Volume 2 • Issue 2 • 1000117Madridge J Intern Emerg Med.
Journal of Internal and Emergency Medicine
Case Report Open Access
Tree man Syndrome
Professor, Department of Nursing, Mother Theresa Post Graduate & Research Institute of Health Sciences, India
Department of Nursing
Mother Theresa Post Graduate & Research
Institute of Health Sciences
Received: August 8, 2018
Accepted: August 20, 2018
Published: August 27, 2018
Citation: Dash M. Tree man syndrome.
Madridge J Intern Emerg Med. 2018; 2(2): 78-79.
Copyright: © 2018 The Author(s). This work
is licensed under a Creative Commons
Attribution 4.0 International License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the
original work is properly cited.
Published by Madridge Publishers
Tree man syndrome is an extremely rare condition more formally known as
Epidermodysplasia Verruciformis. Epidermodysplasia Verruciformis (EV, also called
Lewandowsky–Lutz dysplasia), colloquially known as tree man illness is an extremely
rare autosomal recessive genetic  hereditary skin disorder associated with a high risk
of carcinoma of the skin. It is characterized by abnormal susceptibility to human
papillomaviruses (HPVs) of the skin . The resulting uncontrolled HPV infections result
in the growth of scaly macules and papules, particularly on the hands and feet. It is
typically associated with HPV types 5 and 8,  which are found in about 80% of the
normal population as asymptomatic infections,  although other types may also
The condition usually has an onset of between the ages of one and 20,  but can
occasionally present in middle age . It is named after the physicians who first
documented it, Felix Lewandowsky and Wilhelm Lutz (
Keywords: Infections; Tree man; Syndrome; Epidermodysplasia; Scaly macules and
The cause of the condition is an inactivating PH mutation in either the EVER1 or
EVER2 genes, which are located adjacent to one another on chromosome. These genes
play a role in regulating the distribution of zinc in the cell nuclei. Zinc is a necessary
cofactor for many viral proteins, and the activity of EVER1/EVER2 complex appears to
restrict the access of viral proteins to cellular zinc stores, limiting their growth .
Signs and Symptoms
Clinical diagnostic features are lifelong eruptions of pityriasis versicolor-like
flat wart-like papules, one to many cutaneous horn-like lesions, and development of
cutaneous carcinomas .
Patients present with flat, slightly scaly, red-brown macules on the face, neck, and
body, recurring especially around the penial area, or verruca-like papillomatous lesions,
seborrheic keratosis-like lesions, and pinkish-red plane papules on the hands, upper
and lower extremities, and face. The initial form of EV presents with only flat, wart-like
lesions over the body, whereas the malignant form shows a higher rate of polymorphic
skin lesions and development of multiple cutaneous tumors. Generally, cutaneous
lesions are spread over the body, but some cases have only a few lesions which are
limited to one extremity , .
No curative treatment against EV has been found yet. Several treatments have been
0.5–1 mg/day for 6 months’ duration is the most effective
treatment owing to anti proliferative and differentiation-inducing effects.
Madridge Journal of Internal and Emergency Medicine
Volume 2 • Issue 2 • 1000117Madridge J Intern Emerg Med.
Interferons can also be used effectively together with
retinoids. Cimetidine was reported to be effective because of its
depressing mitogen-induced lymphocyte proliferation and
regulatory T cell activity features. A report by Oliveira et al.
showed that cimetidine was ineffective. Hayashi et al. applied
topical calcipotriol to a patient with a successful result.
As mentioned, various treatment methods are offered
against EV; however, most importantly, education of the patient,
early diagnosis, and excision of the tumoral lesions take
preference to prevent the development of cutaneous tumors.
A young Bangladeshi girl with bark-like growths on her
face could be the first female afflicted by “tree man” syndrome,
doctors studying the rare genetic condition. Sahana Khatun,
10, has growths on her chin, ear and nose, but doctors at
Dhaka’s Medical College hospital are still conducting tests to
establish if she has the unusual skin disorder.
Fewer than half a dozen people worldwide have
epidermodysplasia verruciformis but none so far have been women,
said Samanta Lal Sen, the head of the hospital’s burn and plastic
surgery unit. “We believe she is the first woman,” Sen said.
Huge growths weighing five kilogrammes (11 pounds)
each had consumed the hands of 27-year-old
the first recorded Bangladeshi to be suffering from the
1. Ramoz N, Rueda LA, Bouadjar B, Montoya LS, Orth G, Favre M. Mutations
in two adjacent novel genes are associated with epidermodysplasia
verruciformis. Nature Genetics. 2002; 32(4): 579–81. doi: 10.1038/ng1044
2. Lazarczyk M, Pons C, Mendoza JA, Cassonnet P, Jacob Y, Favre M.
Regulation of cellular zinc balance as a potential mechanism of EVER-
mediated protection against pathogenesis by cutaneous oncogenic
human papillomaviruses. The Journal of Experimental Medicine. 2008; 205
(1): 35-42. doi: 10.1084/jem.20071311. doi: 10.1084/jem.20071311
3. Orth G. Epidermodysplasia verruciformis: a model for understanding the
oncogenicity of human papillomaviruses. Ciba Foundation Symposium.
1986; 120: 157-74.
4. Antonsson A, Forslund O, Ekberg H, Sterner G, Hansson BG. The ubiquity
and impressive genomic diversity of human skin papillomaviruses suggest
a commensalic nature of these viruses. Journal of Virology. 2000; 74(24):
11636-41. doi: 10.1128/JVI.74.24.11636-11641.2000
5. Gül U, Kiliç A, Gönül M, Cakmak SK, Bayis SS. Clinical aspects of
epidermodysplasia verruciformis and review of the literature.
International Journal of Dermatology. 2007; 46 (10): 1069-72. doi:
6. Lewandowsky-Lutz dysplasia: Who Named It?
7. Lazarczyk M, Favre M. Role of Zn2+ ions in host-virus interactions. Journal
of Virology. 2008; 82(23): 11486-94. doi: 10.1128/JVI.01314-08
8. Stigation. 122. American Society for Clinical Investigation. 3239-47.
9. Lowy DR, Androphy EJ, Warts. In Freedberg IM, Eisen AZ, Wolff K, et al.
Fitzpatrick’s Dermatology in General Medicine (6th ed). New York City:
McGraw-Hill. 2003; 2119-2131.
10. Pereira de Oliveira WR, Carrasco S, Neto CF, Rady P, Tyring SK. Nonspecific
cell-mediated immunity in patients with epidermodysplasia verruciformis
HPV. The Journal of Dermatology. 2003; 30(3): 203-9.