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Vesiculobullous Chikungunya fever with a severe and atypical clinical course
P2506
P2508
Atypical clinical manifestation of acyclovir-resistant HSV in an AIDS patient: Case report and review of the literature Denise Woo, MD, Henry Ford Hospital, Detroit, MI, United States; Margaret Douglass, MD, Henry Ford Hospital, Detroit, MI, United States
Varicella zoster myelitis Maulina Sharma, MD, MBBS, Department of Dermatology, Queen’s Medical Centre, Nottingham, Nottinghamshire, United Kingdom; Catherine Roberts, MD, MBBS, Department of Dermatology, Queen’s Medical Centre, Nottingham, Nottinghamshire, United Kingdom; Jan Bong, MD, MBBS, Department of Dermatology, Queen’s Medical Centre, Nottingham, Nottinghamshire, United Kingdom
Background: In immunocompromised patients, HSV frequently presents with atypical clinical morphology. Case report: We report the case of a 45-year-old man with AIDS, a CD4 count of 129/uL, on HAART therapy who presented with a 2-month history of an asymptomatic lesion on his lower lip. Of note, the patient also had a long history of marijuana smoking. The physical examination revealed an approximately 4- 3 3-cm exophytic white stuck-on soft plaque with a smooth surface, located on the lower lip extending from the oral mucosa to the vermilion border and lateral commissures. A shave biopsy specimen revealed herpes cytopathic changes, and a viral culture grew herpes simplex. The lesion did not respond to several courses of oral acyclovir, including an increased dose of 800mg five times daily for 14 days. The patient is currently undergoing treatment with topical trifluridine three times daily. Conclusions: Atypical HSV presentations often occur in HIV patients, especially in advanced disease. These include hyperkeratotic verrucous lesions, exophytic plaques, and nodular lesions, which may appear in nontraditional locations, such as the tongue and endobronchial tube. This case serves as a reminder that HSV should be considered in the differential diagnosis of chronic exophytic plaques in HIV positive patients, and that atypical presentations of HSV infection should prompt screening for underlying associated immunodeficiency. The location on the lower lip has not been reported previously, and suggests a possible contributory role of local burn injury in the pathogenesis given our patient’s history of marijuana smoking. Of note, the majority of these atypical cases are resistant to acyclovir as in our patient, but may respond to higher-bioavailability valacyclovir, topical trifluridine, topical imiquimod, and both topical or intravenous cidofovir or foscarnet. Commercial support: None identified.
Varicella zoster can have significant neurologic complications. We present a case of varicella zoster myelitis. A 66-year-old man presented to the accident and emergency department with rapid onset of spreading saddle anesthesia, difficulty passing urine, constipation, and difficulty walking. He had a 1-week history of prodromal symptoms of headache, bodyache, and tiredness. He had noticed an asymptomatic rash over his buttock 2 weeks before these symptoms. Examination revealed a sensory deficit at S2-S4 sacral levels with decreased anal tone. Examination of skin revealed a cluster of papular eruption on right buttock with central necrosis. A diagnosis of zoster associated with polyradiculopathy was made. Viral skin swab was positive for varicella zoster. PCR of cerebrospinal fluid was also positive for varicella zoster. MRI of the spine showed subtle signal change and enhancement in the cord, conus and cauda equine. Other infectious causes and vasculitis were excluded. Neurology, dermatology, and microbiology teams were involved in his joint care. The patient made a remarkable recovery on IV acyclovir 10mg/kg three times daily for 2 weeks. Varicella zoster virus (VZV) is a double-stranded DNA in a single molecule. Primary infection causes chicken pox (varicella). Following this, it establishes latency and can subsequently reactivate to cause herpes zoster. Central nervous system (CNS) complications can follow both primary infection and reactivation of VZV. The more serious manifestations arise when the virus invades the spinal cord or cerebral arteries after reactivation of the virus, causing diseases such as myelitis and focal vasculopathy. Many of the recently reported cases have been associated with a diagnosis of HIV, and this should always be considered in this context. Although herpes zoster myelitis generally carries a good prognosis, early diagnosis is important, as aggressive antiviral treatment can be effective in preventing complications. Commercial support: None identified.
P2509
P2507
Flavokine, a novel topical antiviral for use against molluscum contagiosum in children and adults Arnold R. Oppenheim, MD, Virginia Beach Dermatology, Virginia Beach, VA, United States; Abigail Pekoe, Dalos BioPharma, Virginia Beach, VA, United States; Amanda K. Houck-Miller, MS, Dalos BioPharma, Virginia Beach, VA, United States; Gary Pekoe, PhD, Dalos BioPharma, Virginia Beach, VA, United States; M. Kirby Query, MS, Dalos BioPharma, Virginia Beach, VA, United States
Vesiculobullous Chikungunya fever with a severe and atypical clinical course Hazel H. Oon, MD, National Skin Centre, Singapore; Mark B. Y. Tang, MBBS, National Skin Centre, Singapore; Shiu Ming Pang, MBBS, Singapore General Hospital, Singapore; T. Thirumoorthy, MBBS, Singapore General Hospital, Singapore
Flavokine (Dalos BioPharma) is a novel complex botanical entity containing more than 270 flavonoids and other components. Different fractions of flavokine have been associated with antiviral, antibacterial, antitumor, antiinflammatory, and enhanced wound healing activity. Mechanisms of action include direct activity against viruses and bacteria including MRSA, as well as stimulation of factors and cells within the skin through a variety of biologic pathways.
Chikungunya is an alfavirus transmitted by the Aedes mosquito. Severe atypical cases, defined as requiring the maintenance of at least one vital function or demise during the course of the disease, are now increasingly recognized since the 2005/2006 outbreak in Reunion. Vesiculobullous Chikungunya is rarely described in adults and is associated with a poor clinical prognosis. We report a case of severe Chikungunya in an adult with an extensive blistering dermatosis who progressed to develop septic shock, rhabdomyolysis, and Guillain-Barre´ syndrome. Initial laboratory investigations revealed mild leukocytosis, a low normal platelet count of 143000/L (normal range, 140-440 3 109/L), markedly elevated creatinine kinase, and creatinine. Histologic examination revealed a subepidermal blister with a few mononuclear cells and some fibrin strands. Direct immunofluorescence of perilesional skin was negative. The serum Chikungunya reverse transcription real-time polymerase chain reaction (RT-PCR) serology for Chikungunya IgG and IgM were positive; dengue PCR was negative. Blister fluid and paraffin block section of the blister for chikungunya RT-PCR were positive. While little is known about vesiculobullous Chikungunya, this entity may herald a more severe clinical course of illness and mortality. Our patient featured an array of rare manifestations of Chikungunya, including blistering dermatoses, rhabdomyolysis, acute renal failure, hypotension, autonomic neuropathy of the bladder, and Guillain-Barre´ syndrome. Clinicians should have a high index of suspicion for this entity in epidemic, endemic areas and in the returning traveler.
Molluscum contagiosum (MC) is a common infection worldwide, accounting for about 1% of all diagnosed skin disorders in the US. Children, most commonly under 5 years old, become infected through direct skin-to-skin contact or by touching MCcontaminated objects. In adults, MC can be a sexually transmitted disease. It is estimated that 5% of children and up to 20% of AIDS patients have MC. In healthy children and adults, the MC rash will eventually clear, but it can last 18 months or longer, and is bothersome for parents and children because of its appearance and contagiousness. MC causes a characteristic lesion/rash with one or more round, dome-shaped pink, waxy papules, with a small central indentation. They are usually 2.5 mm in diameter but can be as large as 1cm in diameter. Current treatments for MC include curettage, cautery, cryotherapy, or blistering agents. Eighty-two patients aged 18 months to 62 years who had used flavokine twice daily for MC were evaluated for their response to the agent. The mean time of application was 6 weeks. Thirty-seven patients (45%) had complete clearing of their lesions. Twenty-four patients (30%) experienced partial clearing of their lesions. Twenty-one patients (25%) had no clearing of their lesions. Two patients reported mild skin irritation that may or may not have been related to flavokine. A partial or complete response rate of 75% of MC to flavokine is very positive, as no other topical antiviral agent demonstrates this response in this troublesome albeit benign skin disease. Flavokine may have potential across a broad range of topical conditions because of its complex nature and biologic activity.
Commercial support: None identified.
Commercial support: 100% is sponsored by Dalos BioPharma.
AB90
J AM ACAD DERMATOL
MARCH 2010
P2508
Atypical clinical manifestation of acyclovir-resistant HSV in an AIDS patient: Case report and review of the literature Denise Woo, MD, Henry Ford Hospital, Detroit, MI, United States; Margaret Douglass, MD, Henry Ford Hospital, Detroit, MI, United States
Varicella zoster myelitis Maulina Sharma, MD, MBBS, Department of Dermatology, Queen’s Medical Centre, Nottingham, Nottinghamshire, United Kingdom; Catherine Roberts, MD, MBBS, Department of Dermatology, Queen’s Medical Centre, Nottingham, Nottinghamshire, United Kingdom; Jan Bong, MD, MBBS, Department of Dermatology, Queen’s Medical Centre, Nottingham, Nottinghamshire, United Kingdom
Background: In immunocompromised patients, HSV frequently presents with atypical clinical morphology. Case report: We report the case of a 45-year-old man with AIDS, a CD4 count of 129/uL, on HAART therapy who presented with a 2-month history of an asymptomatic lesion on his lower lip. Of note, the patient also had a long history of marijuana smoking. The physical examination revealed an approximately 4- 3 3-cm exophytic white stuck-on soft plaque with a smooth surface, located on the lower lip extending from the oral mucosa to the vermilion border and lateral commissures. A shave biopsy specimen revealed herpes cytopathic changes, and a viral culture grew herpes simplex. The lesion did not respond to several courses of oral acyclovir, including an increased dose of 800mg five times daily for 14 days. The patient is currently undergoing treatment with topical trifluridine three times daily. Conclusions: Atypical HSV presentations often occur in HIV patients, especially in advanced disease. These include hyperkeratotic verrucous lesions, exophytic plaques, and nodular lesions, which may appear in nontraditional locations, such as the tongue and endobronchial tube. This case serves as a reminder that HSV should be considered in the differential diagnosis of chronic exophytic plaques in HIV positive patients, and that atypical presentations of HSV infection should prompt screening for underlying associated immunodeficiency. The location on the lower lip has not been reported previously, and suggests a possible contributory role of local burn injury in the pathogenesis given our patient’s history of marijuana smoking. Of note, the majority of these atypical cases are resistant to acyclovir as in our patient, but may respond to higher-bioavailability valacyclovir, topical trifluridine, topical imiquimod, and both topical or intravenous cidofovir or foscarnet. Commercial support: None identified.
Varicella zoster can have significant neurologic complications. We present a case of varicella zoster myelitis. A 66-year-old man presented to the accident and emergency department with rapid onset of spreading saddle anesthesia, difficulty passing urine, constipation, and difficulty walking. He had a 1-week history of prodromal symptoms of headache, bodyache, and tiredness. He had noticed an asymptomatic rash over his buttock 2 weeks before these symptoms. Examination revealed a sensory deficit at S2-S4 sacral levels with decreased anal tone. Examination of skin revealed a cluster of papular eruption on right buttock with central necrosis. A diagnosis of zoster associated with polyradiculopathy was made. Viral skin swab was positive for varicella zoster. PCR of cerebrospinal fluid was also positive for varicella zoster. MRI of the spine showed subtle signal change and enhancement in the cord, conus and cauda equine. Other infectious causes and vasculitis were excluded. Neurology, dermatology, and microbiology teams were involved in his joint care. The patient made a remarkable recovery on IV acyclovir 10mg/kg three times daily for 2 weeks. Varicella zoster virus (VZV) is a double-stranded DNA in a single molecule. Primary infection causes chicken pox (varicella). Following this, it establishes latency and can subsequently reactivate to cause herpes zoster. Central nervous system (CNS) complications can follow both primary infection and reactivation of VZV. The more serious manifestations arise when the virus invades the spinal cord or cerebral arteries after reactivation of the virus, causing diseases such as myelitis and focal vasculopathy. Many of the recently reported cases have been associated with a diagnosis of HIV, and this should always be considered in this context. Although herpes zoster myelitis generally carries a good prognosis, early diagnosis is important, as aggressive antiviral treatment can be effective in preventing complications. Commercial support: None identified.
P2509
P2507
Flavokine, a novel topical antiviral for use against molluscum contagiosum in children and adults Arnold R. Oppenheim, MD, Virginia Beach Dermatology, Virginia Beach, VA, United States; Abigail Pekoe, Dalos BioPharma, Virginia Beach, VA, United States; Amanda K. Houck-Miller, MS, Dalos BioPharma, Virginia Beach, VA, United States; Gary Pekoe, PhD, Dalos BioPharma, Virginia Beach, VA, United States; M. Kirby Query, MS, Dalos BioPharma, Virginia Beach, VA, United States
Vesiculobullous Chikungunya fever with a severe and atypical clinical course Hazel H. Oon, MD, National Skin Centre, Singapore; Mark B. Y. Tang, MBBS, National Skin Centre, Singapore; Shiu Ming Pang, MBBS, Singapore General Hospital, Singapore; T. Thirumoorthy, MBBS, Singapore General Hospital, Singapore
Flavokine (Dalos BioPharma) is a novel complex botanical entity containing more than 270 flavonoids and other components. Different fractions of flavokine have been associated with antiviral, antibacterial, antitumor, antiinflammatory, and enhanced wound healing activity. Mechanisms of action include direct activity against viruses and bacteria including MRSA, as well as stimulation of factors and cells within the skin through a variety of biologic pathways.
Chikungunya is an alfavirus transmitted by the Aedes mosquito. Severe atypical cases, defined as requiring the maintenance of at least one vital function or demise during the course of the disease, are now increasingly recognized since the 2005/2006 outbreak in Reunion. Vesiculobullous Chikungunya is rarely described in adults and is associated with a poor clinical prognosis. We report a case of severe Chikungunya in an adult with an extensive blistering dermatosis who progressed to develop septic shock, rhabdomyolysis, and Guillain-Barre´ syndrome. Initial laboratory investigations revealed mild leukocytosis, a low normal platelet count of 143000/L (normal range, 140-440 3 109/L), markedly elevated creatinine kinase, and creatinine. Histologic examination revealed a subepidermal blister with a few mononuclear cells and some fibrin strands. Direct immunofluorescence of perilesional skin was negative. The serum Chikungunya reverse transcription real-time polymerase chain reaction (RT-PCR) serology for Chikungunya IgG and IgM were positive; dengue PCR was negative. Blister fluid and paraffin block section of the blister for chikungunya RT-PCR were positive. While little is known about vesiculobullous Chikungunya, this entity may herald a more severe clinical course of illness and mortality. Our patient featured an array of rare manifestations of Chikungunya, including blistering dermatoses, rhabdomyolysis, acute renal failure, hypotension, autonomic neuropathy of the bladder, and Guillain-Barre´ syndrome. Clinicians should have a high index of suspicion for this entity in epidemic, endemic areas and in the returning traveler.
Molluscum contagiosum (MC) is a common infection worldwide, accounting for about 1% of all diagnosed skin disorders in the US. Children, most commonly under 5 years old, become infected through direct skin-to-skin contact or by touching MCcontaminated objects. In adults, MC can be a sexually transmitted disease. It is estimated that 5% of children and up to 20% of AIDS patients have MC. In healthy children and adults, the MC rash will eventually clear, but it can last 18 months or longer, and is bothersome for parents and children because of its appearance and contagiousness. MC causes a characteristic lesion/rash with one or more round, dome-shaped pink, waxy papules, with a small central indentation. They are usually 2.5 mm in diameter but can be as large as 1cm in diameter. Current treatments for MC include curettage, cautery, cryotherapy, or blistering agents. Eighty-two patients aged 18 months to 62 years who had used flavokine twice daily for MC were evaluated for their response to the agent. The mean time of application was 6 weeks. Thirty-seven patients (45%) had complete clearing of their lesions. Twenty-four patients (30%) experienced partial clearing of their lesions. Twenty-one patients (25%) had no clearing of their lesions. Two patients reported mild skin irritation that may or may not have been related to flavokine. A partial or complete response rate of 75% of MC to flavokine is very positive, as no other topical antiviral agent demonstrates this response in this troublesome albeit benign skin disease. Flavokine may have potential across a broad range of topical conditions because of its complex nature and biologic activity.
Commercial support: None identified.
Commercial support: 100% is sponsored by Dalos BioPharma.
AB90
J AM ACAD DERMATOL
MARCH 2010