“Acquired epidermodysplasia verruciformis” in kidney transplant patients

Background

Epidermodysplasia verruciformis (EV) is a well known inherited autosomal recessive skin disease associated with numerous early onset viral warts on the sun exposed parts of the body that usually progress into skin malignancies. Kidney transplant patients are also commonly associated with viral warts that might change into skin cancers.

Objective

To describe the clinical pictures of extensive viral warts with skin malignancies in kidney transplant patients in comparison with inherited (EV) features.

Patients and methods

This case controlled study that included 130 patients with kidney transplantation was done in kidney transplantation centers in Baghdad and Al-Karma Teaching Hospitals during December 2002 to September 2004. All recruited patients were receiving multiple immunosuppressive drugs like methyl prednisolone succinate, oral prednisolone, azathioprine and cyclosporine. History was taken from all patients including all the relevant points. These patients were divided into three groups according to the duration of kidney transplant: group A 1–10 years, group B 11–20 years and group C more than 20 years. Biopsies were performed from the viral warts lesions and the associated tumors.

Two hundred and sixty apparently healthy individuals, 206 males and 54 females had been examined as control cases for the presence of viral warts and tumors. These control cases had been taken randomly from general population in multiple regions in Baghdad.

Results

Sixty-five patients out of 130 with kidney transplantation had viral warts. Their ages ranged from 20 to 71 (45.49 ± SD 10.82) years, 51 males and 14 females, while the duration of the warts ranged from 0.5 to 10 (3.74 ± SD 2.67) years. The distribution of patients with viral warts among the groups was as follows: group A 28 (43.1%), group B 30 (46.2%) and group C 7 (10.7%) cases. Viral warts were seen in 10 (3.8%) of the control group. There were statistically significant differences between patients and control cases (P value <0.001). Most of the viral warts in patients with kidney transplantation were multiple and of the verrucae vulgaris type. They were mainly located on the exposed areas of the body, mostly on the face and dorsa of hands.

Skin malignancies were observed in 6 (9.2%) cases: five squamous cell carcinomas and one case of basal cell carcinoma. Squamous cell carcinoma was mainly located on the lower lips in 3 cases and 2 on the dorsa of hands, while basal cell carcinoma was observed on the nose. Two cases (7.1%) of squamous cell carcinoma were seen in group A, 2 (6.6%) in group B and 1 (14%) in group C. One case of basal cell carcinoma was noted in group B .No skin malignancy was observed in the control group.

Conclusion

Kidney transplant patients have an increased susceptibility to infection with human papilloma virus and have served as a model for viral induced carcinogenesis. This collection of features deserves the term “acquired epidermodysplasia verruciformis”.