記住我
Soumya Jagadeesan1, Lekshmi Sajini1, Prasanna Duraisamy1, Lakshmi Valliyil2
1 Department of Dermatology, Amrita Institute of Medcial Sciences, Kochi, Kerala, India
2 Consultant Dermatologist, Queen Haoura Aesthetic Clinic, Calicut, Kerala, India
Correspondence Address:
Lekshmi Sajini
Department of Dermatology, Amrita Institute of Medcial Sciences, Kochi, Kerala
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/ijd.ijd_647_22
How to cite this article:Sir,
Chronic graft-versus-host disease (cGVHD) is a common complication of allogeneic haematopoietic cell transplant (HCT) and can have heterogenous manifestations involving any organ system. cGVHD predominantly involves the skin and mucous membranes, commonly presenting as lichenoid or sclerodermoid lesions; however, various atypical presentations have been reported.[1] Here, we report a case of cutaneous cGVHD presenting with acral verrucous lesions mimicking verruca vulgaris.
A 42-year-old man with acute myeloid leukaemia underwent an allogenic bone marrow stem cell transplant. He was on prednisolone and cyclosporine as maintenance immunosuppressive therapy. One year post-transplant, he presented with multiple discrete lesions over both palms and soles of 1-month duration. He did not have any past history of similar lesions. There was no history of any new drug intake prior to the onset of lesions. Dermatological examination showed multiple discrete hyperpigmented hyperkeratotic verrucous papules and plaques of sizes ranging from 1 to 2 cm diameter over both the palms and soles [Figure 1]a, [Figure 1]b, [Figure 1]c. No other skin lesions were noted. The systemic examination was normal. Based on the morphology, lesions were diagnosed as verruca vulgaris and treated with 3 cycles of cryotherapy. However, the treated lesions worsened with vesiculation and tenderness, and the patient developed new verrucous lesions. A skin biopsy was taken from the lesions, which showed parakeratotic hyperkeratosis, acanthosis, hypogranulosis, basal cell degeneration and pigment incontinence with focal lichenoid infiltrate [Figure 2]. There was an absence of koilocytes or papillomatosis. These findings were suggestive of a cutaneous graft-versus-host disease. The patient was initially treated with halobetasol 0.05% ointment but continued to develop new lesions. In view of the worsening of lesions, extracorporeal photopheresis was considered; however, patient was unwilling. He was started on oral ruxolitinib 5 mg twice-daily along with adjuvant UVA/NBUVB hand-foot phototherapy. Following treatment, the patient's lesions completely resolved [Figure 3]a and [Figure 3]b.
Figure 1: Clinical images – (a) verrucous papules and plaques over the palms, (b) verrucous papules and plaques over the palms and (c) verrucous papules and plaques over the soles
Figure 2: Histopathological images showing (a) epidermis showing parakeratotic hyperkeratosis, regular acanthosis and a reduced granular layer. Lichenoid infiltrate with focal basal cell degeneration, necrotic keratinocytes and colloid bodies is noted (Haematoxylin and Eosin, 40×) (b) Lichenoid infiltrate with interface changes – basal cell degeneration, colloid bodies and pigment incontinence (Haematoxylin and Eosin, 100×) (c) Necrotic keratinocytes (Haematoxylin and Eosin, 400×)
Figure 3: Clinical images – Resolution of lesions post-treatment over the (a) palm and (b) soleChronic GVHD usually presents 100 days post-transplantation and predominantly involves the skin, followed by mucosal, hepatic, ocular and pulmonary manifestations. Cutaneous cGVHD of the skin classically presents as lichen-planus-like, lichen-sclerosus-like, poiklodermatous, sclerodermoid and morphea-like variants; however, several atypical presentations such as pityriasis-rubra-pilaris-like, ichthyosis-like, keratosis pilaris-like, psoriasiform and ezcematoid eruptions have been reported.[1]
Cases of cGVHD mimicking warts have been previously described in the literature.[2],[3] In our patient, the hyperkeratotic papules on the palms and soles were initially diagnosed as warts. Considering his immunocompromised state, the appearance of multiple warts in a short duration was not considered unusual. However, cryotherapy targeting the lesions resulted in their worsening along with the development of newer verrucous lesions. Subsequent histopathological examination of newly developing lesions showed features of a lichenoid interface dermatitis along with the absence of papillomatosis and koilocytosis. Considering the previous history of transplant and the clinical and histopathological features, we arrived at a diagnosis of verruca-like presentation of cGVHD. Although lichen planus of the palms and soles can also present as hyperkeratotic verrucous papules and plaques with lichenoid features on histopathology; considering the immunosuppressed state (systemic steroids and cyclosporine) of the patient, along with the absence of any triggers like drugs, it was considered to be unlikely. In a previous report, patients with verruca-like cGVHD were treated successfully with topical immunosuppressants; however, our patient did not respond adequately to topical therapy.[2] Janus-Kinase-inhibitors like ruxolitinib have emerged as an effective treatment option for GVHD. Our patient was started on a lower dose of ruxolitinib 5 mg twice-daily, which resulted in complete resolution of lesions within 6 months.
cGVHD is a significant cause of morbidity and mortality in patients with allogeneic HCT. Verruca-like cutaneous cGVHD can be misdiagnosed as palmoplantar warts because of their morphologic similarity; however, notable differences include the rapid onset and symmetric distribution of verruca-like cGVHD. Our case is highlighted as a reminder that it is imperative that dermatologists maintain clinical suspicion for GVHD in post-transplant patients with cutaneous eruptions, even if their lesions are not classical. Early recognition of such atypical forms of cutaneous cGVHD can help reduce morbidity through prompt initiation of treatment.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published, and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Acknowledgement
The authors would like to thank Dr Neeraj Siddarthan, Department of Hematology, Amrita Institute of Medical Sciences and Dr Malini Eapen, Department of Pathology, Amrita Institute of Medical Sciences for their support and help in managing this case.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References 
留言 (0)