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 Table of Contents  
LETTER TO EDITOR
Year : 2019  |  Volume : 5  |  Issue : 2  |  Page : 115-117

A curious case of development of verruca vulgaris over the site of autoimplantation: Subsequently treated with measles, mumps and rubella vaccine


Department of Dermatology, Venereology and Leprosy, GMC, Kota, Rajasthan, India

Date of Web Publication16-Dec-2019

Correspondence Address:
Suresh Kumar Jain
Department of Dermatology, Venereology and Leprosy, GMC, Kota - 324 005, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijdd.ijdd_47_19

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How to cite this article:
Mohta A, Gautam U, Kushwaha RK, Jain SK. A curious case of development of verruca vulgaris over the site of autoimplantation: Subsequently treated with measles, mumps and rubella vaccine. Indian J Drugs Dermatol 2019;5:115-7

How to cite this URL:
Mohta A, Gautam U, Kushwaha RK, Jain SK. A curious case of development of verruca vulgaris over the site of autoimplantation: Subsequently treated with measles, mumps and rubella vaccine. Indian J Drugs Dermatol [serial online] 2019 [cited 2020 Feb 18];5:115-7. Available from: http://www.ijdd.in/text.asp?2019/5/2/115/272962



Sir,

The prevalence of cutaneous warts is around 7%–10%.[1] In some patients, they resolve spontaneously within 1–2 years without treatment, but in others, they can persist despite repeated treatments and become recurrent or recalcitrant.[2] Recently, autoimplantation and immunotherapy have emerged as popular techniques for the treatment of such recalcitrant or extensive warts.[2] They act by enhancing patient's immune status which results in the resolution of warts both at treated, as well as, distant site. Although autoimplantation seems quite lucrative, it does not warrant complete resolution of warts, and in rare cases, it can lead to the recurrence or development of various side effects.

An 18-year-old male patient had presented to us 9 months back with multiple warts on the dorsum of the right hand for 4 years. He had been previously treated with radiofrequency ablation for the same which was followed by recurrence. Therefore, after ensuring that the patient was hemodynamically stable and immunocompetent, a homologous autoimplantation was done at the flexor aspect of the left forearm, according to the technique followed by Shivakumar et al.[3] A monthly follow-up was done for the next 3 months, with no improvement in preexisting warts. Interestingly, in the meantime, a new, sharply defined, rounded lesion with a rough, keratotic, and hyperpigmented verrucous surface developed over the site of autoimplantation [Figure 1], [Figure 2]a and [Figure 3]a. The lesion was diagnosed as verruca vulgaris on the basis of its typical appearance and further confirmed by histopathological examination of the lesion which revealed the presence of koilocytes [Figure 4]a and [Figure 4]b.
Figure 1: Wart developed at the site of autoimplantation on the left forearm and unhealed distant warts on the dorsum of the right hand

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Figure 2: Serial improvement in injected wart; (a) prior to the first injection, (b) 2 weeks after the second dose, (c) complete clearance after the third dose

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Figure 3: Serial improvement in distant warts; (a) prior to the first injection, (b) 2 weeks after the second dose, (c) complete clearance after the third dose

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Figure 4: (a) H and E stain of warty lesion (×40) showing hyprekeratosis and papillomatosis with incurving of rete ridges consistent with verruca vulgaris. (b) H and E stain (×400) showing koilocytes in the epidermis

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Ensuing this unusual development, the immune status of the patient was reassured. The patient was found to be immunocompetent. Subsequently, the verruca which had developed at the site of autoimplantation was treated with 0.5 mL of intralesional measles, mumps, and rubella (MMR) vaccine, after reconstitution with distilled water. Three doses of MMR vaccine were given at 2 weeks' interval, following which a complete clearance of the injected as well as distant warts was noted [Figure 2] and [Figure 3]. Thereafter, a monthly follow-up was done for the next 6 months. No recurrence was noted.

The huge armamentarium available for the treatment of warts includes various conventional medical and surgical treatments such as destructive, topical sensitizing, and immunotherapeutic interventions. Yet, no single therapy has been found to be effective and cosmetically acceptable in majority of the patients. Most of these therapies have only a 60%–70% success rate,[2] and their effectiveness is suboptimal in multiple warts or at warts on remote sites. They might ablate the wart itself, but the causative organism, Human Papillomavirus (HPV), still resides in the host skin and can resurface as visible warts from time to time, especially in those who have a compromised HPV-specific cell-mediated immunity. Warts, on their own, lack to ability to stimulate an aggressive ablative host immune response by the virtue of their strict epidermal location without invasion of the dermis. This prevents the immune mediators and cells present in the dermis and deeper tissue from being exposed to the HPV.

Owing to all of the above factors, in recent times, the concept of immunological therapy has loomed. In theory, autoimplantation on one such therapy acts by significantly altering the immune status and upregulating both viral-specific IgM and IgG antibodies as well as delayed hypersensitivity to the virus. It produces Th1 cytokines such as tumor necrosis factor-α and interleukin-1 (IL-1) which downregulate HPV genes, along with interferon-gamma (IFN-γ) and IL-2 which upregulate cytotoxic T-cells and natural killer cells. This cascade further aids in the eradication of HPV-infected cells.[3]

Although MMR stimulates the immune system in the same way as autoimplantation, it is the delayed hypersensitivity reaction that acts against intralesional antigen as well as the wart-causing viruses. The concurrent use of three antigens (MMR) together helps in evoking a stronger immune response against HPV due to the adjuvant effects of different antigens on one another. It stimulates the Th1 immune response and its cytokine such as IL-2, IL-4, IL-5, IL-12, and IFN-γ[4] as well as activates cytotoxic T-cells and natural killer cells to eradicate HPV-infected cells.

The effect of MMR vaccine as an immunotherapy for recalcitrant warts was first reported by Nofal and Nofal,[5] with an impressive clearance rate of 84.6%. Later, several studies reported similar results ranging from 75% to 87%[5],[6],[7] with minimal recurrence. MMR has an excellent tolerability and also holds leverage over other immunotherapeutic agents such as PPD tuberculin and candida antigen owing to the absence of any side effects such as abscess formation [8] and postinflammatory depigmentation,[9] respectively.

While various studies in the past have highlighted several shortcomings of autoimplantation, such as lack of complete resolution (in up to 27%–37% cases),[2],[3] recurrence, infection of the donor site, keloids, and hypopigmentation up to 25% of cases,[2] to the best of our knowledge, in none of these studies, a case of development of a new wart at the site of autoimplantation itself has been reported in the past.

The failure of autoimplantation in our patient could possibly be explained either by the lack of development of a virus-specific immune response or due to the accidental introduction of the autoinoculation tissue into the epidermis instead of the dermis. Since the primary site of infection of HPV is a basal layer of the epithelium, followed by replication in the suprabasal layers, the accidental epidermal implantation could have led to the pseudo-koebnerization of HPV. Nevertheless, the rarity of this reported complication of autoimplantation, especially in a perfectly immune competent patient, made our findings further astounding.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Gulanikar AD, Bhide DS, Pethe SA. Autoimplantation therapy for recalcitrant viral warts. Clin Dermatol Rev 2018;2:74-7.  Back to cited text no. 1
  [Full text]  
2.
Shivakumar V, Okade R, Rajkumar V. Autoimplantation therapy for multiple warts. Indian J Dermatol Venereol Leprol 2009;75:593-5.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Lal NR, Sil A, Gayen T, Bandyopadhyay D, Das NK. Safety and effectiveness of autoinoculation therapy in cutaneous warts: A double – Blind, randomized, placebo – Controlled study. Indian J Dermatol Venereol Leprol 2014;80:515-20.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Awal G, Kaur S. Therapeutic outcome of intralesional immunotherapy in cutaneous warts using the mumps, measles, and rubella vaccine: A Randomized, placebo-controlled trial. J Clin Aesthet Dermatol 2018;11:15-20.  Back to cited text no. 4
    
5.
Nofal A, Nofal E. Intralesional immunotherapy of common warts: Successful treatment with mumps, measles and rubella vaccine. J Eur Acad Dermatol Venereol 2010;24:1166-70.  Back to cited text no. 5
    
6.
Gamil H, Elgharib I, Nofal A, Abd-Elaziz T. Intralesional immunotherapy of plantar warts: Report of a new antigen combination. J Am Acad Dermatol 2010;63:40-3.  Back to cited text no. 6
    
7.
Zamanian A, Mobasher P, Jazi GA. Efficacy of intralesional injection of mumps-measles-rubella vaccine in patients with wart. Adv Biomed Res 2014;3:107.  Back to cited text no. 7
[PUBMED]  [Full text]  
8.
Nimbalkar A, Pande S, Sharma R, Borkar M. Tuberculin purified protein derivative immunotherapy in the treatment of viral warts. Indian J Drugs Dermatol 2016;2:19-23.  Back to cited text no. 8
  [Full text]  
9.
Perman M, Sterling JB, Gaspari A. The painful purple digit: An alarming complication of Candida albicans antigen treatment of recalcitrant warts. Dermatitis 2005;16:38-40.  Back to cited text no. 9
    


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