PRACE KAZUISTYCZNE / Case reports

Dermatologia Kliniczna 2009, 11 (4): 219-221 ISSN 1730-7201 Copyright 2009 Cornetis; www.cornetis.com.pl

Giant molluscum contagiosum

Miczak zakany olbrzymi. Opis przypadku
Zulfugar Q. Farajev, Irina A. Amirova, Farid R. Mahmudov, Ilkin Z. Babazarov
Department of Dermatology, Azerbaijan Medical University, Baku, Azerbaijan Republic

Address for correspondence: Prof. Zulfugar Q. Farajev Department of Dermatology Azerbaijan Medical University Az 1022, Street Bakichanov 23, Baku, Azerbaijan Republic; e-mail: fariddoc@mail.ru

ABSTRACT

Molluscum contagiosum (MC) is a common skin and mucosal disease of viral origin, but unusual clinical features cause difficulties in its diagnosis. Clinical and histological features of atypical giant molluscum contagiosum are described. Key words: molluscum contagiosum

STRESZCZENIE

Miczak zakany (MC) jest czsto wystpujc chorob skry i bon luzowych o podou wirusowym. W przypadkach o nietypowych objawach klinicznych postawienie rozpoznania moe sprawia trudnoci. W pracy kazuistycznej opisano obraz kliniczny i histologiczny miczaka zakanego olbrzymiego. Sowa kluczowe: miczak zakany

Introduction
Molluscum contagiosum (MC) was first described in the literature in 1817. Its viral etiology was determined by Juliusburg in 1905 (1). The stimulus is the Molluscum contagiosum virus (MCV) of the Poxviridae family, the largest human lesion-forming virus (2). It has a round or rectangular form. Its genome is contained in a linear double-stranded DNA segment, encoding an antioxidant selenoprotein (MC066L) which absorbs active metabolites of oxygen, thus protecting the cells from ultraviolet and peroxide damage. Four types of MCV have been discerned, all of which produce an identical clinical picture. MCV-1 is the most common type (3-6). Many authors noted that lesion frequencies by the different subtypes vary depending on region and country (3-6). MC spreads in tropical and subtropical regions and is connected with lower desquamation associated with high humidity (1). No ethnic, sex, or age predisposition for MC has been noted, but this infection is found more often in children with a localization on the skin of the face, torso, and extremities and rarely among infants because of the inherited mothers immunity and the long incubation period (7). The characteristic feature of infection in adults is localization in the genital area (8). MC seldom affects the palm, sole, and mucous membrane of the oral cavity. Humans are the usual source of infection, seldom animals, as cases of MC in chickens, sparrows, pigeons, chimpanzees, dogs, and horses have been described. The more frequent mode of transferring MC is direct connect with the source of infection, but infection is possible through household items and by sexual transmission (9). The incubation period is from 2 weeks to 6 months. MC is characterized by the appearance at the sites of inoculation of virus round, shiny, semitransparent papule of dense elastic consistency with a smooth surface, clear border, and a characteristic concavity visible in the center. The color varies

from flesh and pink to dark red with a violet shade. They are not inclined to grouping or mixing, but they can mix to a large rounded lesion (giant molluscum) (10). Pressing the MC papule with forceps eliminates the core mass from the central part. Subjective symptoms are as a rule absent, but sometimes pruritus and pain are noted. During secondary infection, an increased acute inflammatory picture can be seen, during which a scaling appears on the surface of the eruption. Eczema may be found around the focus. The presence of eczema or other accompanying diseases can violate the protective function of the skin, resulting in a quicker and wider spread of MC. A pseudo-Koebner phenomenon, appearing as a new eruption as a result of autoinoculation of MCV, is noted. During immunosuppression (infection, therapy, immune depressant, cytostatics, HIV), there is an increased atypical form of MC (giant MC, GMC) characterized by greater sizes of the elements (more than 2 cm) (11), their rapid spread on a wide area of skin surface, an inclination to grouping and mixing, leading to the visible formation of a large lesion, and resistance to therapy. Such cases of a difficult course of MC have been described in patients receiving immunosuppressive therapy (glucocorticoids and methotrexate), with 500 to 700 elements, mainly on the face (12, 13). During it, the classical features of MC elements (indentation visible in the center) can be significantly pronounced (14). In such cases, topical application of antiviral preparations (acyclovir, cidofovir) combined with isotretinoin and cidofovir per os is recommended (15, 16). Such spreading of difficult forms of MC, markers of late-stage HIV infection, can be regarded as an HIV-indicator disease. Moreover, during immune suppression there is a possible association of dermatosis with other infections and somatic diseases. Such a situation was described in a case of molluscum infection of the face skin of a patient with HIV infection. During microscopic examinations, molluscum bodies and Cryptococcus neoformans were determined (17). Singh et al. (18) reported increased MC and Kaposis sarcoma in an HIV-infected patient. 219

Farajev Z.Q., Amirova I.A., Mahmudov F.R., Babazarov I.Z. Giant molluscum contagiosum

Dermatologia Kliniczna 2009, 11 (4)

MC is diagnosed on basis of the clinical picture. Histological examination of material obtained by curettage or biopsy is necessary in the presence of an atypical focus of GMC. The histology of MC is characterized by acanthotic bands of epidermis close to one another and increased dystrophia in infected keratinocytes. This results in rejection of dystrophic cells in the center. The pathognomonic histological features of MC are molluscum bodies (Henderson-Peterson bodies). They are either degenerated epidermal cells or large eosinophilic structures appearing as a result of destroying by CMV (19, 20). Polymerase chain reaction (PCR) is a highly specific and sensitive method of MC diagnostics. The treatment of MC is realized by: cryotherapy, curettage, laser therapy, 5% imiquimod cream (it promotes local increases in the levels of IFN- and other cytokines) three times a week for three months. It is especially effective during treatment of MC on the face, where the formation of cicatrix is not acceptable (21), applications of a 20% water solution KOH once a day at night until the appearance of inflammation or superficial ulceration (22), after treatment, new focuses can appear which were too small to be determined during the first visit, which is why they demand subsequent attention. Papules are also often among pubic hair (21), which is why examination of this area must be especially attentive. In immune-competent persons the disease lasts approximately 6-8 weeks, after which it subsides on its own.

Fig. 1. Two lesions of the giant mollusca contagiosa in the axillary cavity Ryc. 1. Olbrzymi miczak zakany dwa ogniska w okolicy pachowej

Case report
A five-month-old girl was admitted to the Republic Dermatological-Venereological Dispensary with the complaint of small and large lesions on the skin. Her mother said that she had been ill for nearly two months. She did not remember the beginning. She had not been treated. The pregnancy lasted without pathology. The child was born at term (40 weeks) and by 3 months it had increased pathology. Among inoculations the mother reported vaccination again poliomyelitis and hepatitis B, which the patient received normally. Local status: the child had different sized nodes, from lentil to hazelnut, which were located on the back of the neck, back surface of the neck, both axillary cavities (fig. 1), left scapula (fig. 2), upper 1/3 of the left shoulder (fig. 3), the inguinal folds, and the upper 1/3 of the left femur. There was infiltrate around nodules in some of the larger areas and a hyperemic torus around them was noted, showing a scaly surface. The consistency was soft. There was a large amount of maceration in the inguinal folds. The general condition was good. Body temperature was normal (36.8C) Biochemical and general analyses of the blood were within the normal ranges (except for moderate leukocytes). The diagnosis of giant molluscum contagiosum was made. Surgical dissection of the largest nodes was recommended. Henderson-Peterson bodies were revealed in the histological examination.

Fig. 2. Lesion on the left scapular region Ryc. 2. Zmiana w okolicy opatkowej lewej

Discussion
GMC, characterized by more widely spreading focuses of lesion and greater sizes of the elements, is usually found in immunocompromised persons. It is met in combined infections in this group of patients (associations of CM with fungal, bacterial, and others viral infections). Immunopathologies were not noted 220 in the described patient. An atypical course of CM in children

Fig. 3. Two lesions of the giant mollusca contagiosa on the left shoulder Ryc. 3. Olbrzymi miczak zakany dwa ogniska na lewym barku

Farajev Z.Q., Amirova I.A., Mahmudov F.R., Babazarov I.Z. Miczak zakany olbrzymi. Opis przypadku

of younger age is probably connected with imperfection of their immune system. The reported case is therefore interesting because of the rare description of the pathology and the difficulty in its diagnostics.

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12. Hellier F.F.: Profuse mollusca contagiosa of the face induced by corticosteroids. Br. J. Dermatol., 1971, 85, 398. 13. Rosenberg E.W., Yusk J.W.: Molluscum contagiosum: eruption following treatment with prednisone and methotrexate. Arch. Dermatol., 1970, 101, 439-441. 14. .., ..: : . , 1989:372. [Berejbejn B.A., Studnicyn A.A.: Diagnostyka rnicowa chorb skry. Przewodnik dla lekarzy. Medycyna, 1989, 372.] 15. Cronin T.A., Resnik B.I., Elgant G., Kerdel F.A.: Recalcitrant giant molluscum contagiosum in a patient with AIDS. J. Am. Acad. Dermatol., 1996, 35, 266-267. 16. Meadows K.P., Tyring S.K., Pavia A.T., Rallis T.M.: Resolution of recalcitrant molluscum contagiosum virus lesions in human immunodeficiency virus infected patients treated with cidofovir. Arch. Dermatol., 1997, 130, 987-990. 17. Langewar D.N., Shroff H.J., Kohli M.A., Hira S.K.: Cutaneous cryptococcosis and molluscum contagiosum occurring in the same lesion in a patient with AIDS. Ind. J. Dermatol. Venerol. Leprol., 1998, 64, 25-28. 18. Singh V.R., Singh S., Pandey S.S.: Numerous giant mollusca contagiosa and Kaposis sarcomas with HIV disease. Ind. J. Dermatol. Venerol. Leprol., 1996, 62, 173-174. 19. Martins M.N., Tullu M.S., Mahajan S.A.: Molluscum contagiosum and Jobs syndrome. J. Posgrad. Med., 2001, 47, 268-269. 20. Rona M. MacKie: Clinical dermatology. Oxford University Press, Oxford 2003, 146-148. 21. .: . /. . , 2007, 190-192. [Habif T.: Skin disease. Diagnosis and treatment. Translation from English. MedPress, 2007, 190-192.] 22. Mahajan B.B., Pall A., Gupta R.R.: Topical 20% KOH an effective therapeutic modality for moluscum contagiosum in children. Ind. J. Dermatol. Venerol. Leprol., 2003, 69, 175-177.

Received: 2009.05.25

Approved: 2009.12.04

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