HPV73-Mediated CINII/III in a Gardasil Vaccinated Patient
Pradip Manna, Spencer Kerley, Robert Corder, Shaheen Ahmed, Paul Munyer. Physicians Reference Laboratory, Overland Park, KS; Heartland Women's Health, Saint Joseph, MO
Background: Human papillomaviruses (HPVs) are responsible for about 500,000 cases of cervical cancer, 10 million further cases CIN II/III, and 30 million anogenital warts or low grade CIN each year. Two prophylactic HPV vaccines have been developed to prevent this disease: Gardasil(R), a quadrivalent vaccine (targeting HPV6, 11, 16, 18) and Cervarix(R), a bivalent vaccine (targeting HPV-16 and -18). Both vaccines contain L1 virus-like particles (VLPs) derived from HPV16 and 18, which are most frequently associated with cervical cancer. These type-specific vaccines can effectively prevent infection of only two out of 18 potential oncogenic HPV types. Here, we report a case of CINII/III, a precursor to malignancy that a patient developed two years after Gardasil vaccination. HPV testing showed that this premalignancy is caused by HPV73, a high risk HPV type that is not detected by most commercial tests. To our knowledge, this is the first evidence of CINII/III following Gardasil vaccination.
Design: A 21 year old female with a history of normal Pap smears for two years had the recommended three injections of Gardasil vaccine within six months. No HPV testing was performed because of the normal Pap history.
Results: Two years following the Gardasil vaccination, the patient developed LSIL. No HPV testing was performed for this abnormal cytology, instead, the patient was directly referred to colposcopic biopsy examination, in which CINII/III was confirmed. COMPLeTe Care HPV, a HPV test that simultaneously detects and types all 15 oncogenic HPV types, was performed on the biopsy tissue and HPV73 was detected. The patient returned to normal Paps following the removal of the affected areas by a laser procedure.
Conclusions: The current L1-VLP vaccines are type-specific and therefore, either a multivalent L1-VLP or a broad-spectrum vaccine against all oncogenic HPV types would be the ultimate strategy to prevent HPV related diseases.
An HPV test that detects all oncogenic HPV types is an important component to prevent false-negative results in managing HPV related diseases. Additional tools such as typing can confirm the persistency of infection and multiple infections, type prevalence, type-specific etiology, and type-specific risk assessment to better manage the disease.
Finally, even small DNA viruses like HPV have salvage and backup pathways that have been honed over thousands of years of evolution and many replicative cycles. With increasing vaccination, one can predict an imbalance of the existing oncogenic types and potential emergence of new ones.
Category: Gynecologic & Obstetrics
Wednesday, March 21, 2012 1:00 PM
Poster Session VI # 186, Wednesday Afternoon