*Giant Molluscum Contagiosum with Concurrence of Molluscum Dermatitis

Galderma


Dermatol Sinica,

Giant Molluscum Contagiosum with Concurrence ofMolluscum DermatitisWen-Yu Chang Chih-Po Chang Sen-An Yang Wan-Ting Huang** Gwo-Shing ChenFrom the Departments of Dermatology and Pathology,** Kaohsiung Medical University Hospital Dermatologic Clinic of Yang*Accepted for publication: Decembe 06, 2004Reprint requests: Gwo-Shing Chen, Ph.D., Department of Dermatology, Kaohsiung Medical University. No. 100, Shih-Chuan 1stRd., Kaohsiung, Taiwan, R.O.C.TEL: 07-3208214 FAX: 07-3216580Molluscum contagiosum is a common disease encountered by dermatologist. However, there aresome atypical presentations rarely encountered in daily practice and thus a correct impression difficultto make. We proposed the first case reported in Taiwan, a 31 year-old female, with the atypical presen-tation of a 1.5 X 1.5 cm solitary nodule with underlying erythematous base at left medial thigh, whichpathologically proved to be a giant molluscum contagiosum with molluscum dermatitis. We made abrief review of previously reported cases in the English literature and possible mechanisms of the atypi-cal clinical and pathological presentation. We also raised the importance of including molluscum contagiosumwhen encountering clinical simulants and general survey of immune status.(Dermatol Sinica 23: 81-85, 2005)Key words: Molluscum contagiosum, Giant molluscum, Molluscum dermatitis็

INTRODUCTION

Molluscum contagiosum (MC) is a viralinfection of the epidermal keratinocytes thatresults in a cutaneous tumor with characteristicintracytoplasmic inclusions. Although the MClesions tend to be flesh colored with a centralumbilication and without signs of inflammation,occasionally patients present with large and ten-der nodules with or without underlying erythe-matous base. Such atypical presentations maybe difficult to diagnose clinically, requiring abiopsy to rule out infectious or neoplasticprocesses. We herein report an atypical presen-tation of giant molluscum with concurrence of Dermatol Sinica, June 2005ૺ௼ൂFig. 1A large solitary 1.5 X 1.5 cm dome-shaped nodule withunderlying erythemaFig. 2The lesion was totally intradermal under the intact acanthotic epi-dermis with diffuse dense inflammatory infiltrates. (H&E, 40X)molluscum dermatitis, which should be carefullymanaged and surveyed.CASE REPORTA 31-year-old female, pregnant for 2months, visited our out-patient clinic with thecomplaint of a solitary asymptomatic erythema-tous nodule over her left inner thigh for half ayear. She denied underlying systemic diseases,atopic diathesis, drug, trauma or animal contacthistory. She noticed the nodule accidentallywith the initial presentation of a 0.3 X 0.3 cmflesh-colored papule and it gradually enlargedin recent three months. There was no discharge,erosion, or ulceration. She also denied sense oftenderness but only mild itch.Physical examination at our clinic revealeda large solitary 1.5 X 1.5 cm dome-shaped nod-ule with underlying erythema without demarcat-ed border (Fig. 1). Palpation of inguinal area didnot reveal any lymphadenopathy. There was noabnormal skin lesion around inguinal and geni-tal area. Under the impression of skin tumorwith differential diagnoses of verruca, der-matofibroma, keratoacanthoma, malignancy orother inflammatory or infectious diseases, weperformed total excision of the skin tumor andsent the specimen for pathologic examination.Under the microscope, the intact epidermisshowed mild hyperkeratosis, variable acanthosiswithout erosion or ulceration. The lesion wastotally intradermal (Fig. 2). Medium powerview showed lobules of epidermal cells withsome eosinophilic materials encased by denseinflammatory infiltrate. High power viewrevealed numerous enlarged keratinocytes withintracytoplasmic eosinophilic inclusion bodieswhich compressed the nucleus of keratinocytesinto a thin crescent, characteristic of molluscumbodies, with mixed cell infiltration engulfingthe tumor (Fig. 3a, b). Perivascular mixed cellinfiltrate was also noted diffusely down to deepdermis. Under the clinical presentation of a soli-tary skin nodule without history of discharge orulceration, and the pathologic presentation ofintracytoplasmic inclusion bodies, the diagnosisof giant molluscum contagiosum was given.The clinical underlying erythema and the patho-logical findings of diffuse perivascular infiltratefurther establish the diagnosis of molluscumdermatitis.We further performed laboratory examina-tion including complete blood with differentialcounts, liver and renal function, sugar level,immunoglobulin levels, subsets of lymphocytes,and the detection of HBV, HCV, HIV infection,which all showed negative results or resultswithin normal limits. We also examined herfamily members, including her husband, whowas not infected, and her two childrens, bothwith scattered flesh-colored tiny papules withcentral umbilication over the trunk and extremi-ties, which were further diagnosed molluscumcontagiosum. The patient(s lesion was margin

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Dermatol Sinica, June 200583λ̂ݭ็ߖّహ࠮Ъ׀హ࠮ّϩቲۆfree under microscopic examination so we sug-gested further observation and follow-up. Wealso arranged cryotherapy for her children.DISCUSSIONMolluscum contagiosum (MC) is a com-mon, benign, viral transmitted disease causedby a double-stranded DNA poxvirus, mollus-cum contagiosum virus (MCV) which replicatesin epidermal cells and produces characteristiccytopathic effects on biopsy. It typically pres-ents as variable numbers of small, discrete,waxy, skin-colored, dome-shaped papules withcentral umbilication, and involutes sponta-neously in immunocompetent patients.Histopathologically, it shows epidermal cellscontain intracytoplasmic eosinophilic structurestermed molluscum bodies. There are usuallypaucity of inflammatory and immune responseeven in lesions of immunocompetent patients. Itis explained by the MCV genome which mayinterfere with immune recognition and hostdefense mechanisms include (1) a major histo-compatibility complex class I heavy chainhomologue that may inhibit presentation ofMCV-specific peptides, (2) a chemokine homo-logue that may inhibit inflammation, and (3) aglutathione peroxidase homologue that mayprotect the virus and infected cells from oxida-tive damage by peroxides, which may form inresponse to infection.1-3There are some features worth noticing inour patient: first, the atypical clinical presenta-tion of a solitary giant lesion; second, the intra-dermal mass with intact epidermis despite fur-ther deep-cuts and the unusual dense mixed cellinflammatory infiltrate around the molluscumcontagiosum lesion.Rarely the molluscum lesion may becomeas large as 1 cm or more. This giant type soli-tary lesion was reported on the sole,4, 5 eyelid,6or scalp7 and causes difficulties in differentiat-ing with keratoacanthoma, verruca vulgaris,basal cell carcinoma,8 and other inflammatory,infectious, or neoplastic diseases. It has beenreported with increased incidence recent yearswith the association with HIV infection9-12 andimmunocompromised status.6, 13 Cribier B et al.had retrospectively reviewed 578 cases of mol-luscum contagiosum diagnosed under patholog-ic examination. They found only a 42% propor-tion of correct clinical diagnosis. Although theexact incidence of giant molluscum contagio-sum has not been established, they found 8giant molluscum contagiosum (1.6%) in thislarge series study with 2 of them occurring inHIV positive patients. None of them was a cor-rect clinical diagnosis made initially.14Cribier B et al. also concluded that giantmolluscum contagiosum often assumes anendophytic and cystic-like growth pattern,which should not be confused with an epider-mal cyst. The intradermal growth may beexplained by various proposed mechanisms,including (1) a section of epidermis carrying theMCV may be carried down to the dermis as theresult of trauma and there to form an implanta-tion, (2) the virus may involve the pilarinfundibulum, which subsequently closes toform an inclusion cyst, and (3) when regression,the acute inflammatory response caused bydelayed-type hypersensitivity reaction inducesdisruption of virus-infected epidermal tissueand further implantation into the dermis.15-18 Thenature of primarily follicular involvement maybe supported by areas of hair bulb or sebaceousglands differentiation, or the presence of arrec-tor pili muscles at the periphery of a molluscumFig. 3(a) Characteristic intracytoplasmic molluscum bodies withinthe tumor nodules; (b) with diffuse mixed cell inflammatorycell infiltrates. (H&E, 400X)

Dermatol Sinica, June 2005ૺ௼ൂcontagiosum lesion. It has been suggested themolluscum contagiosum induces follicular neo-genesis or preferentially colonizes theinfundibulum of normal follicles. It is thereforenot suprising to observe follicular cysts colo-nized by molluscum contagiosum virus.19In our patient, although there was no evi-dence of intact peripheral follicular structures,sebaceous glands, or arrector pili muscles inserial sections, we suspected it was obscured bydense surrounding inflammatory infiltrates, pos-sibly during regression phase.There are also several explanations of pos-sible mechanisms of inflammatory response tointradermal molluscum. One thought is compa-rable to inflammatory reactions in a rupturedepidermal cyst as the epidermis is carried downinto the dermis. The delayed-type inflammatoryreaction involved in regression, also calledņmolluscum dermatitisŇ, clinically presents asareas of eczema around the molluscum papules,and histologically presents as dense infiltrate20-23occasionally mimicking pseudolymphoma,24which could be misdiagnosed if serial sectionswere not made to visualize the molluscum bod-ies.24-26 These are thought to be due to the dis-charge of molluscum bodies to the dermis, fol-lowed by the release of proinflammatorycytokines and activation of the complementpathway.27 In about 10% of cases with classicalmolluscum contagiosum, particularly in atopicsubjects, molluscum dermatitis, usually presentsas an erythematous patch a month or more afterthe onset of molluscum contagiosum.21, 23 It maysporadically develops in the form of erythemaannulare centrifugum,28 erythema multiforme-like,21 or ecthyma-like lesions29 around the mol-luscum papules. In contrast to molluscum der-matitis, which develops immediately around themolluscum papules, a so called ņid reactionŇhas been reported in a few cases, in whicheczematoid lesions occurred ņseparatelyŇfrom the viral papules. Moreover, clinicallythese lesions of id reaction may simulate erythe-ma multiforme, erythema nodosum, erythemaannulare centrifugum, lichen scrofulosorum,dyshidrotic eczema, seborrheic dermatitis,lichenoid and sarcoid-like lesions.30Atypical lesions of molluscum contagio-sum, often reaching great size as giant lesions10or mimicking other lesions such as sebaceousnevus of Jadassohn, ecthyma, giant condylomataacuminata,29 basal cell carcinoma,8 soft fibro-mas, can be seen in immunodeficiency condi-tion, such as atopy, corticosteroid and immuno-suppressive therapy, leukemias, and AIDS.11 Because of HIV-infected patients feature mol-luscum contagiosum with atypical morphologyin about two thirds of the cases, it is importantfor all the tumorous lesions to be biopsied inAIDS patient and also important for all thepatients with atypical molluscum contagiosumto be screened of immune status. All theimmunoglobulin levels, subsets of lymphocytecounts, and HIV, HBV, HCV screening in ourpatient were all normal. Although some authorsproposed that abnormal immune systemascribed to pregnancy, chronic viral hepatitis, ormalignancies have played a part in the develop-ment of molluscum folliculitis,19 the associationof pregnancy and giant molluscum has not beenwell established. Further observations withmore cases may be necessary in elucidating thepossible relationship.Currettage is the treatment of choice.Applications of cantharidin, liquid nitrogen,trichloroacetic acid, silver nitrate, topicalretoinoids, imiquimod, and cidofovir are alterna-tives.7, 9 Our treatment was simply total excisiondue to the initial impression of skin tumor withsuspected intradermal component. The erythemafaded spontaneously after two weeks follow-up.We here describe a case of giant mollus-cum contagiosum with concurrence of mollus-cum dermatitis, demonstrate the atypical clini-cal and histopathological presentations, andbriefly review the English literature. Molluscumcontagiosum infection should be considered ineven a giant solitary and pathologically abscesslesion. Serial sections are always necessary.Further investigation is mandatory as this mayoccur in immunocompetent subjects but is alsoone of the cutaneous signs of underlyingimmune deficiency such as HIV infection.
Dermatol Sinica, June 200585REFERENCES1. Senkevich TG, Koonin EV, Bugert JJ, et al.: Thegenome of molluscum contagiosum virus: analysisand comparison with other poxviruses. Virology233: 19-42, 1997.2. Moss B, Shisler JL, Xiang Y, et al.: Immune-defense molecules of molluscum contagiosumvirus, a human poxvirus. Trends Microbiol 8: 473-477, 2000.3. Bugert JJ, Darai G: Recent advances in molluscumcontagiosum virus research. Arch Virol Suppl 13:35-47, 1997.4. Dickinson A, Tschen JA, Wolf JE, Jr.: Giant mol-luscum contagiosum of the sole. Cutis 32: 239-240, 243, 1983.5. Ha SJ, Park YM, Cho SH, et al.: Solitary giantmolluscum contagiosum of the sole. PediatrDermatol 15: 222-224, 1998.6. Linberg JV, Blaylock WK: Giant molluscum con-tagiosum following splenectomy. Arch Ophthalmol108: 1076, 1990.7. Lew W, Lee SH: Scalp mass. Arch Dermatol 131:719-722, 1995.8. Fivenson DP, Weltman RE, Gibson SH: Giantmolluscum contagiosum presenting as basal cellcarcinoma in an acquired immunodeficiency syn-drome patient. J Am Acad Dermatol 19: 912-914,1988.9. Buckley R, Smith K: Topical imiquimod therapyfor chronic giant molluscum contagiosum in apatient with advanced human immunodeficiencyvirus 1 disease. Arch Dermatol 135: 1167-1169,1999.10.Petersen CS, Gerstoft J: Molluscum contagiosumin HIV-infected patients. Dermatology 184: 19-21,1992.11.Vozmediano JM, Manrique A, Petraglia S, et al.:Giant molluscum contagiosum in AIDS. Int JDermatol 35: 45-47, 1996.12.Cronin TA, Jr., Resnik BI, Elgart G, et al.:Recalcitrant giant molluscum contagiosum in apatient with AIDS. J Am Acad Dermatol 35: 266-267, 1996.13.Taskapan O, Yenicesu M, Aksu A: A giant solitarymolluscum contagiosum, resembling nodular basalcell carcinoma, in a renal transplant recipient.Acta Derm Venereol 76: 247-248, 1996.14.Cribier B, Scrivener Y, Grosshans E: Molluscumcontagiosum: histologic patterns and associatedlesions. A study of 578 cases. Am JDermatopathol 23: 99-103, 2001.15.Egawa K, Honda Y, Ono T: Multiple giant mollus-cum contagiosa with cyst formation. Am JDermatopathol 17: 414-416, 1995.16.Park SK, Lee JY, Kim YH, et al.: Molluscum con-tagiosum occurring in an epidermal cyst–report of3 cases. J Dermatol 19: 119-121, 1992.17.Hodge SJ, Fliegelman MT, Schrodt R, et al.:Molluscum contagiosum occurring in epidermalinclusion cysts. Arch Dermatol 108: 257-258,1973.18.Brandrup F, Asschenfeldt P: Molluscum contagio-sum-induced comedo and secondary abscess for-mation. Pediatr Dermatol 6: 118-121, 1989.19 Jang KA, Kim SH, Choi JH, et al.: Viral folliculi-tis on the face. Br J Dermatol 142: 555-559, 2000.20.Henao M, Freeman RG: Inflammatory molluscumcontagiosum. Clinicopathological study of sevencases. Arch Dermatol 90: 479-482, 1964.21.Lee HJ, Kwon JA, Kim JW: Erythema multi-forme-like molluscum dermatitis. Acta DermVenereol 82: 217-218, 2002.22.Rockoff AS: Molluscum dermatitis. J Pediatr 92:945-947, 1978.23.Kipping HF: Molluscum dermatitis. ArchDermatol 103: 106-107, 1971.24.de Diego J, Berridi D, Saracibar N, et al.:Cutaneous pseudolymphoma in association withmolluscum contagiosum. Am J Dermatopathol 20:518-521, 1998.25.Ackerman AB, Tanski EV: Pseudoleukemia cutis:report of a case in association with molluscumcontagiosum. Cancer 40: 813-817, 1977.26.Moreno-Ramirez D, Garcia-Escudero A, Rios-Martin JJ, et al.: Cutaneous pseudolymphoma inassociation with molluscum contagiosum in anelderly patient. J Cutan Pathol 30: 473-475, 2003.27.Takematsu H, Tagami H: Proinflammatory proper-ties of molluscum bodies. Arch Dermatol Res 287:102-106, 199428.Vasily DB, Bhatia SG: Erythema annulare cen-trifugum and molluscum contagiosum. ArchDermatol 114: 1853, 1978.29.Itin PH, Gilli L: Molluscum contagiosum mimick-ing sebaceous nevus of Jadassohn, ecthyma andgiant condylomata acuminata in HIV-infectedpatients. Dermatology 189: 396-398, 1994.30.Rocamora V, Romani J, Puig L, et al.: Id reactionto molluscum contagiosum. Pediatr Dermatol 13:349-350, 1996.λ̂ݭ็ߖّహ࠮Ъ׀హ࠮ّϩቲۆ

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