Poster presentationsDP11 Bright, eosinophilic intracytoplasmic inclusion bodies: a rare presentation of acquired epidermodysplasia verruciformis with widespread human papillomavirus infection in a transplant recipient
Authors: Han Chieun , Karim Shakir , Orpin Stephen 
Published: June 2024

Abstract
Acquired epidermodysplasia verruciformis (EV) is an uncommon dermatological condition exclusively observed in immunosuppressed individuals. Clinically, it is characterized by hyperpigmented papules resembling flat warts, brown–orange pityriasis versicolor-like macules and patches, or, in some instances, lesions mimicking seborrhoeic keratoses. Historically, it has been linked to patients infected with HIV, with only a few cases reported in association with organ transplantation worldwide. We present the case of a 46-year-old Afro-Caribbean woman with a history of poorly controlled type 1 diabetes mellitus. She presented after pancreas–kidney transplant with a widespread, symmetrical, follicle-centred eruption consisting of discrete, pigmented, keratinous papules on the face, trunk and limbs. Especially, the lesions on the face exhibited a spiny or spiculated appearance. Clinically, this latter feature was suggestive of trichodysplasia spinulosa (TS), a disorder seen in transplant recipients and caused by TS-associated polyomavirus (TSPyV). TSPyV typically manifests with dilated hair follicles, hyperkeratosis, perifollicular parakeratosis and follicular plugging, resulting in spicule-like projections and hair follicle distortion. Surprisingly, punch biopsies revealed histological features consistent with EV, despite the clinical suspicion of TS. Although EV shares hyperkeratotic aspects with TS, it differs significantly in its susceptibility to specific human papillomavirus (HPV) types, not polyomavirus. Furthermore, histologically, EV displays epidermal dysplasia and vacuolated cells with abundant blue–grey cytoplasm within the upper spinous layer. Microscopically, this case exhibited features of EV, including hair follicle dilation, prominent dyskeratosis, and replacement of the follicular wall by cells with large vesicular nuclei and grey cytoplasm – distinctive features associated with EV. The punch biopsy also failed to reveal the typical histological features of TS, such as intranuclear basophilic inclusion bodies and SV-40-positive staining to indicate the presence of polyomavirus. Notably, a unique type of intracytoplasmic inclusion body was observed – a group of homogeneous, bright, eosinophilic intracytoplasmic inclusion bodies, resembling molluscs. These findings, while unusual, are considered pathognomonic for HPV-49 infection. EV is typically associated with viral serotypes HPV-3, 4, 5, 8 and 51, making the association with HPV-49 exceedingly rare, with only one case published worldwide. In conclusion, this case represents a rare presentation of acquired EV in a post-transplant patient, featuring histological findings indicative of unique eosinophilic viral changes with a homogeneous type of intracytoplasmic inclusion bodies. This occurrence, associated with HPV-49, is a rare but intriguing phenomenon, with only the second reported case in a patient with EV.