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July 21, 2008

Acute Skin Eruptions That Are Positive for Herpes Simplex Virus DNA Polymerase in Patients With Stem Cell Transplantation: A New Manifestation Within the Erythema Multiforme Reactive Dermatoses

Author Affiliations

Author Affiliations: Departments of Dermatology (Dr Burnett) and Pharmacology (Drs Burnett and Aurelian and Ms Laing) and Program in Experimental Therapeutics, Greenebaum Cancer Center (Drs Burnett and Aurelian), University of Maryland School of Medicine, Baltimore.

Arch Dermatol. 2008;144(7):902-907. doi:10.1001/archderm.144.7.902

Background  Patients with stem cell transplantation (SCT) develop erythematous eruptions (SCTE) that are often misdiagnosed and poorly treated. Latent herpes simplex virus (HSV) is likely to be reactivated by SCT-associated immunosuppression. Therefore, one of the differential diagnostic possibilities for SCTE is HSV-associated erythema multiforme (HAEM) in which HSV genetic fragments localize in stem cells that deliver them to the skin on differentiation.

Observations  Lesional skin from patients with SCTE, HAEM, HSV, or drug-induced erythema (DIEM) was stained with antibodies to the HSV antigen DNA polymerase (Pol) and the major capsid protein, virion protein 5 (VP5). The HSV DNA polymerase Pol was expressed in 79% of patients with SCTE and 75% of those with HAEM. The protein VP5 was not expressed in these patients, indicative of the absence of virus replication. Findings in patients with DIEM were negative for both antigens, and those with HSV lesions were positive for both antigens.

Conclusions  There is a growing problem with SCTE, related to the increasing numbers of performed SCT. The greater frequency of SCT-generated circulating stem cells in patients with hematological malignant neoplasms (who have latent HSV infection) may result in a widespread SCTE characterized by skin deposition of HSV DNA fragments, notably those expressing Pol antigen. This HAEM-like presentation should be considered in the differential diagnosis of SCTE. Prolonged high-dosage antiviral chemotherapy during and after hospitalization may be warranted.