or mucosae. The diagnosis is made by clinical assessment associated to lab confirmation. Despite the fact that there’s no treatment leading to cure, some antiviral drugs are capable of reducing the duration of the disease and prevent lesions, and in specific cases prophylactic treatment with chronic suppression is recommended. Nowadays, great efforts aim to fight genital herpes infection with the development of vaccines. Case report: A 38-year-old man from Paraıba - Brazil, arrived in outpatient facility in 2008 with a group of painful vesicular lesions with an erythematous base that ulcerated in the penis area 6 months earlier, with no other complaints associated. The patient denied having a steady partner and claimed having promiscuous behavior. Negative results for sexually transmitted diseases. He was treated with antiviral drugs for genital herpes. In 2012, the patient returns with the same complaints, although with intermittent episodes. A treatment with acyclovir 400 mg/day was indicated and he was requested to test the vaccine against HSV in an attempt to reduce the severity of the symptoms.
P7112 Gloves and socks syndrome caused by parvovirus B19 infection Susana Vilac¸a, MD, Centro Hospitalar do Porto, Porto, Portugal; Aristoteles Rosmaninho, MD, Centro Hospitalar do Porto, Porto, Portugal; Madalena Sanches, MD, Centro Hospitalar do Porto, Porto, Portugal; Manuela Selores, MD, Centro Hospitalar do Porto, Porto, Portugal
Discussion: There are few studies about the best strategy to be adopted, so we conclude that the individualization of the treatment is essential. The doctorepatient dialogue should be clear about different therapeutic measures, and that the patient’s opinion is crucial for a better prognosis. It is expected that the physician be prepared to attend the patients’ perspectives, as well as psychosocial aspects and the emotional feelings that might appear when the patient is aware of the infection.
The papular purpuric gloves and socks syndrome (PPGSS) is an uncommon dermatosis described for the first time by Harms et al in 1990. It is characterized by the presence of pruritus, edema and symmetric erythema, well defined at the wrists and ankles with a gloves-and-socks distribution. We described a case of a 64year-old man seen in our department with symmetric erythema and edema of the hands and feet, with gradual progression to petechiae and purpura with a sharp demarcation located exclusively on the wrists and ankles. Edema, itching, and pain were also present. This eruption was preceded by fever, anorexia, and asthenia. Diagnosis of this syndrome was made by the clinical dermatologic characteristics and confirmed by specific serology for parvovirus B19. Neither oral lesions nor lymphadenopathies were present. Serology for, hepatitis B and C, EpsteineBarr virus, HIV, cytomegalovirus, and herpes simplex virus were negative. The eruption resolves spontaneously in 2 weeks and does not result in residual scarring. PPGSS is a rare, but clearly defined clinical entity with distinctive characteristics which permit its rapid recognition and diagnosis. The syndrome is generally self-limited, as in our case, but some patients may occasionally need hospitalization for supportive therapy. Diverse acral dermatitis and disorders associated with acral petechiae have to be considered in the differential diagnosis, such as GianottieCrosti syndrome, atypical measles, rickettsial diseases, Kawasaki disease and meningococcemia.
Commercial support: None identified.
Commercial support: None identified.
APRIL 2013
J AM ACAD DERMATOL
AB133