Francesco Broccolo

Pityriasis rosea: An update with a critical appraisal of its possible herpesviral etiology

Pityriasis rosea is an acute, self-healing exanthem characterized by oval erythematous-squamous lesions of the trunk and limbs, that usually spares face, scalp, palms, and soles. Constitutional symptoms, which have the character of true prodromes; clinical features, which resemble those of the known exanthems; and many epidemiologic data all suggest an infectious origin. A host of infectious agents have been incriminated, but, recently, human herpesvirus 6 and 7 have been extensively studied. The goal of this review is to outline the epidemiologic, clinical, histologic, and ultrastructural features of pityriasis rosea, but mainly to stress its possible human herpesvirus nature. In addition, clues have been added to help the reader to go through the complex subtleties of the virologic investigation.

Calibrated Real-Time PCR Assay for Quantitation of Human Herpesvirus 8 DNA in Biological Fluids

ABSTRACT Accurate laboratory tests for the diagnosis of active human herpesvirus 8 (HHV-8) infection are becoming essential to study the pathogenesis of HHV-8-associated tumors and for the clinical management of HHV-8-infected individuals. We have developed a highly sensitive, calibrated quantitative real-time PCR assay for the measurement of cell-free HHV-8 DNA in body fluids, based on the addition of a synthetic DNA calibrator prior to DNA extraction. The calibrator controls each sample for the presence of PCR inhibitors, determines a cutoff value of sensitivity for negative samples, and normalizes positive samples for the efficiency of DNA recovery. The assay shows a wide dynamic range of detection (between 1 and 106 viral genome equivalents/reaction) and a high degree of accuracy even in the presence of high amounts (up to 1 μg) of human genomic DNA. Moreover, the assay has a very high sensitivity (lower detection limit, 10 genome equivalents/ml) and a high degree of reproducibility and repeatability with a coefficient of variation (CV) of <15 and 23%, respectively. Furthermore, the use of the calibrator improves the accuracy of quantitation and decreases the intersample variability (CV, 9 and 6%, respectively). The sensitivity and specificity of the assay were tested with a series of clinical specimens obtained from patients affected by various HHV-8-related diseases, as well as from a wide number of controls. In conclusion, our calibrated real-time PCR assay provides a reliable high-throughput method for quantitation of HHV-8 DNA in clinical and laboratory specimens.

Myocardial revascularization with miniaturized extracorporeal circulation versus off pump: Evaluation of systemic and myocardial inflammatory response in a prospective randomized study.

OBJECTIVE This prospective randomized study sought to verify the systemic inflammatory response, inflammatory myocardial damage, and early clinical outcome in coronary surgery with the miniaturized extracorporeal circulation system or on the beating heart. METHODS Sixty consecutive patients were randomized to miniaturized extracorporeal circulation (n = 30) or off-pump coronary revascularization (off-pump coronary artery bypass grafting, n = 30). Intraoperative and postoperative data were recorded. Plasma levels of interleukin-6 and tumor necrosis factor-alpha were measured from systemic blood intraoperatively, at the end of operation, and 24 and 48 hours thereafter. Levels of the same markers and blood lactate were measured from coronary sinus blood intraoperatively to evaluate myocardial inflammation. Markers of myocardial damage were also analyzed. RESULTS One patient died in the off-pump coronary artery bypass grafting group. There was no statistical difference in early clinical outcome in both groups. Release of interleukin-6 was higher in the off-pump coronary artery bypass grafting group 24 hours after the operation (P = .03), whereas levels of tumor necrosis factor-alpha were not different in both groups. Cardiac release of interleukin-6, tumor necrosis factor-alpha, and blood lactate were not different in both groups. Release of troponin T was not significantly different in both groups. Levels of creatine kinase mass were statistically higher in the miniaturized extracorporeal circulation group than in the off-pump coronary artery bypass grafting group, but only at the end of the operation (P < .0001). Hemoglobin levels were significantly higher in the miniaturized extracorporeal circulation group than in the off-pump coronary artery bypass grafting group after 24 hours (P = .01). CONCLUSION Miniaturized extracorporeal circulation can be considered similar to off-pump surgery in terms of systemic inflammatory response, myocardial inflammation and damage, and early outcome.

Pityriasis rosea and herpesviruses: facts and controversies.

Pityriasis rosea is an acute exanthem with many clinical and epidemiologic features of an infectious disease. To date, human herpesvirus (HHV)-6 and HHV-7 appear to be the most indicted culprits, and the evidence in favor of this hypothesis and the controversial results produced elsewhere are discussed. The complex pathophysiology of HHV-6 and HHV-7 infection, their diffusion in the population at large, the difficulties of understanding whether the infection is still latent or is clinically manifest, and well as whether pityriasis rosea depends on a reinfection or on a viral reactivation, all make the issue extremely difficult to study and understand.

Reactivation of human herpesvirus 6 (HHV-6) infection in patients with connective tissue diseases

BACKGROUND Little is known about the involvement of human herpesviruses 6 and 7 (HHV-6 and HHV-7) in autoimmune connective tissue diseases (ACTD). OBJECTIVE To determine the prevalence of active infection with HHV-6 and HHV-7 in patients with ACTD. STUDY DESIGN The presence and quantity of HHV-6 DNA was determined by quantitative real-time PCR in a cross-sectional study of serum, peripheral blood mononuclear cells, and tissues obtained from 58 ACTD patients and 38 healthy subjects (HS). Specific anti-HHV-6 antibody titer was also measured. RESULTS HHV-6 serum viremia occurred in a significantly higher proportion of ACTD patients compared to HS [26/58 (44.8%) vs. 1/38 (2.6%), p=0.001] with the highest reactivation frequency [7/10 (70%)] observed in patients with scleroderma. Moreover, HHV-6 in serum was associated with ACTD activity (22/38 vs. 4/20, p<0.05). Higher titers of HHV-6 antibodies were found in ACTD patients than in HS, although HHV-6 seroprevalence among patients with ACTD and HS was similar. HHV-7 viremia was not detected in any patients or HS controls. CONCLUSION The frequent reactivation of HHV-6 in scleroderma and other ACTD, especially when active, suggests that HHV-6 may play a role in the pathogenesis of these diseases.

Possible Role of Human Herpesvirus 6 as a Trigger of Autoimmune Disease

Human herpesvirus 6 (HHV-6) infection is common and has a worldwide distribution. Recently, HHV-6A and HHV-6B have been reclassified into two distinct species based on different biological features (genetic, antigenic, and cell tropism) and disease associations. A role for HHV-6A/B has been proposed in several autoimmune disorders (AD), including multiple sclerosis (MS), autoimmune connective tissue diseases, and Hashimotos thyroiditis. The focus of this review is to discuss the above-mentioned AD associated with HHV-6 and the mechanisms proposed for HHV-6A/B-induced autoimmunity. HHV-6A/B could trigger autoimmunity by exposing high amounts of normally sequestered cell antigens, through lysis of infected cells. Another potential trigger is represented by molecular mimicry, with the synthesis of viral proteins that resemble cellular molecules, as a mechanism of immune escape. The virus could also induce aberrant expression of histocompatibility molecules thereby promoting the presentation of autoantigens. CD46-HHV-6A/B interaction is a new attractive mechanism proposed: HHV-6A/B (especially HHV-6A) could participate in neuroinflammation in the context of MS by promoting inflammatory processes through CD46 binding. Although HHV-6A/B has the ability to trigger all the above-mentioned mechanisms, more studies are required to fully elucidate the possible role of HHV-6A/B as a trigger of AD.

Human bocaviruses: Possible etiologic role in respiratory infection

Four species of human bocaviruses (HBoV) are currently included in the Bocavirus genus. There is satisfactory evidence demonstrating an association between HBoV1 and respiratory disease in children, and there is evidence that HBoV2 (and possibly the HBoV3 and HBoV4 species) are associated with gastroenteritis. In particular, HBoV1 has been associated with a prolonged period of persistence in the mucosa of the respiratory tract. Virus persistence does play a role in the high frequency of co-infections with proper pathogens of the upper and lower respiratory tracts. The high detection rate of multiple respiratory viruses in up to 83% of respiratory specimens and the presence of asymptomatic HBoV1 infections complicate the elucidation of the pathogenic role of the agent. Overall, a large amount of data are available concerning HBoV1, whereas little information is available about other bocavirus species. High viral loads are often associated with symptoms, and viremia may be associated with systemic manifestations such as encephalopathy. The effects and mechanisms of latency, persistence, reactivation, and reinfection are poorly understood. Thus, particularly in co-infections, the pathogenic contribution of the detected bocavirus species cannot be accurately stated. This review summarizes the current knowledge of HBoV species and provides perspectives for future clinical studies.

Selective reactivation of human herpesvirus 6 in patients with autoimmune connective tissue diseases

Viral infections have been associated with autoimmune connective tissue diseases. To evaluate whether active infection by Epstein–Barr virus (EBV), cytomegalovirus (CMV), human herpesvirus (HHV)‐6, ‐7, ‐8, as well as parvovirus B19 (B19V) occur in patients with autoimmune connective tissue diseases, viral DNA loads were assessed in paired samples of serum and peripheral blood mononuclear cells (PBMCs) of 115 patients affected by different disorders, including systemic sclerosis, systemic, and discoid lupus erythematosus, rheumatoid arthritis, and dermatomyositis. Two additional groups, patients affected by inflammatory diseases (n = 51) and healthy subjects (n = 58) were studied as controls. The titers of anti‐HHV‐6 and anti‐EBV antibodies were also evaluated. Cell‐free HHV‐6 serum viremia was detected in a significantly higher proportion of connective tissue diseases patients compared to controls (P < 0.0002); a significant association between HHV‐6 reactivation and the active disease state was found only for lupus erythematosus (P = 0.021). By contrast, the rate of cell‐free EBV viremia was similar in patients and controls groups. Cell‐free CMV, HHV‐8, and B19V viremia was not detected in any subject. Anti‐HHV‐6 and anti‐EBV early antigen IgG titers were both significantly higher in autoimmune diseases patients as compared to healthy controls, although they were not associated with the presence of viremia. EBV, HHV‐6, ‐7 prevalence and viral load in PBMCs of patients with connective tissue diseases and controls were similar. These data suggest that HHV‐6 may act as a pathogenic factor predisposing patients to the development of autoimmune connective tissue diseases or, conversely, that these disorders may predispose patients to HHV‐6 reactivation. J Med. Virol. 85:1925–1934, 2013.

Prevalence and viral load of oncogenic human papillomavirus types associated with cervical carcinoma in a population of North Italy

A cross‐sectional study was carried out in a population of North Italy to determine the prevalence of eight oncogenic human papillomavirus (HPV) types most commonly found in cervical carcinoma and to study the relationship between HPV DNA loads and severity of disease. A total of 597 cervical samples obtained from patients with pathological findings (n = 472) and from women with normal cytology (n = 125) were analyzed by means of normalized Real‐time PCR assays to quantify HPV‐16, ‐18, ‐31, ‐45, and ‐33 group (including ‐33, ‐52, ‐58, ‐67); the normalization of oncogenic HPV viral load was carried out by quantitation of a single copy gene. The two most common oncogenic HPV types found were 16 and 31 (24.3% and 22.9% of pathological samples, respectively); multiple infections were demonstrated in 22% of pathological samples. Overall, the HPV total viral load was found to increase with increasing severity of associated lesions, although a stronger association was observed only for HPV‐31 and HPV‐16 (γ = 0.49 and 0.41, respectively) as compared to HPV‐18 and ‐33 group (γ = 0.19 and 0.02, respectively). However, we found that high levels of HPV‐31 or 33 group DNA could be prognostic of minor oncogenic risk for high‐grade squamous intraepithelial lesions (H‐SIL) (age adjusted odds ratio [AORs] = 1.57 and 1.26, respectively) than HPV‐16 and HPV‐18 (AORs = 30 and 8, respectively). The AORs also increased with HPV total viral load and reached a maximum of AORs = 15.7. Thus, HPV load is a type‐dependent risk marker for the development of H‐SIL. J. Med. Virol. 81:278–287, 2009.

Pityriasis rosea and pityriasis rosea-like eruptions

To the Editor: We read with great interest the case of pityriasis rosea (PR)elike eruption associated with lamotrigine by Papadavid et al. This articlemay raise the issue of why a drug eruption presents with clinical features that strikingly resemble genuine PR. It may be speculated that the drug could have triggered human herpesvirus (HHV) 6 and/or HHV 7, recently implicated in the pathogenesis of PR, to abandon their latency and to reactivate. This phenomenon has been demonstrated in drug reactions associated with eosinophilia and systemic symptoms (DRESS). Our experience, however, seems to disprove such a hypothesis. In fact, we studied 12 patients with PR-like eruptions from a clinical, histopathologic, and virologic point of view. The eruptions followed, without a definite interval, a lesion resembling the herald patch in only 3 cases. Lesions were more confluent than in typical PR, they involved the limbs more extensively, in 2 cases the face, in 6 cases the mucous membranes (mouth and tongue), and caused excessive itching. No patient experienced prodromal symptoms. Fivepatients had a slight blood eosinophilia. Histopathology was studied in 9 patients showing eosinophils in the dermis in all cases, a perivascular infiltrate in 7 cases, necrotic keratinocytes within the epidermis in 8 cases, and signs of junctional vacuolar degeneration in 7 cases. All the patients recovered 2 weeks after discontinuing the drug, which is less than it takes for typical PR. In 10 patients we searched for HHV 6 and HHV 7 DNA in plasma and blood mononuclear cells, by calibrated quantitative real-time polymerase chain reaction as previously described. HHV 6 DNA, a marker of active infection, was detected in the plasma of only 1 patient. We hypothesize that the clinical and histopathologic features and, above all, the virologic investigations, may help to distinguish typical PR from PR-like eruptions, although, considering our small series of patients, further studies are needed.