Want to take quizzes and track your credits?
A woman in her 70s presented with a 1-year history of a facial cutaneous eruption initially affecting malar cheeks and eyebrows. Subsequently it spread to involve nose, chin, upper trunk, and extremities. The lesions were mildly pruritic. Her medical history included a cadaveric renal transplant 2 years earlier for end-stage renal failure. Immunosuppressant medications included mycophenolate mofetil, 200 mg, twice daily and tacrolimus, 8 mg, twice daily. Tacrolimus levels were therapeutic. Physical examination revealed multiple 1-mm flesh-colored follicular papules and keratin spines against a diffuse erythematous background affecting the face (Figure, A and B) and upper trunk. Her scalp and eyebrow hairs were unremarkable. Serology results were unremarkable. Results of skin biopsy from the right ear demonstrated dilatation and keratotic plugging of the hair infundibula with marked dystrophy and expansion of the inner root sheath. The inner root sheath cells were enlarged with irregular trichohyaline granules and apoptotic cells with abrupt cornification without formation of a granular layer (Figure, C). Immunohistochemical analysis for SV40 polyomavirus was positive (Figure, D).
Please finish quiz first before checking answer.
Read the answer below and download your certificate.
Read the discussion below and retake the quiz.
A. Trichodysplasia spinulosa
Taking the clinical and histopathological findings together, the diagnosis is consistent with trichodysplasia spinulosa. Treatment options included reduction in tacrolimus dose; however, owing to the risk of transplant rejection this was not deemed to be a safe option. To date, the rash persists and has further spread to involve most of the trunk and extremities.
Trichodysplasia spinulosa is a rare viral infection reported in immunosuppressed patients with a medical history of organ transplantation or patients who are immunosuppressed from hematologic malignant abnormalities treated with chemotherapy. Trichodysplasia spinulosa-associated polyomavirus (TSPγV) was first identified in 2010.1 The causal mechanism by which this TSPγV human polyomavirus causes trichodysplasia spinulosa remains unknown. Despite this, on a molecular level, TSPγV has been shown to activate factors implicated in the mitogen-activated protein kinase (MAPK) pathway leading to cellular proliferation characteristics of trichodysplasia spinulosus.2
Sign in to take quiz and track your certificates
JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 CME Credit™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC
Corresponding Author: Flora Poon, MBBS, MRT, MHSc, Department of Dermatology, Monash Health, 246 Clayton Rd, Clayton, Victoria, Australia 3168 (email@example.com).
Published Online: July 18, 2018. doi:10.1001/jamadermatol.2018.1267
Conflict of Interest Disclosures: None reported.
Additional Contributions: We thank Richard Turner, MBBCh, Oxford University Hospitals, for provision of photos. We also thank the patient for granting permission to publish this information.
You currently have no searches saved.