|Year : 2008 | Volume
| Issue : 2 | Page : 89-91
Extensive molluscum contagiosum in a HIV positive woman
N Bhanumathi, BK Vishwanath
J.J.M Medical College, Davangere, Karnataka, India
Room No 310, Kaveri Womens Hostel, Behind Bapuji Hospital, JJMMC Campus, Davangere
| Abstract|| |
A 22-year-old married woman presented with multiple, asymptomatic, skin-colored raised lesions all over the body since two months. She also complained of recurrent fluid filled lesions over the genitalia associated with fever and malaise since three days. Cutaneous examination revealed multiple pearly white papules with central umbilication, measuring 3-5mm in diameter, and few lesions were >1 cm in diameter. Koebner's phenomenon was present. The lesions were distributed in a generalized pattern with sparing of hands and feet. Examination of her genitalia revealed multiple superficial erosions and few intact vesicles along with B/L inguinal lymphadenopathy. Histopathology of the skin lesion was consistent with molluscum contagiosum. Her hemogram was within normal range, HIV-I and II reactive, CD4 count was 49 cells/cumm, and VDRL and HBSAg negative. A final diagnosis of molluscum contagiosum with recurrent herpes genitalis was made. The patient was started on HAART, but did not show any improvement.
Keywords: Extensive, molluscum contagiosum, human immunodeficiency virus
|How to cite this article:|
Bhanumathi N, Vishwanath B K. Extensive molluscum contagiosum in a HIV positive woman. Indian J Sex Transm Dis 2008;29:89-91
|How to cite this URL:|
Bhanumathi N, Vishwanath B K. Extensive molluscum contagiosum in a HIV positive woman. Indian J Sex Transm Dis [serial online] 2008 [cited 2014 Jul 28];29:89-91. Available from: http://www.ijstd.org/text.asp?2008/29/2/89/48732
| Introduction|| |
In HIV-infected patients, molluscum contagiosum manifests itself most commonly when the immune function has been dramatically reduced. Several studies document that molluscum contagiosum infection is a clinical sign of marked HIV progression and very low CD4 cell counts. 
Between 10 and 30% of patients with symptomatic HIV disease or AIDS have molluscum contagiosum. 
Herein we report a case of extensive molluscum contagiosum with recurrent herpes genitalis in a HIV-positive woman.
| Case report|| |
A 22-year-old married woman presented with multiple, asymptomatic, skin-colored raised lesions all over the body since two months. Initially, the lesions appeared over her neck, around the eyes, trunk, and later became generalized all over the body within a span of two months. She also complained of recurrent fluid filled lesions over the genitalia following which she developed painful erosions, associated with fever and malaise since three days. She also had a history of significant weight loss since six months. The patient's husband was HIV positive and had abandoned her after she developed these extensive skin lesions.
On examination, there were multiple (hundreds of lesions) skin colored, smooth surfaced dome shaped papules, seen all over the trunk [Figure 1] and extremities, with relative sparing of hands and feet. Koebner's phenomenon [Figure 2] was characteristically seen. Most of the lesions measured within a range of 3-5mm in diameter, but few lesions measured >1cm in diameter. Typical central umbilication was seen in the larger papules.
Examination of the genitalia revealed multiple large superficial ulcers and erosions over the labia majora, labia minora, and clitoris [Figure 3]. Few intact vesicles were seen over the vulva. On palpation, the ulcers were tender, nonindurated, soft in consistency, and did not bleed on touch. B/L inguinal lymphadenopathy was present. Rest of the systemic examination was normal. The hemogram was within normal limits. A histopathologic examination of the skin lesion was consistent with features of molluscum contagiosum. Multiple intracytoplasmic inclusion bodies were seen in the lower epidermis [Figure 4].
The patient tested positive for HIV I and II. Her CD4 count was 49cells/mm 3 , and VDRL and HBsAg was nonreactive. A final diagnosis of molluscum contagiosum with recurrent herpes genitalis was kept.
The patient was started on a three-drug HAART, she was adherent, but did not respond to treatment as her CD4 was below 50cells/cumm, which was a poor responder to HAART. She was given Tab. Acyclovir 400mg five times/day for eight days. The patient was also treated with Tab. Levimasole 150mg on two consecutive days/week for eight weeks as an immunomodulator. Despite these treatments, the patient did not show any clinical improvement of the molluscum lesions. Her CD4 count was repeated at the end of three months of HAART, it had fallen down to 19cells/cumm.
| Discussion|| |
Molluscum contagiosum is a common and at times severely disfiguring cutaneous viral infection in patients with HIV infection.  In these patients, the characteristic skin-colored, umbilicated papules of molluscum contagiosum can be large (1cm or more in diameter), multiple, confluent, and disfiguring, especially once the CD4 count drops below 200cells/cumm. The lesions appear verrucous, pruritic or eczematous. 
Considerable debate remains as to whether the disease is caused by the reactivation of latent virus or whether it represents a recently acquired infection complicating the patient's progressive immunosuppression. Clinically, Molluscum Contagiosum in HIV-positive persons appears to be transmitted in both sexual and nonsexual patterns. Lesions in healthy, sexually active adults commonly occur on the lower abdomen, inner thighs, and genitalia. HIV-infected patients may have lesions with this distribution, but lesions on the face and neck are more common. 
One of the most important aspects of molluscum contagiosum virus disease is the differential diagnosis, which includes cryptococcosis, penicillinoses, histoplasmosis, pneumocystosis, pyogenic granuloma, basal cell carcinoma, kerato acanthoma, and atypical mycobacterial infections. 
Atypical molluscum lesions may resemble comedones, abscesses, furuncles, condylomas, syringomas, keratoacanthomas, basal cell carcinomas, ecthyma, sebaceous nevus of Jadassohn, and a cutaneous horn. 
Toluidine blue or Giemsa staining of the white curd-like material expressed from just below the surface of the umbilicated lesion reveals eosinophilic molluscum or Henderson-patterson bodies. 
However, in one study of a cohort of 199 patients, four developed molluscum contagiosum as an immune reconstitution inflammatory syndrome (IRIS) phenomenon. The lesions appeared after a median of eight weeks of starting HAART. There were also case reports of IRIS presenting as an inflamed mollusca. 
Treatment modalities for molluscum contagiosum include surgical methods, such as, curettage, electrodesiccation, cryotherapy, and laser surgery. Cytodestructive methods use cantharadin, iodine, lactic acid, phenol, salicylic acid, silver nitrate, tretinoin, and trichloroacetic acid. Cidofovir, interferon and imiquimod are the chemotherapeutic and antiviral drugs that are effective.  Molluscum contagiosum in HIV-positive patients is notoriously difficult to treat.  The best treatment for Molluscum contagiosum in HIV-positive patients includes initial treatment of HIV with antiretroviral medications.  In our case the declining CD4 counts suggested failure of HAART. This may probably be due to very low CD4 count. Immunological failure can occur when the CD4 count is very low before initiating HAART.  This could explain the persistence of molluscum contagiosum after three months of HAART.
Gold reported on the successful use of Amino Levulinic Acid-Photodynamic Therapy in the treatment of recalcitrant molluscum contagiosum in an HIV individual.  PDT (photodynamic therapy) is a viable option for treating molluscum contagiosum in HIV-positive patients and immunocompromised children. 
| References|| |
|1.||Czelusta A, Yen-Moore A, Van der Straten M, Carrasco D, Tyring SK. An overview of sexually transmitted diseases: Part III, Sexually transmitted diseases in HIV infected patients. J Am Acad Dermatol 2000;43:409-32. [PUBMED] [FULLTEXT]|
|2.||Koopman RJ, van Merriλnboer FC, Vreden SG, Dolmans WM. Molluscum contagiosum a marker for advanced HIV infection. Br J Dermatol 1992;126:528-9. |
|3.||Schwartz JJ, Myskowski PL. Molluscum contagiosum in patients with human immunodeficiency virus infection: A review of twenty seven patients. J Am Acad Dermatol 1992;27:583-8. [PUBMED] |
|4.||Hogan MT. Cutaneous infections associated with HIV/AIDS. Dermatol Clin 2006;24:473-95. [PUBMED] [FULLTEXT]|
|5.||Lehloenya R, Meintjes G. Dermatologic manifestations of the immune reconstitution inflammatory syndrome. Dermatol Clin 2006;24:549-70. [PUBMED] [FULLTEXT]|
|6.||Perna AG, Tyring SK. A review of the dermatologic manifestations of poxvirus infections. Dermatol Clin 2002;20:343-6. [PUBMED] |
|7.||Final draft ART guidelines 25 August 2006. Antiretroviral therapy for HIV infected Adults and Adolescents. Technical Guidelines 2006 National AIDS control organization, Ministry of Health and Family Welfare Government of India. Pg. 20. |
|8.||Gold MH. The use of ALA-PDT in the treatment of recalcitrant molluscum contagiosum in HIV / AIDS affected individuals. J Laser Surg Med 2003;15:40. |
|9.||Gold MH, Moiin A. Treatment of verrucae vulgaris and Molluscum Contagiosum with Photodynamic Therapy. Dermatol Clin 2007;25:75-80. [PUBMED] [FULLTEXT]|
[Figure 1], [Figure 2], [Figure 3], [Figure 4]