HTLV-1 Lymphomas, the Skin and its Histogenesis
Hubert Daisley1, Wavney Charles2 and Solange De Noon3
1General Hospital San Fernando Trinidad and Tobago WI, USA
2General Hospital Port of Spain Trinidad and Tobago WI, USA
3General Hospital San Fernando, USA
*Corresponding author: Hubert Daisley, General Hospital San Fernando Trinidad and Tobago WI, USA, Tel: 1868-3990188; Email: profhdjr@yahoo.com
Received Date: 26 May, 2016; Accepted Date: 27 June, 2016 Published Date: 11 July, 2016
Citation: Daisley H, Charles W, Noon SD (2016) HTLV-1 Lymphomas, the Skin and its Histiogenisis. Gav J Case Report 17-21.
Human T-cell leukemia/lymphoma virus type 1
(HTLV-1) associated lymphomas, namely adult T-cell leukemia/lymphoma (ATLL),
are endemic in the Caribbean. Generalized lymphadenopathy, hepatosplenomegaly,
maculopapular rash and hypercalcemia are some of the distinguishing clinical
features of this lymphoma. Historically much attention was given to the
development of adult T-cell lymphoma (ATL) within lymph nodes with secondary
involvement of the skin.
It has become apparent that the histiogenesis of ATL may originate
within the skin (Primary ATL of the skin) with a protracted indolent course,
which eventually involves lymph nodes and other organs.
Three cases of primary ATL of the skin are presented in support
of this theory.
Keywords: ATL; Histiogenesis; Primary ATL of the Skin; HTLV-1
1. Introduction
The HTLV-1 virus is endemic in the Caribbean,
Southwestern Japan, Central and South America and certain regions of Africa
[1-5].
The virus is transmitted via blood transfusion, breast milk and
sexual contact [6]. Like HIV infection, HTLV-1 is associated with immune
suppression and carriers of HTLV-1 may be infested with Norwegian scabies [7]
and Strongyloides stercoralis [8].
HTLV-1 is also associated with childhood infective dermatitis
[9] the inflammatory condition HAM/TSP [10] and ATL or HTLV-1 lymphomas.
ATL/ HTLV-1 associated adult T-cell lymphomas is an aggressive
type of leukemia/Lymphoma which has classically presented with generalized
lymphadenopathy, hepato-splenomegaly, a maculopapular rash, peripheral
blood leukocytosis, elevated levels of Lactate dehydrogenase and bilirubin, and
intractable hypercalcaemia. [2,11,12]. It has been postulated that in HTLV-1
induced oncogenesis, viral proteins such as Tax and HBZ promote the
proliferation of HTLV-I infected cells and induce ATL in about 2-6% of carriers
after a long latent period [13-15].
ATL is generally resistant to chemotherapy and carries a dismal
prognosis particularly for the acute and lymphoma subtypes [16,17].
The histiogenesis of ATL is unclear and like morphologically
similar non-HTLV1 non-Hodgkin’s lymphomas, may originate from lymph nodes,
which may secondarily involve other organs like the heart and the skin.
However there is a body of evidence, which shows the skin as the
primary site of ATL evolution [18-20]. This latter form of ATL is primary
cutaneous ATL. The three cases described from Trinidad W.I serve to support the
histiogenesis of ATL from the skin.
2. Case Reports
2.1. Case 1
The history is that of a 58-year-old African female who
developed a pruritic rash on her face and upper trunk since 2005. A clinical
diagnosis was made on her presentation to the Dermatology clinic as acne
conglobata, with a differential of granulomatous rosacea. She was treated with
topical ointments and oral antibiotics with some good effect.
A skin biopsy then showed keratotic plugging and a dermal
non-specific perivascular chronic inflammatory cell infiltrate. She migrated to
another island and was lost to follow up for nine years. She reappeared in 2015
with pruritic papules involving her face (Figure 1) and upper trunk and a
swelling in her scalp. Biopsy of the skin lesion from her back revealed a
T-cell lymphoma. This was manifested as a band like lymphocytic infiltrate
within the dermis amongst dermal blood vessels (Figure 2). This infiltrate was
also seen in a mild patchy fashion in the deeper layers of the skin, and
expressed CD3 positivity, CD5 positivity and CD45 positivity.
The bone marrow biopsy showed no infiltrate of lymphoma cells.
She was tested for HTLV-1 and was positive. She was HIV negative. Whole body CT
scan showed a 4cm lymph node in the right infraclavicular region. No other
organ showed involvement on CT scan.
Her Hb was 12.3 g/dL, HCT 38.1 uL, MCH 27.2 pg, MCV 84.8 fL,
MCHC 32.4 g/dL, platelets 211 (10^3/uL), WBC 8.6 (10^3/uL), Neutrophils 31%.
Lymphocytes 47% Eosinophil 2%. There were no atypical lymphocytes seen.
Her C-reactive protein (CRP) was positive, Rheumatoid Factor
(RF) was positive and also her Antinuclear Antibody (ANA) was positive. Serum
Calcium 10.3 mg/dL, LDH 169 U/L.
She was started on CHOP chemotherapy regimen with a repeat cycle
every 21 days. She has been responding favorably to therapy. One of her
daughters is also HTLV-1 positive but is free of HTLV-1 disease.
2.2. Case 2
This is a 52-year-old African female who presented with
non-pruritic discoid plaques on both forearms since October 2014.
She was afebrile, and had no lymphadenopathy. She suffered no
weight loss. Biopsy of the plaque showed a cutaneous T-cell lymphoma (Figures 3
and 4), which was CD3 and CD7 positive, and CD20 negative. She was HTLV-1
positive. She was HIV negative.
Skeletal survey revealed an absence of lytic lesions, and whole
CT scan revealed a nodule of the left lobe of the thyroid gland, fibroid uterus,
and an absence of internal lymphadenopathy.
Her bone marrow was hypercellular with lymphocytes bearing CD3
positivity (>20%), CD20 expression (<20%), and CD138 expression
(>20%).
Her Hb was 8.5 g/dL, HCT 30.1 uL, MCV 62 fL, MCH 17.5 pg, MCHC
283 g/dL, Platelets 269 (10^3/uL), LDH 158 U/L, Calcium 9.2 mg/dL, Total
Protein 8.7 g/dL Albumin 4.2 g/dL, Globulin 4.5 g/dL TSH 1.52 mIU/L, IgG 2250
mg/dL, IgA 333 mg/dL, IgM 68 mg/dL-polyclonal gammopathy.
She was started on Zidovudine and Interferon therapy. In 2016
her plaques transformed into nodules (Figure 5).
2.3. Case 3
This is a 26-year-old African female who presented in 2015 with
a history of having a hypo-pigmented rash for the past 6 months. These
hypo-pigmented discoid patches had a generalized body distribution involving
trunk face and limbs. They then were gradually transformed from hypo pigmented
to a pigmented scaly macular rash. (Figures 6 and 7) Clinically diagnoses of
Psoriasis, Dermatitis, and Mycosis Fungoides were made and she was treated with
topical steroids.
In July 2015 a biopsy of the lesion from her back showed a
cutaneous T-cell lymphoma, with CD3, CD5 and CD45 positivity. CD20 was
negative. She was HTLV-1 positive. Her RF was positive, ANA positive, HIV
negative.
Whole body CT scan showed no abnormality. Bone marrow biopsy
showed no infiltration with lymphoma cells. Her Hb was 12.3 g/dL. WBC 5.3
(10^3/uL) lymphocytes 42%, platelets 317(10^3/uL), LDH 261 U/L, Calcium 8.0
mg/dL. IgG 1572 mg/dL, IgA 273 mg/dL, and IgM 178 mg-dL-polyclonal gammopathy.
3. Discussion
HTLV-1 lymphoma often presented with generalized lymphadenopathy
and or a leukemic spill, hepatosplenomegaly, hypercalcaemia and a maculopapular
rash. In the earlier years of its observance, little attention was given to the
skin lesion in ATL [21,22] and it was considered to be a secondary
accompaniment and stigmata of ATL. This presentation of ATL was seen most often
in the 1980’s and represented advanced or late presentation of the disease [2].
The three cases presented above are primary cutaneous HTLV-1
associated adult T-cell lymphomas [23,24]. Case 1 has a 10-year progression of
the disease, which started as papules, which now clinically demonstrates
supra-clavicular nodal involvement and hypercalcemia. Case 2 started off as plaques
but now has advanced to tumor nodules. Case 3 most likely bears the
true histiogenesis of ATL lymphomas which begins with early
macular lesions which transform into plaques and may then transform into
tumor nodules with progressive involvement of other organs. These three
cases resemble the smoldering type of ATL reported by Bittencourt et al. [19]
and Lyra-Da-Silva et al. [20] in Brazil. Barring the HTLV-1 positivity, these
cases clinically resemble mycoses fungoides by their indolent course
evolving from patches to plaques and eventually tumor nodules, although
epidermotrophism was not a feature of their histology. They may very well
represent the histiogenesis of ATL.
The early presentation of ATL may very well be ill defined skin
manifestations in HTLV-1 carriers, since the skin manifestation may have a
protracted insidious course and may resemble other common dermatomes such as
acne, rosacea, etc., before the advanced manifestation of ATL is seen. La
Granade et al. [9] in Kingston Jamaica described the clinical pathological and
immunological features of Human T-Lymphocytic virus type`1 associated infective
dermatitis in children. What in fact this group of workers was describing was
the early manifestation of cutaneous ATL for these children were all HTLV-1
positive, and had dermatopathic lymphadenitis with palpable lymph nodes and
T-cell activation with elevated CD4 and CD8. This group of workers earlier in
1991 described a case of infective dermatitis, which evolved into ATL after 17
years [25]. There have been similar reports of childhood infective dermatitis
evolving into HAM/TSP and ATL in Brazil [26,27]. Goncalves et al [28] stated
that HTLV-1 associated infective dermatitis might be an indolent HTLV-1
associated lymphoma [28]. These bodies of evidence support the notion that the
skin is the primary site of ATL evolution. Yves et al. [29] reporting from
Martinique on the characteristics of Adult T-Cell Leukemia/Lymphoma patients
with long survival concur with the hypothesis that the skin tissue could be a
primary, precocious and privileged location for ATL cell, and that infiltration
of other tissues would therefore be secondary, delayed, and metastatic in
nature.
The early presentation of ATL may very well be ill-defined skin
lesions in HTLV-1 carriers, since the skin manifestations may have a protracted
insidious course and may resemble other common dermatoses such as acne,
rosacea, eczemas [27] or infective dermatitis [28].
Because of the fact that HTLV-1 positive carriers can have
insidious skin manifestation of ATL, it should be mandatory that all HTLV-1
positive carriers be examined carefully for early skin manifestations of the
disease. These early skin lesions should be biopsied and biomarker studies be
performed to verify their pathogenesis, and treatment with Zidovudine and
Interferon [30,31] commenced to halt the progression of the disease to its
advanced stage. Education in the prevention of the transmission of the
HTLV-1 virus should be part of the public health drive to eradicate ATL in endemic
regions [32].
Figure 1: Shows papules on the face of the 58-year-old female in case 1
Figure 2: The biopsy of the papule shows band like infiltrate of lymphocytes in the dermis of the 58 year old female.
Figure 3: Shows the ATL cell infiltrate with the dermis and deeper layer of the skin in the 52-year-old female.
Figure 4: Shows a higher magnification of the biopsy from case 2. Note the perivascular infiltrate.
Figure 5: Shows the nodules on the upper limb of the 52-year-old female.
Figure 6: Shows the hypo-pigmented spots on the upper limb of the 26-year-old female.
Figure 7: Shows the hyper-pigmented macular rash on upper limb off the 26-year-old female.
- Bartholomew C,
Charles W (1985) T cell Leukemia/Lymphoma in Trinidad. Br Med J (Clin Res Ed)
290:
- Gibbs WN,
Lofters WS, Campbell M, Hanchard B, Grenade L, et al. (1984) Adult T-cell
Leukemia/Lymphoma in Jamaica and its relationship to human T-cell
Leukemia/Lymphoma virus type1-associated lymphoproliferative disease. Princess
Takamatsu Symn. 15: 77-90.
- Fox JM, Mutalima
N, Molyneux E, Carpenter LM, Taylor G P et al. (2016) Seroprevalence of HTLV-1
and HTLV-2 amongst mothers and children in Malawi within the context of a
systematic review and meta-analysis of HTLV seroprevalence in Africa. Trop Med
Int Health 21: 312-324.
- Maekawa K,
Moriguchi-Goto S, Kamiunten A, Kubuki Y, Shimoda K et al. (2014) Primary
central nervous system lymphoma in Miyazaki, southwestern Japan, a human
T-lymphotropic virus Type-1 (HTLV-1)-endemic area: clinicopathological review
of 31 cases. J Clin Exp Hematop 54: 179-185.
- Paiva A, Casseb
J (2015) Origin and prevalence of human T-lymphotropic virus type 1 (HTLV-1)
and type 2 (HTLV-2) among indigenous populations in the Americas. Rev Inst Med
Trop Sao Paulo 57: 1-13.
- Percher F,
Jeannin P (2016) Mother-to-Child Transmission of HTLV-1 Epidemiological
Aspects, Mechanisms and Determinants of Mother-to-Child Transmission. Viruses.
- Daisley H,
Charles W, Suite M (1993) Crusted (Norwegian) scabies as a pre-diagnostic
indicator for HTLV-1 infection. Trans R Soc Trop Med Hyg 87: 295.
- Tanaka T, Hirata
T, Parrott G, Higashiarakawa M, Kinjo T, et al. (2016) Relationship Among
Strongyloides stercoralis Infection, Human T-Cell Lymphotropic Virus Type 1
Infection, and Cancer: A 24-Year Cohort Inpatient Study in Okinawa, Japan. Am J
Trop Med Hyg 94: 365-370.
- La Grenade L,
Manns A, Fletcher V, Derm D, Carberry C, et al. (1998) Clinical, pathologic,
and immunologic features of human T-lymphotrophic virus type I-associated
infective dermatitis in children. Arch Dermatol 134: 439-444.
- Bartholomew C,
Cleghorn F, Charles W, Ratan P, Roberts L, et al. (1986) HTLV-I and tropical
spastic paraparesis. Lancet 2: 99-100.
- Suzuki M,
Matsuoka H, Yamashita K, Maeda K, Kawano K, et al. (1998) CD45RO expression on
peripheral lymphocytes as a prognostic marker for adult T-cell leukemia. Leuk
Lymphoma 28: 583-590.
- Tsukasaki K,
Hermine O, Bazarbachi A, Ratner L, Ramos JC et al. (2008) Definition,
Prognostic Factors, Treatment, and response Criteria of Adult T-cell
Leukemia-Lymphoma: A proposal from an international consensus meeting. J Clin
Oncol 27: 453-459.
- Doi K, Wu X, Taniguchi Y, Yasunaga J, Satou Y et al. (2005) Preferential
selection of human T-cell leukemia virus type I provirus integration sites in
leukemic versus carrier states. Blood 106: 1048-1053.
- Mesnard JM,
Barbeau B, Devaux C (2006) HBZ, a new important player in the mystery of adult
T-cell leukemia. Blood 108: 3979-3982.
- Ghezeldasht SA,
Shirdel A, Mohammad A, Assarehzadegan MA, Hassannia T, et al. (2013) Human T
Lymphotropic Virus Type I (HTLV-I) Oncogenesis: Molecular Aspects of Virus and
Host Interactions in Pathogenesis of Adult T cell Leukemia/Lymphoma (ATL). Iran
J Basic Med Sci 16: 179-195.
- Bazarbachi A,
Suarez F, Fields P, Hermine O (2011) How I treat adult T-cell
leukemia/lymphoma. Blood 118: 1736-1745.
- Katsuya H,
Yamanaka T, Ishitsuka K, Utsunomiya A, Sasaki H, et al. (2012) Prognostic index
for acute- and lymphoma-type adult T-cell leukemia/lymphoma. J Clin Oncol 30:
1635-1640.
- Shimizu S, Yasui
C, Koizumi K, Ikeda H, Tsuchiya K (2007) Cutaneous-type adult T-cell
leukemia/lymphoma presenting as a solitary large skin nodule: a review of the
literature. J Am Acad Dermatol 57: S115-S117.
- Bittencourt AL,
da Graças Vieira M, Brites CR, Farre L, Barbosa HS (2007) Adult T-cell
leukemia/lymphoma in Bahia, Brazil: analysis of prognostic factors in a group
of 70 patients. Am J Clin Pathol 128: 875-882.
- Lyra-da-Silva
JO, de Mello Gonzaga YB, de Melo Espindola O, de Andrada-Serpa MJ, Dib C, et
al. (2012) Adult T-cell leukemia/lymphoma: a case report of primary cutaneous
tumoral type. Dermatol Pract Concept 2: 202a03.
- Nagatani T,
Matsuzaki T, Iemoto G, Kim S, Miyamoto H et al. (1990) Comparative study of
cutaneous T-cell lymphoma and adult T-cell Leukemia/lymphoma. Clinical,
histopathological, and immunohistochemical analyses. Cancer 66: 2380-2386.
- Nagatani T,
Miyazawa M, Matsuzaki T, Iemoto G, Ishii H, et al. (1992) Adult T-cell
leukemia/lymphoma (ATL) clinical, histopathological, immunological and
immunohistochemical characteristics. Exp Dermatol 1: 248-252.
- Amano M,
Kurokawa M, Ogata K, Itoh K, Kataoka H et al. (2008) New entity, definition and
diagnostic criteria of cutaneous adult T-cell Leukemia/lymphoma: human
T-lymphotrophic virus type 1 proviral DNA load can distinguish between
cutaneous and smoldering types. J Dermatol 35: 270-275.
- Tsukasaki K,
Tobinai K (2014) Human T-cell lymphotropic virus type I-associated adult T-cell
leukemia-lymphoma: new directions in clinical research. Clin Cancer Res 20:
5217-5225.
- Hanchard B,
LaGrenade L, Carberry C, Fletcher V, Williams E, et al. (1991) Childhood
infective dermatitis evolving into adult T-cell leukaemia after 17 years.
Lancet 338: 1593-1594.
- Bittencourt AL,
de Oliveira Mde F (2010) Cutaneous manifestations associated with HTLV-1
infection. Int J Dermatol 49: 1099-1110.
- Hlela C,
Bittencourt A (2014) Infective dermatitis associated with HTLV-1 mimic’s common
eczemas in children and may be a prelude to severe systemic disease. Dermatol
Clin 32: 237-248.
- Gonçalves DU,
Guedes AC, Carneiro-Proietti AB, Lambertucci JR (2000) HTLV-I associated
infective dermatitis may be an indolent HTLV-I associated lymphoma. Braz J
Infect Dis 4: 100-102.
- Yves P, Stephane
M, Rishika B, Christine D, Gérard P (2015) Characteristics of Adult T-Cell
Leukemia/Lymphoma Patients with Long Survival: Prognostic Significance of Skin
Lesions and Possible Beneficial Role of Valproic Acid. Leuk Res Treatment 2015:
476805.
- Kchour G,
Makhoul NJ, Mahmoudi M, Kooshyar MM, Shirdel A et al. (2007) Zidovudine and
interferon-alpha treatment induces a high response rate and reduces HTLV-1
proviral load and VEGF plasma levels in patients with adult T-cell leukemia
from North Iran. Leuk Lymphoma 48: 330-336.
- Ahmadi
Ghezeldasht S, Shirdel A, Assarehzadegan MA, Hassannia T, Rahimi H, et al.
(2013) Human T Lymphotropic Virus Type I (HTLV-I) Oncogenesis: Molecular
Aspects of Virus and Host Interactions in Pathogenesis of Adult T cell
Leukemia/Lymphoma (ATL). Iran J Basic Med Sci 16: 179-195.
- Wilks RJ,
LaGrenade L, Hanchard B, Campbell M, Murphy J, et al. (1993) Sibling adult
T-cell leukemia/lymphoma and clustering of human T-cell lymphotropic virus type
I infection in a Jamaican family. Cancer 72: 2700-2704.