Oral Human Papillomavirus Lesions in an HIV-Positive Child
A 6-year-old girl presented to a clinic in South Africa with a 1-year history of verrucous papules on the lips and oral mucosa extending to the surrounding skin, consistent with human papillomavirus (HPV) infection. The girl also had numerous asymptomatic, flat-topped, pigmented papules on her face and neck consistent with verruca plana.
The girl was HIV-positive with a baseline CD4 lymphocyte count of 189/µL. She was placed on highly active antiretroviral therapy (HAART), with her last CD4 lymphocyte count of 283/µL. Topical therapies, including salicylic acid, imiquimod, cantharidin, podophyllin, and cryotherapy, prompted little or no response.
The patient currently is on a trial course of oral ranitidine, 100 mg twice daily. She continues to use topical tretinoin cream, 0.1%, with sun protection for the verruca plana.
Persons with impaired cell-mediated immunity such as those with HIV are predisposed to HPV-related diseases, including oral warts.1 In addition, HIV infection alters the natural history of HPV by increasing the odds of greater virulence and more persistent infection.2 Warty keratoses at the angle of the mouth, most often bilaterally, are considered very characteristic and even unique HPV manifestations in patients with AIDS.1
In general, treatment of warts in patients with HIV is challenging. Despite reconstituting the host immune system, HAART’s effect on oral warts appears paradoxical, with several studies indicating an increasing number of warts with treatment.3-6 The cause of such an increase with HAART remains unclear, although it does suggest a role of HIV therapy regimens in the pathophysiology of oral HPV infections in patients with HIV infection.7
We present this case to assist primary care providers in identifying physical manifestations that can serve as a marker for HIV infection so that appropriate therapy can be initiated to prevent the disfigurement seen in our patient.
- Viral diseases of the skin. In: Paller AS, Mancini AJ. Hurwitz Clinical Pediatric Dermatology: A Textbook of Skin Disorders of Childhood and Adolescence. 4th ed. Philadelphia, PA: Elsevier Saunders; 2011:chap 15.
- Kreuter A, Skrygan M, Gambichler T, et al. Human papillomavirus-associated induction of human β-defensins in anal intraepithelial neoplasia. Br J Dermatol. 2009;160(6):1197-1205.
- dos Santos Pinheiro R, França TT, Ribeiro CM, Leão JC, de Souza IP, Castro GF. Oral manifestations in human immunodeficiency virus infected children in highly active antiretroviral therapy era. J Oral Pathol Med. 2009;38(8):613-622.
- King MD, Reznik DA, O’Daniels CM, Larsen NM, Osterholt D, Blumberg HM. Human papillomavirus-associated oral warts among human immunodeficiency virus-seropositive patients in the era of highly active antiretroviral therapy: an emerging infection. Clin Infect Dis. 2002;34(5):641-648.
- Greenspan D, Canchola AJ, MacPhail LA, Cheikh B, Greenspan JS. Effect of highly active antiretroviral therapy on frequency of oral warts. Lancet. 2001;357(9266):1411-1412.
- Leigh J. Oral warts rise dramatically with use of new agents in HIV. HIV Clin. 2000;12(2):7.
- Cameron JE, Mercante D, O’Brien M, et al. The impact of highly active antiretroviral therapy and immunodeficiency on human papillomavirus infection of the oral cavity of human immunodeficiency virus-seropositive adults. Sex Transm Dis. 2005;32(11):703-709.