Intravenous Cidofovir for Recalcitrant Verruca Vulgaris in the Setting of HIV

Abstract

A 34-year-old human immunodeficiency virus (HIV)– seropositive man with a history of Kaposi sarcoma and ocular cytomegalovirus presented with an 8to 10-month history of multiple, progressively enlarging verrucous papules on the proximal nail fold and the distal interphalangeal joint of the right third finger (Figure 1). His CD4 cell count was 21/μL during retroviral therapy. A clinical diagnosis of verruca vulgaris was made, and the patient was treated unsuccessfully with a variety of therapeutic modalities, including liquid nitrogen cryosurgery and hyperthermia, as well as topical imiquimod, tretinoin solution, 0.1% tazarotene gel, and 25%, 50%, and 75% podophyllin, singly and in combination. Subsequently, the patient developed molluscum contagiosum, condylomata accuminata, and periungual warts on 6 other fingers. These conditions were also treated with multiple destructive and topical modalities, without improvement. The verrucous papules on the right third finger coalesced to form a 2-cm, fungating plaque, with resultant nail deformity. The findings of a biopsy that was performed to rule out squamous cell carcinoma showed verruca vulgaris. Because multiple treatments had failed, the verruca was treated with 3% cidofovir ointment, under occlusion, for 8 to 10 hours per day. The molluscum contagiosum and condylomata were treated with topical cidofovir ointment without occlusion. Despite this therapeutic approach, the verrucous plaque on the right third finger enlarged to 2.5 cm. This entire wart was surgically removed, and treatment with topical cidofovir, under occlusion, was reinstituted immediately after reepithelialization. Pathologic examination again showed verruca vulgaris. Within 1 month of debulking, the verruca recurred and enlarged to 3.5 cm. The molluscum contagiosum and condylomata also failed to respond to topical cidofovir therapy.