P2501 Heck disease: Report of two cases Janeth Almaguer-Chavez, MS, Dermatology Department, Hospital Universitario ‘‘Dr. Jose´ E. Gonza´lez,’’ UANL, Monterrey, Mexico; Dan Lopez-Garcia, MD, Dermatology Department, Hospital Universitario ‘‘Dr. Jose´ E. Gonza´lez,’’ UANL, Monterrey, Mexico; Jorge Ocampo-Candiani, MD, Dermatology Department, Hospital Universitario ‘‘Dr. Jose´ E. Gonza´lez,’’ UANL, Monterrey, Mexico; Osvaldo T. Vazquez-Martinez, MD, Dermatology Department, Hospital Universitario ‘‘Dr. Jose´ E. Gonza´lez,’’ UANL, Monterrey, Mexico Introduction: Focal epithelial hyperplasia (FEH) or Heck disease is a very rare disease of the oral mucosa caused by infection of human papillomavirus (HPV). It is a benign condition characterized by epithelial growths that include isolated or multiple soft papular and nodular eruptions on the lower lip, buccal mucosa, and tongue, and less often on the upper lip and palate. The lesions are painless and tend to disappear spontaneously. It is more frequent in younger age groups and sometimes has also a familial occurrence that suggests a genetic predisposition to the development of the disease. This report describes two cases of Heck disease in a third reference institution. Case 1: A 30-year-old female was evaluated for asymptomatic lesions on the oral labial mucosa and tongue for 12 months. She has a sister with the same lesions in oral cavity that disappeared spontaneously through adolescence. The examination of the oral cavity revealed numerous pinkish 2- to 6-mm papules on the mucosal surface of upper and lower lips and distal tip of the tongue. She had no lesions on other mucous membranes or skin and denied high-risk sexual contact. The histologic study was compatible with focal epithelial hyperplasia. The patient refused any treatment. Case 2: A 33-year-old female with no relevant personal or family history consulted for asymptomatic lesions on the oral cavity. The first lesions were noticed 20 years ago. Clinical examination found soft, round, flat-topped, hyperpigmented papules on the buccal edges and pale papules on the tongue. A shave biopsy was performed for histologic evaluation, which demonstrated focal epithelial hyperplasia. She received nine cycles of cryotherapy at one month separation with a good response, but five years later of the last therapy she presents a recurrence of the lesions. Laboratory investigations had normal results. Oral zinc sulphate 600 mg per day was indicated and, the patient refers a 30% response at 1 month of initiated therapy. The patient did not come for further follow-up. Discussion: FEH onset usually occurs in childhood and adolescence, and the condition is more common among women. It is caused by HPV and most cases are associated with serotypes 13 and 32. The lesions are usually asymptomatic and are characterized by multiple, circumscribed, soft papules and nodules of color similar to the adjacent mucosa. Histologic findings are suggestive of HPV infection with epithelial hyperplasia, acanthosis with koilocytosis, parakeratosis and fusion of dermal papillae. These two cases represent two lesions that clinically and histologically correspond to a focal epithelial hyperplasia. Zinc sulphate is an efficacious therapeutic option for recalcitrant viral warts and we use this agent to treat the recurrence of Heck disease in our second patient after several therapies with cryotherapy. Commercial support: None identified.
INFECTION (VIRAL) P2500 Disseminated primary herpes simplex virus infection in a newborn Ana Maria Mosca de Cerqueira, MD, Hospital Municipal Jesus, Rio de Janeiro, Brazil; Cinthia Dinis, MD, Policlinica Geral do Rio de Janeiro, Rio de Janeiro, Brazil; Ericka Andrade de Aguiar, MD, Policlinica Geral do Rio de Janeiro, Rio de Janeiro, Brazil; Milhele Monteiro, MD, Policlinica Geral do Rio de Janeiro, Rio de Janeiro, Brazil Background: Clinical manifestations of herpes simplex virus (HSV) depend on the site of viral inoculation, host immunity, and viral strain acquired. In newborn, immunocompromised persons and severely malnourished infants, a serious systemic infection may occur. Methods: A 7-month-old male was admitted as a case of pneumonia and bronchiolitis showing no response with antibiotics and steroids intravenous treatment. During hospitalization, he presented left hemiparesis and vesicles on head and neck region. The patient was then admitted on the Muncipal Jesus Hospital presenting with fever, tachypnea, crepitant rales, hepatosplenomegaly, and left hemiparesis. After the third day, grouped vesicles on an erythematous base were disseminated throughout the body. Laboratory findings included hyponatremia, anemia, elevated hepatic enzymes, and low protein levels. Radiographs showed confluent paracardiac condensation on the right lower lobe evoluating with worsening of the patterns. Computed tomographic scans of the patient’s head revealed characteristic images of hemorrhagic infarction secondary to herpetic encephalitis. Enzyme-linked immunosorbent assay with immunoglobulin M HSV antibody was positive. Systemic hypertension caused by acute adrenal insufficiency also occurred. Results: He was treated with systemic antibiotics, inhaled steroids, intravenous acyclovir, and antihypertensives. After the seventh day of treatment, improvement of skin lesions, arterial hypertension, hepatosplenomegaly, and respiratory tract were seen. He was then released on the thirtieth day. Conclusions: Previous use of steroid and systemic immunocompromised therapy increases the chance of disseminated HSV infection. Commercial support: None identified.
J AM ACAD DERMATOL
P2502 Cytomegalovirus-induced cutaneous microangiopathy manifesting as lower limb ischemia in an HIV infected patient Ana Molina-Ruiz, MD, Virgen del Rocı´o University Hospitals, Sevilla, Spain; Luis Requena, MD, PhD, Fundacio´n Jime´nez Dı´az, Madrid, Spain; Rafael Luque, MD, PhD, Virgen del Rocio University Hospitals, Sevilla, Spain; Teresa Zulueta, MD, PhD, Virgen del Rocı´o University Hospitals, Sevilla, Spain Cutaneous involvement by cytomegalovirus (CMV) is rare, and often difficult to diagnose both clinically and histopathologically. A wide range of different clinical presentations have been reported in the literature, especially in immunosuppressed patients, such as transplant recipients and patients with AIDS. CMV-induced thrombosis has also been reported in these patients, and various mechanisms have been proposed to explain the role of CMV in thrombosis, including direct damage of the endothelial cells, activation of coagulation factors and inducing the production of antiphospholipid (aPL) antibodies. We describe the case of an HIVinfected female with history of deep venous thrombosis who developed distal cutaneous ischemic lesions during a generalized CMV infection. The atypical cutaneous lesions were the clue for the diagnosis of a generalized CMV infection, and clinical resolution was achieved after specific treatment. We discuss the role of CMV and aPL antibodies in the pathogenesis of thrombotic microangiopathy in immunosuppressed patients. Commercial support: None identified.