Track: Case Reports

Abstract:

Intralesional human papilloma virus (HPV) vaccine administration is an effective treatment for cutaneous warts. Documented adverse events are limited to transient injection-site reactions. While granuloma formation following intramuscular administration is documented, cases associated with intralesional delivery have not been reported. An immunocompetent 75-year-old female presented to the dermatology clinic with recalcitrant warts on the bilateral digits. Intralesional 9-valent HPV vaccine was administered into two verrucous plaques. She returned five weeks later with pain and growth of a 3.0 cm plaque on the left fourth digit which was subsequently excised. Histopathology showed epidermal hyperplasia, papillomatosis, and koilocytes consistent with verruca vulgaris; the underlying dermis showed palisaded granulomas with CD163 positive histiocytes surrounding geometric central areas of eosinophilic fibrinoid necrotic material. GMS, Gram and AFB stains were negative. PAS stain highlighted multiple eosinophilic granules within histiocytes. Due to negative stains and suppurative granulomatous dermatitis, rubella-IHC testing was performed and positive within the granulomatous inflammation. Rubella associated granulomatous dermatitis (RAGD) is a reactive dermatosis with increasing recognition in immunocompetent patients. Histopathology shows palisaded granulomas with neutrophilic or lymphocytic infiltrate. While rubella granulomas in association with prior trauma and measles, mumps, and rubella (MMR) intramuscular vaccine are documented, this case demonstrates that RAGD must be considered for granulomatous reactions to other triggers including intralesional HPV vaccines. While confirmatory testing was not available, the histopathologic findings of central necrosis and granular material within histiocytes raise suspicion for concurrent aluminum granuloma formation, which has not been reported in association with intralesional injections or rubella granulomas to date.

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Daren Diiorio