HPV Type 26 Causing Invasive Squamous Cell Carcinomas of Fingernails - AIDS Patient on HAART

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(a–c) Hyperkeratotic verrucous tumours of the fingertips originating from the nailbed. Following surgical removal and destruction of nail matrices, tumours recurred and eventually invaded into adjacent periungual skin. Histology revealed invasive squamous cell carcinomas. (d) Massive involvement of the perianal region with whitish-brown plaques (leucoplakias). Multiple biopsies revealed high-grade squamous intraepithelial neoplasias. Aggregates of hyperkeratotic condylomata acuminata are widely disseminated on the genitalia, perineum and buttocks.

Summary:
Squamous cell carcinoma (SCC) of the nail unit is a rare disorder. An association with high-risk genital human papillomavirus (HPV) infection has been reported. We report a 28-year-old human immunodeficiency virus (HIV)-infected bisexual man who had multiple invasive SCC of the fingers, infected with the rare type HPV 26. Classification of HPV 26 as high- or intermediate-risk type has been uncertain, due to its rare presence in cervical cancer. Despite successful treatment with highly active antiretroviral therapy (HAART), the patient developed extensive hyperkeratotic nailbed proliferations of all fingers. Tumours were refractory to treatment and invaded into adjacent tissues. X-rays of the hands demonstrated bone invasion, necessitating amputation of distal phalanges of several fingers. Histologically, highly differentiated preinvasive and invasive verrucous SCCs were identified. Molecular DNA typing identified HPV 26 in the SCCs and in some premalignant lesions. By in situ hybridization HPV 26 DNA was detected in numerous tumour cells, indicating productive infection with high-level amplification of the viral genome. In the remaining proliferations, high-risk HPV type 58, cutaneous HPVs and a putative new HPV type were identified. HPV 26 infection appears to be causally involved in the development of SCC of the nail unit in this immunosuppressed patient. Timely evaluation of chronic verrucous nailbed tumours is recommended, especially in immunocompromised patients. Identification of HPV 26, besides known high-risk HPV types, may identify patients at risk for developing SCC of the nailbed and possibly at other locations.