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CASE REPORT
Year : 2022  |  Volume : 15  |  Issue : 5  |  Page : 756-759  

Giant molluscum contagiosum in an HIV-Positive patient – A case with unusual presentation and review of diagnostic modalities


1 Department of Dermatology, Smt. Kashibai Navale Medical College and General Hospital, Pune, Maharashtra, India
2 Professor and Head of Department, Department of Dermatology, Smt. Kashibai Navale Medical College, Pune, Mumbai, Maharashtra, India

Date of Submission14-Aug-2020
Date of Decision01-May-2021
Date of Acceptance02-Jun-2021
Date of Web Publication19-Jul-2022

Correspondence Address:
Dr. Abhishek Shriram Patokar
Department of Dermatology, Smt. Kashibai Navale Medical College and General Hospital, Pune, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.mjdrdypu_455_20

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  Abstract 


Molluscum contagiosum (MC) is a benign cutaneous viral infection caused by the MC virus belonging to the poxviridae family. The disease is self-limiting in immunocompetent individuals, while it is severe and prolonged when associated with Human Immunodeficiency Virus infection. Dermoscopic examination shows the presence or absence of an orifice and the vascular pattern of vessels. Henderson-Patterson bodies on histopathology, representing intracytoplasmic assemblies of the virus, are pathognomonic. Here, we present a 33-year-old unmarried male with extensive papulonodular lesions over the face, genitals, and groin, for 6 months. Dermoscopy, cytology, and histopathology were consistent with MC. His CD4 count was 9 cell/cu.mm, and HIV-1 and 2 antibodies were reactive. Thus, the diagnosis of giant MC was confirmed, and he was started on anti-retroviral therapy, cryotherapy, and topical imiquimod 5% cream over the lesions.

Keywords: Dermoscopy, Henderson-Paterson bodies, immune-compromised, umbilicated papules


How to cite this article:
Patokar AS, Gandhi MH, Kukreja M, Khatu SS, Chaudhari N. Giant molluscum contagiosum in an HIV-Positive patient – A case with unusual presentation and review of diagnostic modalities. Med J DY Patil Vidyapeeth 2022;15:756-9

How to cite this URL:
Patokar AS, Gandhi MH, Kukreja M, Khatu SS, Chaudhari N. Giant molluscum contagiosum in an HIV-Positive patient – A case with unusual presentation and review of diagnostic modalities. Med J DY Patil Vidyapeeth [serial online] 2022 [cited 2022 Dec 1];15:756-9. Available from: https://www.mjdrdypv.org/text.asp?2022/15/5/756/351334




  Introduction Top


Molluscum contagiosum (MC) is a viral infection caused by a double-stranded DNA virus, belonging to the intermediate group of poxviridae family. It replicates in the epidermis enhancing cell mitosis and disrupting epidermal cell differentiation by the upregulation of the expression of epidermal growth factor receptor.[1] There are two different strains of the virus MCV-1 and MCV-2, both are universally distributed. The commonly affected areas include the trunk, armpit, and genitals, rarely affecting the palms and soles or mucous membranes. It has bimodal incidence, one during the first 5 years of life and the other one in sexually active young adults with no difference between sexes. It is transmitted by direct contact with the skin of affected individual. Vertical transmission has also been reported as congenital disease.[2]


  Case Report Top


A 33-years-old unmarried male, driver by occupation, came to dermatology outpatient department with chief complaints of multiple, raised, white-colored lesions over face, genitals, and groin for 6 months. Lesions were asymptomatic and gradually increasing in size. There was a history of herpes zoster in the past over right flank few years ago for which he took medications and his lesions resolved with hyperpigmentation. There was a history of extramarital sexual abuse only once 6–7 months ago. There was no history regarding the HIV status of the partner whom he had contact. There was no history of blood transfusion or trauma or any drug intake before the appearance of these lesions.

Cutaneous examination revealed multiple, dome-shaped, smooth, pearly-white colored, papules with few nodules over the face, lower abdomen, shaft of penis, scrotum, groins, and left thigh. Few of them had central umbilication present. Most lesions were approximately measuring about 10–25 mm in diameter and few lesions were <10 mm in size [Figure 1]. These lesions were not tender, and no discharge was present from the lesions. Postinflammatory hyperpigmentation was present over right T12 and L1 dermatome [Figure 1]. There were no other signs and symptoms of acquired immunodeficiency syndrome. Oral, ocular, hair, and nail examinations were normal. Local lymphadenopathy was absent.
Figure 1: Giant molluscum contagiosum seen over the face, lower abdomen, shaft of penis, scrotum, groins, and right thigh. Postinflammatory hyperpigmentation of herpes zoster infection is present over right T12, L1 dermatome

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Differential diagnosis of giant MC, cutaneous cryptococcosis, and cutaneous histoplasmosis was considered.

Routine hematological and biochemical investigations were within the normal limits. Comb Aids test, MeriScreen test, and Tredo test were reactive for HIV antibodies. Serological tests for hepatitis B surface antigen, VDRL test was done to rule out syphilis, and anti-HCV were negative. Qualitative Rapid Plasma Reagin test was nonreactive. His CD4 absolute count was 9 cells/cu. mm (3%). Mantoux test showed no induration and no abnormalities were detected on chest X-ray.

Dermoscopic examination from the nodules over the face revealed few poly-lobular, white-yellow, amorphous structure in the center with a surrounding crown of vessels that do not cross the centers of the lobules. Few lesions showed open orifices with mixed vascular pattern, crown, and radial vessels on dermoscopy [Figure 2].
Figure 2: Dermoscopy from the nodules over the face: Polylobular, white-yellow, amorphous structure in the center with surrounding vessels showing mixed vascular pattern (crown and radial patterns)

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Histopathology examination from the nodule over the left thigh showed epidermal hyperplasia and a cup-shaped lesion with inverted lobule of hyperplastic squamous epithelium which expanded into the dermis. Henderson-Paterson bodies were seen composed of round to oval, large intracytoplasmic eosinophilic inclusions in keratinocytes pushing the nucleus to the periphery [Figure 3]. Giemsa staining of the lesions over the lower abdomen was done and cytopathological examination showed anucleate and nucleate squames. Multiple basophilic ovoid bodies with a hyaline, homogenous structure surrounded by membrane were noted. Background showed mild lymphocytic infiltrate [Figure 3].
Figure 3: (a and b) Histopathology: H and E stain, (×40 and ×100) showing hyperplastic squamous epithelium with intracytoplasmic eosinophilic Henderson-Paterson bodies. (c) Tzanck smear (Giemsa stain, ×100, oil immersion) shows squamous epithelial cells and multiple basophilic ovoid bodies with a hyaline, homogenous structure surrounded by membrane

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The diagnosis of Giant MC was confirmed on characteristic clinical features and investigations. The patient was counseled about the condition and was reassured. He was started on anti-retroviral treatment, tenofovir, lamivudine, and efavirenz fixed-dose combination. Topical Imiquimod 5% cream was given alternate day overnight over lesions. Cryotherapy with liquid nitrogen was performed on nodules over lower abdomen, groins, and genitals once every 2 weeks. He is currently under follow-up period.


  Discussion Top


MC was first described by Bateman in 1817 and in 1841 Paterson demonstrated its infectivity. Its viral etiology was determined by Juliusberg in1905. A revolutionary breakthrough came in 1996 when the genome of this tumorigenic virus was sequenced. MC is caused by up to four closely related types of poxvirus, MCV 1–4 and their variants. MCV-1 is the most common type 75%–96% and commonly affects children. In patients infected with HIV, MCV-2 causes majority of infections.[3]

Regarding seroprevalence, the findings are variable in different populations. An Australian study using the enzyme-linked immunosorbent assay (ELISA) revealed an overall seropositivity rate for MCV of 23% in children and adults.[4] Sherwani et al. found a seroprevalence of 14.8% in German children and adults between 0 and 40 years, and 30.3% in a population of 30 healthy individuals from the United Kingdom with a mean age of 27 years; in both studies, seroprevalence was determined by the ELISA of antibodies against MC084 protein.[5] Watanabe et al. found a seroprevalence of 6% in a healthy Japanese population, determined by the ELISA of antibodies against an N-terminal truncation of MC133 protein.[6]

Dermoscopy of MC was first reported by Vásquez-López et al. in 2004. The clinical aspect of the umbilication of the papules is manifested on the dermoscopic plane by amorphous zones in the form of orifices. These orifices presented two types of morphology, either with a yellow-white substance in its center which is keratin, or the type with a homogeneous orifice and without any visible central and rounded structure of uniform color. Dermoscopy mainly identifies the presence of vessels and its patterns which is the main advantage of this diagnostic noninvasive technique. The different vascular patterns found in MC are crown, punctiform, radial, or mixed pattern.[7],[8]

Histopathological examination of MC reveals the lesions involving the follicular epithelium. The lesion is acanthotic and cup-shaped. In the cytoplasm of prickle cells, numerous small eosinophilic and later basophilic inclusion bodies called molluscum bodies or Henderson-Paterson bodies are formed. Eventually, their bulk compresses the nucleus to the side of the cell. In the fully developed lesion, each lobule empties into central crater. Characteristic brick-shaped poxvirus particles are seen in electron microscopy in epidermis.[3],[9] Tzanck smear with Giemsa or Wright stain shows squamous epithelial cells with distinct homogenous pear-shaped molluscum bodies.[10]

Anti-retroviral therapy is the mainstay of treatment in HIV-positive patients. Treatment options in immunocompromised patients include topical cidofovir 1%–3% cream, imiquimod 5% cream, 10% trichloroacetic acid, 10%–20% potassium hydroxide solution can be used. Physical modalities include intralesional IFN, cryotherapy, electron beam therapy, and photodynamic therapy. Oral cimetidine 40 mg/kg/day can be used.[11],[12] A single case report of successful treatment of recalcitrant molluscum in HIV-infected patients with paclitaxel has been reported.[13] Subsequent good adherence to anti-retroviral therapy results in a good response manifesting as an increased CD4 count and resolution of molluscum lesions with appropriate treatment.

Our case is being reported because of its unusual presentation and to increase awareness about its association with HIV infection. Thus, any patient presenting with giant MC or any atypical form of MC, especially of the face should be thoroughly investigated for immunosuppressive states, especially HIV infection.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Chen X, Anstey AV, Bugert JJ. Molluscum contagiosum virus infection. Lancet Infect Dis 2013;13:877-88.  Back to cited text no. 1
    
2.
Pérez-Díaz CE, Botero-García CA, Rodríguez MC, Faccini-Martínez ÁA, Calixto OJ, Benítez F, et al. Giant molluscum contagiosum in an HIV positive patient. Int J Infect Dis 2015;38:153-5.  Back to cited text no. 2
    
3.
Mohan RP, Verma S, Singh AK, Singh U. Molluscum contagiosum: report of one case with overview. BMJ Case Rep. 2013;2013:bcr2013008744. Published 2013 Apr 17. doi:10.1136/bcr-2013-008744.  Back to cited text no. 3
    
4.
Konya J, Thompson CH. Molluscum contagiosum virus: Antibody responses in persons with clinical lesions and seroepidemiology in a representative Australian population. J Infect Dis 1999;179:701-4.  Back to cited text no. 4
    
5.
Sherwani S, Farleigh L, Agarwal N, Loveless S, Robertson N, Hadaschik E, et al. Seroprevalence of molluscum contagiosum virus in German and UK populations. PLoS One 2014;9:e88734.  Back to cited text no. 5
    
6.
Watanabe T, Nakamura K, Wakugawa M, Kato A, Nagai Y, Shioda T, et al. Antibodies to molluscum contagiosum virus in the general population and susceptible patients. Arch Dermatol 2000;136:1518-22.  Back to cited text no. 6
    
7.
Ianhez M, Cestari Sda C, Enokihara MY, Seize MB. Dermoscopic patterns of molluscum contagiosum: A study of 211 lesions confirmed by histopathology. An Bras Dermatol 2011;86:74-9.  Back to cited text no. 7
    
8.
Ziani J, Chaoui R, Oukarfi S, Bennani M, Elloudi S, Baybay H, et al. Different dermoscopic aspects of molluscum contagiosum in the same patient: Case report. Asp Biomed Clin Case Rep 2020;3:128-31.  Back to cited text no. 8
    
9.
Vora RV, Pilani AP, Kota RK. Extensive giant molluscum contagiosum in a HIV positive patient. J Clin Diagn Res 2015;9:D01-2.  Back to cited text no. 9
    
10.
Singh S, Swain M, Shukla S, Chander R. An unusual presentation of giant molluscum contagiosum diagnosed on cytology. Diagn Cytopathol 2018;46:794-6.  Back to cited text no. 10
    
11.
Sen S, Goswami BK, Karjyi N, Bhaumik P. Disfiguring molluscum contagiosum in a HIV-positive patient responding to antiretroviral therapy. Indian J Dermatol 2009;54:180-2.  Back to cited text no. 11
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12.
Poojary SA, Kokane PT. Giant molluscum contagiosum with granulomatous inflammation and panniculitis: An unusual clinical and histopathological pattern in an HIV seropositive child. Indian J Sex Transm Dis AIDS 2015;36:95-8.  Back to cited text no. 12
    
13.
Sisneros SC. Recalcitrant giant molluscum contagiosum in a patient with advanced HIV disease-Eradication of disease with paclitaxel. Top HIV Med 2010;18:169-72.  Back to cited text no. 13
    


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  [Figure 1], [Figure 2], [Figure 3]



 

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