STUDY Infection in HIV-Positive Men

Ulrike Wieland, MD; Steffi Silling, PhD; Nina Scola, MD; Anja Potthoff, MD; Thilo Gambichler, MD; Norbert H. Brockmeyer, MD; Herbert Pfister, PhD; Alexander Kreuter, MD

Objective: To evaluate Merkel cell polyomavirus Results: Among 449 forehead swabs analyzed, MCPyV (MCPyV) DNA prevalence and load among men with hu- DNA was detected in 242 (53.9%). Compared with healthy man immunodeficiency (HIV) (hereafter referred controls, HIV-positive men more frequently had MCPyV to as HIV-positive men) and among healthy male con- DNA on nested polymerase chain reaction (49.4% vs trol subjects. 59.0%, P=.046) and on single-round polymerase chain reaction (15.9% vs 28.1%, P=.002). The MCPyV DNA Design: Prospective study from February 4, 2009, loads in HIV-positive men were similar to those in HIV- through April 24, 2010. negative men, but HIV-positive men with poorly con- trolled HIV infection had significantly higher MCPyV Setting: Dermatology department of a university hospital. DNA loads than those who had well-controlled HIV in- fection (median and mean MCPyV DNA loads, 2.48 and Patients: A total of 449 male adults were prospectively 273.04 vs 0.48 and 11.84; P=.046). recruited, including 210 HIV-positive men who have sex with men and 239 healthy controls. Cutaneous swabs were Conclusions: Cutaneous MCPyV prevalence is in- obtained once from the surface of the forehead in all creased among HIV-positive men who have sex with men. participants. Furthermore, MCPyV DNA loads are significantly higher in HIV-positive men with poorly controlled HIV infec- Main Outcome Measures: Swabs were evaluated for tion compared with those who have well-controlled HIV the presence of MCPyV DNA using single-round and infection. This could explain the increased risk of MCPyV- nested polymerase chain reaction. The MCPyV DNA load associated Merkel cell carcinoma observed among HIV- (the number of MCPyV DNA copies per ␤-globin gene positive individuals. copy) was determined in MCPyV-positive samples using quantitative real-time polymerase chain reaction. Arch Dermatol. 2011;147(4):401-406

ARLY IN 2008, A NOVEL as in leukemia or in iatrogenic immuno- human polyomavirus, des- suppression secondary to solid-organ ignated Merkel cell poly- transplantation, also seems to be a cru- omavirus (MCPyV), was cial risk factor for MCC.3,8,9 Moreover, an detected in Merkel cell car- increased risk for MCC in persons with hu- cinoma (MCC), a rare but aggressive neu- man immunodeficiency virus (HIV) in- E 1 10,11 roendocrine skin tumor. The incidence fection has been reported. of MCC is rising steadily, with numbers almost tripling between 1986 and 2001. Approximately 1500 MCCs are diag- CME available online at nosed in the United States each year.2,3 www.jamaarchivescme.com Merkel cell carcinoma mainly affects older Author Affiliations: Institute of individuals of white race/ethnicity and is Since its discovery in 2008, several re- Virology, National Reference more common among men than among search groups have confirmed the high as- Center for Papillomaviruses and women, with a mean age at presentation sociation of MCPyV with MCC; approxi- Polyomaviruses, University of of approximately 70 years.4,5 The 3-year mately 80% of MCCs demonstrate MCPyV Cologne, Cologne mortality of MCC has been reported to be DNA positivity.1,12-20 In MCC, integration of (Drs Wieland, Silling, and 33%, which is higher than that of mela- the viral DNA into the tumor is fre- Pfister), and Department of noma (approximately 15%).3 Chronic ex- quent.1,21 However, MCPyV was found at Dermatology, Venereology, and Allergology, Ruhr-University posure to UV light seems to be involved lower frequencies (3%-43%) in other skin Bochum, Bochum (Drs Scola, in the pathogenesis of MCC, and more tumors (eg, basal cell carcinomas, squa- Potthoff, Gambichler, than 80% of the tumors are located on sun- mous cell carcinomas, and keratoacantho- Brockmeyer, and Kreuter), exposed areas of the body.3,6,7 Profound mas) and is frequently found in healthy Germany. dysregulation of the immune system, such skin.12,16,19,20,22-28 In contrast to MCC, MCPyV

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©2011 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 Corrected on April 15, 2011 METHODS Table 1. Characteristics of Patients and Control Subjects

Variable Value PATIENTS AND CLINICAL EXAMINATION

HIV-Positive MSM (n=210) We recruited HIV-positive MSM who were older than 18 Age, y years from the infectious diseases unit of the Department of Mean (range) 43.0 (21-75) Dermatology, Venerology, and Allergology, Ruhr-University Median (IQR) 43 (11) Patients receiving HAART, No. (%) 171 (81.4) Bochum, Bochum, Germany. The US Centers for Disease CD4 cell count, cells/µL Control and Prevention (CDC) classification system for HIV Mean (range) 592.6 (80-1822) and AIDS (http://www.aidsetc.org/aidsetc?page=cm-105 Median (IQR) 549 (355) _disease) was used to characterize the severity of HIV disease HIV-1 RNA load, copies/mL by CD4 cell counts and by the presence of specific HIV- Mean (range) 20 052 (0-884 000) related conditions. In all patients, current CD4 cell counts and Median (IQR) 0 (207)a HIV type 1 (HIV-1) viral loads were determined. Moreover, pa- CDC stage of HIV infection, No. (%) tients were interviewed regarding medical history, current use A 52 (24.8) and lifetime use of highly active antiretroviral therapy (HAART), B 92 (43.8) and smoking status. Patients having well-controlled HIV in- C 60 (28.6) fection were defined as those with undetectable plasma Unknown 6 (2.9) HIV-1 RNA and CD4 cell counts exceeding 350 cells/µL.29 As HIV infection, No. (%)b a control group, immunocompetent HIV-negative healthy men Well controlled 109 (51.9) seen at our department for skin cancer screening were in- Poorly controlled 94 (44.8) cluded in the study (Table 1). All 449 participants under- Smoking status went a complete skin examination to exclude the presence of Nonsmoker 117 (55.7) skin cancer, skin infections, and acute and chronic inflamma- Current smoker 93 (44.3) tory dermatoses. Healthy Male Control Subjects (n=239) For MCPyV sampling, a wooden cotton swab was force- Age, y fully rubbed over an area of about 10 cm2 on the forehead of Mean (range) 47.0 (18-79) patients or controls. The protocol of the study was approved Median (IQR) 48 (21) by the ethics review board of Ruhr-University of Bochum, and Smoking status, No. (%) the study was conducted according to principles of the Decla- Nonsmoker 141 (59.0) ration of Helsinki. Patients and controls gave their written in- Current smoker 52 (21.8) formed consent to participate in the study. Unknown 46 (19.2)

Abbreviations: CDC, Centers for Disease Control and Prevention; MCPyV DNA DETECTION HAART, highly active antiretroviral therapy; HIV, human immunodeficiency virus; HIV-1, HIV type 1; IQR, interquartile range; MSM, men who have sex DNA isolation was performed as previously described using with men. a commercially available DNA extraction kit (QIAamp DNA a Median is less than 40. Mini; Qiagen, Hilden, Germany).30 Real-time ␤-globin gene b Seven MSM who had HIV could not be classified as having controlled or uncontrolled HIV infection because of missing data. polymerase chain reaction (PCR) (LightCycler Control Kit DNA; Roche, Mannheim, Germany) was performed to dem- onstrate that samples contained adequate DNA and were free tumor antigen is not expressed in basal and squamous cell of substances inhibitory to PCR. For the detection of 17 carcinomas. MCPyV DNA, samples were analyzed by single-round large A recent pilot study19 performed by some of the T antigen primer set 3 PCR (309 [bp]) (sPCR) and authors of the present study found that MCPyV DNA by nested MCPyV PCR (358 bp) (nPCR) as previously was present in 31% of 120 anal, penile, and oral described, with slight modification.1,31 The LT3 and samples from men with HIV (hereafter referred to as MCPyV_outer sense (OS), _outer antisense (OAS), _inner sense (IS), and _inner antisense (IAS) primer sequences HIV-positive men) who have sex with men (MSM); 1,31 moreover, MCPyV was present in 50% (7 of 14) of have been published. Hot-start PCRs were performed in a plucked eyebrow hairs of HIV-positive MSM. These 50-µL volume containing 5 µL of purified total cellular DNA, 50mM potassium chloride, 20mM Tris-HCl buffer (pH observations encouraged us to screen for the presence 8.4), 1.5mM magnesium chloride, deoxynucleotide triphos- of MCPyV among a larger collective of HIV-positive phates (0.2mM each, Roche), 2.5 U of DNA polymerase MSM as well as among healthy male control subjects. (Platinum Taq; Invitrogen, Karlsruhe, Germany), and prim- Because MCC is frequently located on the head, we ers (0.5µM each). Cycling conditions (T3 Thermocycler; decided to obtain cutaneous swabs from the forehead Biometra, Göttingen, Germany) were 94°C for 5 minutes, of study participants for MCPyV DNA analysis. Given followed by 31 cycles of 94°C for 45 seconds, 58°C for 45 the increased risk reported in the literature10,11 for seconds, and 72°C for 60 seconds for both sPCR and nPCR. MCC development among HIV-infected individuals, For internal nested IS/IAS PCR, 3 µL of OS/OAS PCR prod- we hypothesized that MCPyV would be more fre- uct was used. The PCR products (10 µL) were separated on quently found among HIV-positive men compared 2% agarose gels and visualized by ethidium bromide stain- ing. Negative control samples with water and human placen- with immunocompetent male control subjects. tal DNA instead of patient samples were included in each Furthermore, we compared MCPyV DNA loads in amplification series and never yielded positive results. The HIV-positive and HIV-negative men and in HIV- analytical sensitivity of sPCR was 1000 copies of cloned positive men with well-controlled vs poorly controlled MCPyV LT3 DNA, and that of nPCR was 10 copies of cloned HIV infection. MCPyV LT1 DNA per assay.1

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©2011 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 Corrected on April 15, 2011 MCPyV DNA LOAD DETERMINATION Table 2. Merkel Cell Polyomavirus (MCPyV) DNA All samples positive on sPCR or on nPCR were analyzed by quan- Prevalence Among HIV-Positive MSM and Among Healthy titativeMCPyVPCR(q-PCR)usingareal-timePCRplatform(Light- Male Control Subjects Cycler 480 Real-Time PCR, Roche). The q-PCR was performed in 20 µL containing 5 µL of purified total cellular DNA and gen- MCPyV DNA Positivity, erated a 74-bp amplimer. Primer and locked nucleic acid hydrol- No. (%) ysis probe sequences and PCR conditions have been described by Variable No. nPCR sPCR Sihto et al.18 Differing from the method by Sihto et al, the elon- a gation time at 72°C was reduced to 5 seconds. Primers were syn- HIV-positive MSM 210 124 (59.0) 59 (28.1) thesized (TIB Molbiol, Berlin, Germany), and a locked nucleic acid Well-controlled 109 65 (59.6) 24 (22.0) hydrolysis probe (No. 6 of the Universal Probe Library Set, Roche) HIV infection Poorly controlled 94 58 (61.7) 35 (37.2) was used. Calculation of the initial MCPyV DNA copy numbers HIV infection in samples was performed using software accompanying the PCR Healthy male 239 118 (49.4) 38 (15.9) system (LightCycler 480 [F1 channel setting, second-derivative control subjects maximum analysis, and proportional baseline adjustment]) via Total 449 242 (53.9) 97 (21.6) a standard curve generated with exactly quantified MCPyV DNA 6 plasmid standards (10-fold dilution series from 10 to 10 copies) Abbreviations: HIV, human immunodeficiency virus; MSM, men who have aspreviouslydescribed.32 Theslopeofthegeneratedstandardcurves sex with men; nPCR, nested polymerase chain reaction; sPCR, single-round indicated amplification efficiencies from 1.919 to 2.017 (mean and polymerase chain reaction. median,1.962and1.963[n=20]).TheMCPyVDNAstandardused a Seven MSM who had HIV could not be classified as having controlled or (plasmid pJet1; Fermentas, St Leon-Roth, Germany) carried an uncontrolled HIV infection because of missing data. LT3 MCPyV (309 bp) insert. Ten copies of MCPyV standard DNA were regularly (100%) detectable, and 5 copies and 1 copy were In the latter group, almost all patients (98.2% [107 of frequently (89% and 44%, respectively) detectable by q-PCR. Nega- 109]) were receiving HAART compared with 64.9% (61 tive control samples (human placental DNA) were included in each of 94) in the group of patients who had poorly con- run and never yielded fluorescence signals above background. The trolled HIV infection (PϽ.001) (data were unavailable MCPyV DNA load was defined as the number of MCPyV DNA for 7 patients). Ninety-three HIV-positive MSM were copies per ␤-globin gene copy. The single-copy ␤-globin gene was quantified using a commercially available real-time PCR kit (Light- smokers, and 117 were nonsmokers. Cycler Control Kit DNA).32 In the control group, 239 HIV-negative healthy men (me- dian age, 48 years; age range, 18-79 years) were included. Fifty-two controls were smokers, 141 were nonsmokers, STATISTICAL ANALYSIS and smoking status was unknown in 46 controls. Statistical analyses were performed using commercially avail- At examination, none of the HIV-positive MSM and able software (PASW Statistics 18.0, version 18.0.0 for Mac; none of the controls had cutaneous infectious diseases, SPSS Inc, Chicago, Illinois). Distribution of data was assessed skin cancer precursor lesions (eg, actinic keratosis or Bo- by D’Agostino-Pearson test. t Test (for independent samples) wen disease), acute or chronic inflammatory dermato- was used to assess age dependence of MCPyV prevalence. Quali- ses (eg, psoriasis or atopic dermatitis), or clinical signs tative PCR data (nPCR and sPCR) were analyzed using the ␹2 of skin cancer (eg, squamous cell carcinoma, basal cell test and Fisher exact test (2-sided). The MCPyV DNA load data carcinoma, melanoma, or MCC). None of the HIV- (q-PCR) were analyzed using Mann-Whitney test (for 2 inde- positive MSM and none of the control subjects had a his- pendent samples) or Kruskal-Wallis test (for k-independent tory of skin cancer, including MCC. samples). PϽ.05 was considered significant. MCPyV DNA PREVALENCE AMONG RESULTS HIV-POSITIVE MSM AND AMONG HEALTHY MALE CONTROL SUBJECTS CHARACTERISTICS OF PATIENTS AND CONTROLS Overall, 53.9% and 21.6% of 449 study participants dem- onstrated MCPyV DNA positivity on nPCR and sPCR, Between February 4, 2009, and April 24, 2010, a total of respectively (Table 2). All samples positive on sPCR were 449 men (210 HIV-positive MSM and 239 HIV-negative also positive on nPCR. The MCPyV DNA prevalence did healthy male controls) were evaluated for the presence not vary significantly with age (P=.19 [n=449]). Com- of MCPyV DNA on the surface of the forehead skin. Char- pared with healthy male controls, HIV-positive MSM dem- acteristics of patients and controls are given in Table 1. onstrated MCPyV DNA positivity on their forehead sig- Among HIV-positive MSM, the age range was 21 to 75 nificantly more often on nPCR (49.4% vs 59.0%, P=.046) years (median age, 43 years). The median CD4 cell count and on sPCR (15.9% vs 28.1%, P=.002). When compar- was 549 cells/µL, and the median HIV-1 RNA load was ing HIV-positive men who had well-controlled HIV in- less than 40 copies per milliliter. Fifty-two patients were fection with those who had poorly controlled HIV infec- classified as having CDC stage A disease, 92 as having tion, the latter group showed MCPyV DNA positivity stage B, and 60 as having stage C, and the CDC stage was significantly more often on sPCR (22.0% vs 37.2%, P=.02) unknown in 6 patients. One hundred seventy-one of 210 but not on nPCR (59.6% vs 61.7%, P=.78). The MCPyV HIV-positive patients (81.4%) were receiving HAART at prevalence did not differ significantly among HIV- study enrollment. One hundred nine MSM who had HIV positive men who ever had an AIDS-defining disease in had well-controlled HIV infection at study enrollment. the past (CDC stage C) vs those who had CDC stage A

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©2011 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 Corrected on April 15, 2011 than those with well-controlled HIV infection (median, Table 3. Merkel Cell Polyomavirus (MCPyV) DNA Load 0.48; mean, 11.84) (P=.046). As found for MCPyV DNA Among HIV-Positive MSM and Among Healthy Male prevalence, current smoking status had no influence on Control Subjects MCPyV DNA load, either among HIV-negative men or in HIV-positive men. In HIV-negative men, the median MCPyV MCPyV DNA Load DNA MCPyV DNA loads were 1.23 in nonsmokers (n=68), Positivity, Median Mean 1.00 in smokers (n=27), and 1.37 (n=23) in those with Variable No. (IQR) (Range) unknown smoking status (P=.90). In HIV-positive men, HIV-positive MSMa 124 0.75 (5.10) 133.92 (0-14 650.00) the median MCPyV DNA loads were 0.66 in nonsmok- Well-controlled 65 0.48 (4.04) 11.84 (0-128.65) ers (n=75) and 1.96 in smokers (n=49) (P=.98). HIV infection Poorly controlled 58 2.48 (6.90) 273.04 (0-14 650.00) HIV infection COMMENT Healthy male 118 1.23 (9.83) 99.22 (0-2450.00) control subjects Total 242 0.98 (6.70) 117.00 (0-14 650.00) are a family of small nonenveloped double-stranded DNA that can cause disease in Abbreviations: HIV, human immunodeficiency virus; IQR, interquartile immunocompetent individuals (possibly mild respira- range; MSM, men who have sex with men. a Seven of the MSM who had HIV could not be classified as having tory infections by KI polyomavirus and WU polyomavi- controlled or uncontrolled HIV infection because of missing data. rus) and in immunosuppressed individuals (BK poly- omavirus–induced cystitis or nephropathy and JC polyomavirus–induced leukoencephalopathy) (re- or B disease: MCPyV was positive on nPCR in 63.3% (38 viewed by Jiang et al33). The MCPyV is the probable cause of 60) vs 57.6% (83 of 144) of samples (P=.53), and of most MCC. Integration of the viral genome into the MCPyV was positive on sPCR in 30.0% (18 of 60) vs host genome and expression of the viral oncogene large- 27.1% (39 of 144) of samples (P=.73). An explanation tumor antigen are hallmarks of MCPyV-induced MCC for this is that almost all patients (96.7% [58 of 60]) who development.1,17,21,34-37 On the other hand, stud- ever had an AIDS-defining disease were receiving HAART, ies24,27,38-41 on MCPyV DNA and prevalence have and more than half of them (55.0% [33 of 60]) had well- shown that MCPyV is widespread among the general controlled HIV infection at the time of swab collection. population and is acquired early in life. The association Current smoking status had no influence on MCPyV of MCPyV with skin tumors other than MCC is not very DNA prevalence as measured by nPCR or sPCR, either likely: because frequencies of MCPyV DNA prevalence among HIV-negative men or in HIV-positive men. In HIV- among these other tumors do not exceed those of nor- negative men, 48.2% (68 of 141) of nonsmokers, 51.9% mal healthy skin, viral DNA loads are significantly lower (27 of 52) of smokers, and 50.0% (23 of 46) of those with than those in MCC, and viral oncogenes are not ex- unknown smoking status showed MCPyV DNA positiv- pressed.12,16,17,19,23,26 Besides on the skin, MCPyV DNA has ity on nPCR (P=.90); the respective values on sPCR were been detected in lower frequencies among respiratory se- 15.6% (22 of 141), 11.5% (6 of 52), and 21.7% (10 of cretions (1%-17%), on oral and anogenital mucosa (4%- 46) (P=.38). In HIV-positive men, 64.1% (75 of 117) of 50%), and in the digestive tract (17%-33%).16,19,24,42-45 nonsmokers and 52.7% (49 of 93) of smokers showed By analyzing skin swabs of more than 400 HIV- MCPyV DNA positivity on nPCR (P=.12); the respec- positive and HIV-negative men, we found MCPyV DNA tive values on sPCR were 29.9% (35 of 117) and 25.8% on the forehead among 53.9% of all participants, which (24 of 93) (P=.54). confirms the high MCPyV prevalence previously docu- mented among normal skin.16,19,24,27 For example, Fou- MCPyV DNA LOAD IN HIV-POSITIVE MSM AND longne et al24 detected MCPyV DNA among 80% of cu- IN HEALTHY MALE CONTROL SUBJECTS taneous swabs of healthy volunteers, and Schowalter et al27 recovered complete circular MCPyV from The MCPyV DNA load was determined from all samples skin swabs among 40% of healthy adult volunteers. Fur- positive for MCPyV DNA on sPCR or on nPCR (Table 3). thermore, the latter authors showed that MCPyV DNA The MCPyV DNA load ranged between 0.00 and is chronically shed from skin in the form of assembled 14 650.00 in all swab samples analyzed (median, 0.98; virions. The concept that MCPyV is part of the human mean, 117.00). In samples showing MCPyV DNA posi- skin microbiome is supported by serologic stud- tivity only on nPCR, MCPyV DNA loads ranged be- ies27,38-41,46 of MCPyV that found against MCPyV tween 0.00 and 95.14 (median, 0.25; mean, 3.30); samples proteins in 42% to 88% of adults without MCC showing MCPyV DNA positivity both on sPCR and nPCR and in somewhat lower percentages of children. had MCPyV DNA loads between 0.01 and 14 650.00 (me- To our knowledge, this is the first study that investi- dian, 8.57; mean, 286.97). The MCPyV DNA loads in HIV- gates cutaneous MCPyV infection in HIV-positive indi- positive MSM (median, 0.75; mean, 133.92) were not viduals. Previously, MCPyV DNA was detected in 30% higher than those in HIV-negative men (median, 1.23; to 50% of normal oral and anogenital mucous mem- mean, 99.22) (P=.50). However, when looking at MCPyV brane swabs from HIV-positive MSM,19 and Sharp et al31 DNA loads only in HIV-positive men, patients with poorly analyzed lymphoid tissue biopsy specimens from pa- controlled HIV infection (median, 2.48; mean, 273.04) tients with AIDS who were negative for MCPyV DNA. had significantly higher cutaneous MCPyV DNA loads In the present study, we compared MCPyV DNA preva-

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©2011 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 Corrected on April 15, 2011 lence and load among forehead skin swabs of HIV- controls were not identical. Tolstov et al40 showed an age- positive MSM and healthy male control subjects. On nPCR dependent increase in MCPyV antibody prevalence, while and sPCR, men with HIV were significantly more often other studies38,39,41 have not found variations by age. We positive for MCPyV than HIV-negative men . When look- are unaware of studies of age dependence in cutaneous ing at sPCR (which has a 100-fold lower analytical sen- MCPyV DNA prevalence, but the prevalence of cutane- sitivity than nPCR) only, HIV-positive men with poorly ous betapapillomavirus DNA was shown to increase with controlled HIV infection were more than twice as fre- age.55 Although control subjects were slightly older than quently positive for MCPyV than men without HIV. These HIV-infected men in our study, MCPyV DNA preva- results point to increased MCPyV shedding in severely lence was still higher among the latter group. immunocompromised patients. Viral load determina- In summary, we showed in a large collective of HIV- tions showed that high MCPyV DNA loads can also be positive and HIV-negative men that MCPyV DNA preva- found in healthy HIV-negative men, but HIV-positive pa- lence on forehead skin is increased among HIV-positive tients having poorly controlled HIV infection had sig- men and that HIV-positive men with poorly controlled nificantly higher MCPyV DNA loads than those having HIV infection have significantly higher cutaneous MCPyV well-controlled HIV infection. As already shown for hu- DNA loads than those with well-controlled HIV infec- man papillomavirus infection among HIV-positive indi- tion. Possibly, restoration of immune control by early ini- viduals,47,48 HIV-associated immunosuppression seems tiation of HAART could lower the elevated MCC risk ob- to be associated with increased MCPyV prevalence and served among patients with AIDS by reducing cutaneous load. In contrast to human papillomavirus infection,49 cur- MCPyV replication. On the other hand, prolonged sur- rent smoking status had no influence on MCPyV preva- vival times of HIV-infected patients who receive HAART lence or load among HIV-positive men nor among HIV- could lead to further increases in MCC incidence, as older negative men investigated in our study. In line with this, age is among the risk factors for MCC development.3,5 smoking has been identified as a risk factor for human In any case, our data support the suggestion by Lanoy et papillomavirus–induced anal or cervical cancer but not al11 to regularly screen HIV-positive individuals for the for MCC.3,5,50 Considering the widespread distribution presence of MCC. of MCPyV, MCC development seems to be a rare event.4,5,8 Compared with the general population, HIV-positive pa- Accepted for Publication: December 1, 2010. tients have up to a 13-fold increased risk for MCC de- Correspondence: Alexander Kreuter, MD, Department velopment, and case reports10,11,51-54 of MCC in HIV- of Dermatology, Venereology, and Allergology, Ruhr- infected individuals have been published. Pastrana et al46 University Bochum, Gudrunstrasse 56, 44791 Bochum, suggested that the development of MCC is preceded by Germany ([email protected]). an unusually robust MCPyV infection as measured by Author Contributions: Drs Wieland and Kreuter had full strong antibody responses against the virus. In another access to all the data in the study and take responsibility study,38 significantly more patients with MCC carried an- for the integrity of the data and the accuracy of the data tibodies against MCPyV capsid protein than control sub- analyses. Study concept and design: Wieland and Kreuter. jects. Consistent with this, MCPyV DNA prevalence and Acquisition of data: Wieland, Silling, Scola, Potthoff, and load among nonlesional skin swabs of patients with MCC Kreuter. Analysis and interpretation of data: Wieland, were higher than those of healthy volunteers and of pa- Pfister, and Kreuter. Drafting of the manuscript: Wie- tients with other skin diseases.24 Possibly, the increased land, Silling, and Kreuter. Critical revision of the manu- risk for MCC observed in HIV-positive patients can be script for important intellectual content: Brockmeyer and explained by elevated cutaneous MCPyV DNA loads in Pfister. Statistical analysis: Wieland and Gambichler. Ob- these severely immunocompromised patients, making in- tained funding: Wieland and Silling. Administrative, tech- tegration of the MCPyV genome into the host cell ge- nical, and material support: Wieland, Silling, and Pfister. nome more likely. Study supervision: Wieland and Kreuter. The results presented herein should be interpreted in Financial Disclosure: None reported. consideration of the limitations in the study. Only a single Funding/Support: This study was funded by Bundes- swab from one body site was collected from each par- ministerium für Bildung und Forschung grant 01 KI 0771 ticipant. Therefore, we cannot discern transient and per- (TP7) from the Federal Ministry of Education and Re- sistent MCPyV infection or transmission from other body search and by the National Reference Center for Papil- sites. We cannot rule out that MCPyV DNA prevalence lomaviruses and Polyomaviruses, University of Co- or load among swabs collected from other skin sites or logne, Cologne, Germany (Dr Silling). at different points in time would have been different. Fou- Additional Contributions: Nicole Scholz, Tanja Blome, longne et al24 collected cutaneous swabs from several skin Monika Junk, AMT, and Nabila Ristow, AMT, provided sites of healthy volunteers and found that MCPyV DNA technical assistance. was more frequently detected among swabs taken from the face than from the trunk or limbs. Therefore, by col- lecting forehead swabs, we probably did not underesti- REFERENCES mate cutaneous MCPyV DNA point prevalence. Primar- ily, men of white race/ethnicity were included in our study. 1. 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