A misdiagnosed infection mimicking “tree man disease”

A 10-year-old girl with Down syndrome in Malaysia presented with extensive and generalized hyperkeratotic papules and plaques on her entire body (Fig 1) over a 4-year period. There was mild itching with severe hand and foot deformity. She was socially withdrawn with poor selfesteem and poor hygiene. She was also malnourished and could neither feed herself nor walk due to the deformity of her extremities (Fig 2). The girl’s entire family also had prolonged itchy skin papules, but they were less severe, without any hyperkeratotic plaques or deformity. With a poor socioeconomic background, they had lived in an overcrowded house. The patient lived in a village with the nearest hospital a 3-hour drive away and was taken to multiple small district clinics and traditional healers. She was misdiagnosed with eczema, psoriasis, and fungal infection. Due to the remote location of their home and failed treatments due to incorrect diagnosis, the parents had given up hope seeking treatment and assumed their child had a condition known locally as “orang pokok” or “tree man” (epidermodysplasia verruciformis [EV]), a condition that received widespread media attention several years ago. Resigned to fate and needing financial aid, the family of the patient opted for public donation via the local newspaper. When her case was published, it attracted the attention of the state department of health, and a home visit was done by a dermatology team to investigate.