The aetiology of pityriasis lichenoides (PL) is unknown. One major pathogenic theory suggests that PL is a lymphoproliferative disease or inflammatory reaction triggered by an antigenic stimulus, such as a virus or other infectious agent. We report the second case of PL et varioliformis acuta (PLEVA) occurring after measles vaccination and the first following the combined measles, mumps, rubella vaccination.

Introduction.

Measles is an acute vaccine-preventable infection common in childhood. In this study, the common dermatological signs of measles were designated the 'classic dermatological measles syndrome'. Methods. We attempted to ascertain the prevalence of 'non-classic' dermatological measles presentation in 69 paediatric patients admitted to New Somerset Hospital, Western Cape, during the recent South African measles outbreak. The patients were examined and photographed, after informed consent had been obtained, and findings were assessed by 1 dermatology consultant and 6 dermatology registrars. Measles infection was confirmed in 38 of the patients by means of IgM testing. The data were analysed using Stata version 11.1 statistical software. Outcomes. Of the group, 17.4% (95% CI 8.2 - 26.6%) displayed a classic measles dermatological picture, although all had been clinically diagnosed and admitted as complicated measles cases. Those serologically confirmed to have measles (N=38), 26.3% (95% CI 11.6 - 40.9%) conformed to the classic dermatological picture. Therefore, a significant majority of these patients presented with what was considered in this study to be a 'non-classic' dermatological picture.

Conclusions.

Measles infection in a paediatric population requiring admission may frequently present without a full-house classic dermatological picture. Recognised signs in isolation may be of greater value than the classically described syndrome as a whole. 'Non-classic' dermatological forms may occur more frequently than anticipated in complicated cases needing admission. Skin necrosis may be associated with measles.

A 45-year-old man, on carbamazepine for the past 3 months, was referred as a case of atypical measles. On examination, he had high-grade fever, generalized itchy rash, cough, vomiting and jaundice. A provisional diagnosis of drug hypersensitivity syndrome to carbamazepine was made with a differential diagnosis of viral exanthema with systemic complications. Laboratory investigations revealed leukocytosis with eosnophilia and elevated liver enzymes. Real-time multiplex polymerase chain reaction (PCR) on throat swab and blood was suggestive of human herpesvirus-6 (HHV-6). Measles was ruled out by PCR and serology. The diagnosis of drug-induced hypersensitivity syndrome (DIHS) was confirmed, which could explain all the features manifested by the patient. HHV-6 infects almost all humans by age 2 years. It infects and replicates in CD4 T lymphocytes and establishes latency in human peripheral blood monocytes or macrophages and early bone marrow progenitors. In DIHS, allergic reaction to the causative drug stimulates T cells, which leads to reactivation of the herpesvirus genome. DIHS is treated by withdrawal of the culprit drug and administration of systemic steroids. Our patient responded well to steroids and HHV-6 was negative on repeat real-time multiplex PCR at the end of treatment.

Because of high vaccination rates, population immunity against measles increased in the western world. Nevertheless, outbreaks are still observed. The aim of this article is to document and describe the natural course of dermatological manifestations and compare it with the literature.After detecting a measles index case, the dermatological onset of the disease in the non-vaccinated siblings was prospectively monitored and documented with a digital camera.Our findings show that dermatological symptoms are only limited consistently from one case to another and described heterogeneously in the literature as well.Dermatological manifestations do not seem conclusive in our clinical data set as well as in the literature. Especially the exact onset of the Koplik spots should be further explored in detail. In future, a larger population should be observed and clinical diagnostics for measles defined.

Langerhans cells (LCs) are a distinct subset of DCs that resides in the epidermis and other epithelia. They are potent antigen-presenting cells and strong inducers of T-cell responses. Like other DC types, LCs express C-type lectins that serve as antigen/pathogen uptake receptors, with Langerin/CD207 being the characteristic LC C-type lectin. In this issue of the European Journal of Immunology, Geijtenbeek and colleagues [Eur. J. Immunol. 2011. 41: 2619-2631] assign a role to Langerin on human LCs for binding and capturing measles virus. Interestingly, however, this function does not correlate with productive infection or with cross-presentation of measles virus. These authors show that measles virus does not infect the LCs via Langerin, and that LCs cannot cross-present the virus to CD8(+) T cells; however, presentation of this virus to CD4(+) T cells occurs and is dependent on virus capture by Langerin. Thus, cross-presentation of measles virus may be left to skin DCs other than LCs. This highlights the complexity of anti-viral T-cell responses that originate in the skin and also emphasizes the need for intensified investigations into human skin DCs in order to be able to ultimately harness their potential for immunotherapy.

We report a case of febrile ulceronecrotic Mucha-Habermann disease (FUMHD) in a 12-year-old boy. After 1 week of typical cutaneous appearance of pityriasis lichenoides et varioliformis acuta (PLEVA), he was given a percutaneous injection of measles virus vaccine, and then extensive polymorphous, papular, and ulcerohemorrhagic skin lesions developed along with intermittent high temperature, hepatic dysfunction, and hypoalbuminemia. Thoracic CT scan showed parenchymal nodular infiltration at the tip of vascular structures. Skin biopsy showed a combination of the classic features of PLEVA and an allergic vasculitis. We treated him with prednisolone and methotrexate (MTX) successfully. The evolution in our patient suggests that FUMHD may have been triggered by virus vaccination. We also emphasize that FUMHD in children may be successfully treated with a combination of systemic MTX and high-dose corticosteroids.

Treatment of plantar warts represents a continuing challenge for dermatologists because many of the available therapeutic modalities are associated with unsatisfactory results and high recurrence rates. Several clinical trials have proved the efficacy of intralesional immunotherapy by different antigens in the treatment of different types of warts.To evaluate the efficacy and safety of a new antigen combination-mumps, measles, and rubella (MMR) vaccine in the treatment of plantar warts.The study included 40 patients with single or multiple, recalcitrant or nonrecalcitrant plantar warts. MMR vaccine was injected into single lesions or largest wart in case of multiple lesions at 3-week intervals until complete clearance or for a maximum of 3 treatments. Follow-up was done every 3 months for 9 months to detect any recurrence.Only 23 patients completed the study. The results revealed complete clearance of the warts in 20 patients (87%), partial response in one patient (4.3%), and no response in two patients (8.7%). Complete response was achieved in 75% of patients with recalcitrant plantar warts and 83.3% of patients with warts at sites other than the soles. Recurrence was observed in only one patient (4.3%). A significant relationship was found between therapeutic response and wart duration, but not with other clinical variables. Side effects include pain during injection (82.6%) and flu-like symptoms (4.3%). No erythema, edema, or scarring has been reported.Small study sample and absence of control.Intralesional immunotherapy by MMR vaccine seems to be a simple, effective, and safe treatment modality for plantar warts.

Despite numerous therapeutic modalities reported in the literature, treatment of common warts remains a continuing challenge and there is no universal consensus about optimal treatment. Recently, intralesional immunotherapy by different antigens has proved efficacy in the treatment of different types of warts.To evaluate the efficacy and safety of intralesional mumps, measles and rubella (MMR) vaccine in the treatment of common warts.The study included 135 patients with single or multiple recalcitrant or non-recalcitrant common warts. They were randomly assigned to two groups; the first group (85 patients) received intralesional MMR vaccine, and the second group (50 patients) received intralesional saline as a control group. Both treatments were injected into single lesions or largest wart in case of multiple lesions at 2-week intervals until complete clearance or for a maximum of five treatments. Follow-up was made every 2 months for 6 months to detect any recurrence.A highly significant difference was found between the therapeutic response of common warts to MMR vaccine and saline control group (P < 0.001). In the MMR group, complete response was achieved in 80% and 84.6% of patients presenting with recalcitrant and multiple warts respectively. No recurrence was observed in the MMR group and side effects included pain during injection and flu-like symptoms.Intralesional immunotherapy by MMR vaccine is a promising effective and safe treatment modality for common warts, particularly the multiple ones.