|Year : 2015 | Volume
| Issue : 1 | Page : 95-98
Giant molluscum contagiosum with granulomatous inflammation and panniculitis: An unusual clinical and histopathological pattern in an HIV seropositive child
Shital Amin Poojary, Priyanka Trimbak Kokane
Department of Dermatology, Venereology and Leprology, K.J Somaiya Medical College and Research Centre, Mumbai, Maharashtra, India
|Date of Web Publication||8-May-2015|
Dr. Shital Amin Poojary
A-401, Veena Vihar, Datta Mandir Road, Dahanukar Wadi, Kandivali (West), Mumbai - 400 067, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Molluscum contagiosum is known to occur in the advanced stages of immunodeficiency in HIV infected patients and may present as atypical variants including giant molluscum. Here we describe the rare occurrence of giant molluscum contagiosum in an HIV seropositive child, which warranted surgical excision followed by skin grafting due to its unusually large size. We also highlight in this case report, a rare granulomatous inflammatory reaction pattern to molluscum with panniculitis.
Keywords: Giant, granulomatous, HIV, molluscum contagiosum, panniculitis
|How to cite this article:|
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 2015;36:95-8
|How to cite this URL:|
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 [serial online] 2015 [cited 2023 Mar 27];36:95-8. Available from: https://ijstd.org/text.asp?2015/36/1/95/156750
| Introduction|| |
Molluscum contagiosum is a common viral infection in children.  However in immunocompromised children, atypical presentations including disseminated and giant molluscum can occur similar to those seen in adults. , The atypical variants can mimic other opportunistic infections as well as tumors in the setting of immunosuppression in HIV seropositive children. Molluscum contagiosum normally does not elicit much inflammatory response especially in early lesions although it may show a chronic inflammatory response in regressing lesions.  Here, we report a rare case of giant molluscum with an unusual granulomatous inflammation pattern and panniculitis in an HIV seropositive child.
| Case Report|| |
A 10-year-old female child seropositive for HIV (acquired perinatally) presented to our dermatology outpatient department with a swelling on left cheek, which had gradually increased in size over a period of 6 months. In addition, she also complained of multiple skin coloured to white lesions over face, neck, lower abdomen, both hands and lower extremities since 6 months. Patient didn't have any other systemic complaints. There was no history of tuberculosis, herpes zoster, diarrhoea, or any other opportunistic infections. One-year back, patient had been started on anti-retroviral therapy (ART) (zidovudine, lamivudine, nevirapine [ZLN]) in a government ART centre on account of her low CD4 count (222 cells/mm 3 [normal: 448-1611 cells/mm 3]). However she had poor compliance and her CD4 count was consistently low (ranging between 172 and 224 cells/mm 3 ) during the year.
On examination there was a single, well defined, lobulated, tumoral swelling 5 cm × 6 cm × 7 cm in size on the left cheek [Figure 1]. Skin overlying the swelling was thinned out with surface showing evidence of ulceration, haemorrhagic crust with slough. Swelling was freely mobile over underlying structures. Multiple, discrete, pearly white, umbilicated papules were present over cheek, forehead, upper eyelids, nose, lower extremities and buttocks. There was no lymphadenopathy. Systemic examination including central nervous system examination was normal. A differential diagnosis of giant molluscum contagiosum, keratoacanthoma, squamous cell carcinoma and cryptococcosis was considered.
|Figure 1: Single, well defined, lobulated, tumoral swelling (5 cm × 6 cm × 7 cm in size) on the left cheek. Surface of the swelling showed few pearly white flat topped papules, ulceration with hemorrhagic crust and slough. Multiple, discrete, pearly white, umbilicated papules were present over surrounding skin|
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On investigations, she had anemia (Haemoglobin: 7.6 g/dl [Normal: 9-11 g/dl]) and CD4 count was 251 cells/mm 3 . Other investigations including total leukocyte count, liver function tests and renal function tests were normal. Viral load estimation could not be done as the patient's parent refused to do the same due to financial constraints at that time. A punch biopsy of the tumoral swelling on left cheek revealed acanthosis with keratinocytes showing intracytoplasmic eosinophilic inclusion bodies, which were becoming basophilic in the granular layer. Thus a diagnosis of giant molluscum contagiosum was made.
After correction of anemia, complete excision of the giant molluscum contagiosum was done followed by split thickness skin grafting. The cut surface of the excised lesion showed multiple gyri like corrugations corresponding to the marked acanthosis seen on histopathology. At the base of the excised lesion, multiple pearly white papules could be seen [Figure 2]. On histopathological examination [Figure 3], there was marked acanthosis, keratinocytes showing intracytoplasmic eosinophilic to basophilic inclusions which were extruding out with keratinous debris. The epidermal ridges extended deep into the dermis surrounded by a dense lymphohistiocytic infiltrate with multiple giant cells and few plasma cells/neutrophils. Within the infiltrate, occasional degenerated molluscum bodies were seen. The infiltrate also extended into the subcutaneous fat resulting in septal panniculitis with extensive fibrosis. One-month later, there was complete healing at the site of skin grafting with minimal scarring [Figure 4]. Rest of the lesions were treated with topical 10% trichloroacetic acid (TCA) application resulting in gradual resolution. The patient was continued on ART (ZLN) with thorough counselling regarding compliance with medication. Her CD4 count improved to 676 cells/cmm after 10 months and had undetectable viral load. One-year later, on follow up, there has been no recurrence of lesions.
|Figure 2: The cut surface of the excised lesion showed multiple gyri like corrugations. At the base of the excised lesion, multiple pearly white papules are seen (→)|
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|Figure 3: Histopathology of the excised lesion (H and E). (a) Scanner magnification (×20) showing marked acanthosis with keratinocytes showing intracytoplasmic eosinophilic to basophilic inclusions. The epidermal ridges also extended deep into the dermis which showed dense granulomatous infiltrate along with fibrosis. The infiltrate also extended into the subcutaneous tissue with resultant septal panniculitis and extensive fibrosis. (b) Higher magnification showing marked acanthosis with intracytoplasmic eosinophilic to basophilic inclusions which are extruding out with keratinous debris (H and E, ×100). (c) The dermis showed dense lymphohistiocytic infiltrate with multiple giant cells, few plasma cells/neutrophils and occasional degenerated molluscum bodies (→) (H and E, ×400). (d) Septal pannicultis with marked fibrosis (H and E)|
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|Figure 4: Postexcision and skin grafting: Complete healing with minimal scarring|
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| Discussion|| |
Molluscum contagiosum is caused by Molluscipoxvirus which has four genetically distinct but clinically indistinguishable subtypes (MCV1-MCV4).  A relatively higher incidence of MCV-2 has been reported in adults and in HIV infection as compared to that in children. 
Incidence of molluscum contagiosum in HIV infected persons is 5-18%. In patients with CD4 count <200 cells/mm 3 , incidence rises to 25-35%. Lesions most commonly occur on face (eyelids), neck and genital tract.  Often lesions do not have characteristic dome shape with central umbilication. Patients with advanced HIV disease often have persistent and treatment resistant or disseminated molluscum lesions. An inverse relation has been observed between CD4 count and number of molluscum lesions.  Unusual morphological variants including giant, tumor like nodular lesions (>1 cm), necrotic lesions, abscesses, polypoidal or pseudocystic variants and cutaneous horn have been described in HIV seropositive patients. ,,
Introduction of highly active antiretroviral therapy and subsequent immune restoration can lead to resolution of molluscum contagiosum even without use of topical therapies.  Presence of molluscum contagiosum may herald advancing immunosuppression or very occasionally immune reconstitution.  In our patient, the temporal association of occurrence of the molluscum after the initiation of ART, the rapid increase in size of the lesion and presence of granulomatous infiltrate did lead us to consider the possibility of immune reconstitution inflammatory syndrome. However, since the CD4 count remained persistently at or below baseline levels even upto 1-year after starting ART, it indicated immunological failure. This immunological failure resulted in rapid growth of the giant molluscum as a sign of early clinical failure. However, subsequent good adherence to ART resulted in a good response manifesting as an increased CD4 count and resolution of molluscum lesions with appropriate treatment, which indicated a reversal of the clinical and immunological failure.
Diagnosis of molluscum contagiosum can be made by detection of Henderson Patterson bodies on tissue smear. Histopathology shows acanthosis with epidermal cells containing large intracytoplasmic eosinophilic to basophilic bodies in the stratum malpighii. The surrounding dermis usually shows little or no inflammatory reaction. However, when the lesion ruptures and discharges molluscum bodies into the dermis, it induces a mononuclear inflammatory infiltrate. Granulomatous infiltrate has been very rarely described especially in longstanding lesions and is probably due to discharge of the contents of the papule into the dermis.  Another rare pattern of inflammation described in molluscum is the CD30 + pseudolymphomatous type infiltrate.  Panniculitis has not yet been described in lesions of molluscum contagiosum. In our case, the markedly proliferative epidermis extended fairly deeply into the dermis with extrusion of molluscum bodies, setting off a granulomatous reaction pattern with panniculitis.
Treatment options in immunocompromised patients include topical cidofovir (1-3%), imiquimod 5%, TCA, intralesional IFN, cryotherapy and electron beam therapy. , A single case report of successful treatment of recalcitrant molluscum in HIV infected patient with paclitaxel has been reported. 
Our case was unique in both clinical as well as histological presentation; the tumoral appearance and presence of dense granulomatous infiltrate with panniculitis. A giant molluscum of such a large size has not been described in literature. An important note is that in the setting of immunosuppression due to HIV infection, the atypical presentation of molluscum may resemble tumors (including squamous cell carcinoma, basal cell carcinoma, lymphoma, Kaposi's sarcoma) and mycotic infections (cryptococcosis, histoplasmosis, penicilliosis) and vice versa making histopathological examination a key factor in diagnosis. ,
| Acknowledgements|| |
Dr. J. K. Maniar, for his valuable inputs and guidance.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
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