Treatment of human polyomavirus‐7‐associated rash and pruritus with topical cidofovir in a lung transplant patient: Case report and literature review

Abstract

Human polyomavirus-7-associated rash and pruritus (PVARP) is a chronic superficial viral skin infection, which primarily impacts immunocompromised individuals. We report on a case of PVARP in a lung transplant recipient. Our patient developed symptoms 13 years after being on his immunosuppressive regimen, with an insidious course of progressive gray lichenification with marked islands of sparing and quality of life-altering pruritus. Treatment for PVARP is not established; however, topical cidofovir combined with immunomodulation may offer sustained therapeutic benefit.

The Biology and Clinical Features of Cutaneous Polyomaviruses

“…The constellation of clinical findings of HPyV6/7 infection have been referred to as "HPyV6-and HPyV7-associated pruritic and dyskeratotic dermatoses," "human polyomavirus-7-associated rash and pruritus," and "HPyV-associated hyperproliferative keratinopathy plus/minus pruritus" (Canavan et al, 2017;Ho et al, 2015;Nguyen et al, 2017;Smith et al, 2018). Cutaneous HPyV6 and HPyV7 infection manifests with pruritic, brown to gray, lichenified plaques involving the trunk and extremities (Figure 1c) (Canavan et al, 2017;Ho et al, 2015;Nguyen et al, 2017;Smith et al, 2018). With the exception of one case occurring in a patient immunosuppressed from HIV infection (Nguyen et al, 2017), published cases have been associated with cardiac and lung transplants (Canavan et al, 2017;Ho et al, 2015;Smith et al, 2018).…”

“…Cutaneous HPyV6 and HPyV7 infection manifests with pruritic, brown to gray, lichenified plaques involving the trunk and extremities (Figure 1c) (Canavan et al, 2017;Ho et al, 2015;Nguyen et al, 2017;Smith et al, 2018). With the exception of one case occurring in a patient immunosuppressed from HIV infection (Nguyen et al, 2017), published cases have been associated with cardiac and lung transplants (Canavan et al, 2017;Ho et al, 2015;Smith et al, 2018). Immunosuppressive medicines in these organ transplant recipients included prednisone, azathioprine, sirolimus, tacrolimus, everolimus, and mycophenolate (Canavan et al, 2017;Ho et al, 2015;Smith et al, 2018).…”

“…With the exception of one case occurring in a patient immunosuppressed from HIV infection (Nguyen et al, 2017), published cases have been associated with cardiac and lung transplants (Canavan et al, 2017;Ho et al, 2015;Smith et al, 2018). Immunosuppressive medicines in these organ transplant recipients included prednisone, azathioprine, sirolimus, tacrolimus, everolimus, and mycophenolate (Canavan et al, 2017;Ho et al, 2015;Smith et al, 2018). Histopathology reveals epidermal papillomatosis, dyskeratotic keratinocytes in the epidermis, and irregular columns of parakeratosis, the latter referred to as "peacock plumage," "columnar dyskeratosis," or "tiered parakeratosis with dyskeratosis" (Figure 1d) (Canavan et al, 2018;Champagne et al, 2015;Ho et al, 2015;Nguyen et al, 2017;Pock and Stork, 2010).…”

“…Treatments for infections linked to HPyV6 and HPyV7 remain anecdotal. Specifically, topical and intravenous cidofovir have been successful in isolated cases of HPyV7 infection, likely through its inhibition of viral replication (Canavan et al, 2017;Smith et al, 2018). There are contradictory reports on the benefit of acitretin: one patient had complete resolution of his eruption with acitretin and another patient had no response (Canavan et al, 2017;Smith et al, 2018).…”

“…Specifically, topical and intravenous cidofovir have been successful in isolated cases of HPyV7 infection, likely through its inhibition of viral replication (Canavan et al, 2017;Smith et al, 2018). There are contradictory reports on the benefit of acitretin: one patient had complete resolution of his eruption with acitretin and another patient had no response (Canavan et al, 2017;Smith et al, 2018). Of note, the patient with complete resolution received acitretin 25 mg twice daily, while the nonresponder patient received 25 mg once daily, leaving open the possibility that the dose and frequency of treatment may impact the efficacy.…”