7/31/2019 1-Jurnal OL

1/3

219

Copyright 2009 Cornetis; www.cornetis.com.pl

Dermatologia Kliniczna 2009, 11 (4): 219-221

ISSN 1730-7201PRACE KAZUISTYCZNE / Case reports

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 corresp ondence: 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 andhistological 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 postawie-nie 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 con-

tained 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 beennoted, 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 from2 weeks to 6 months.

MC is characterized by the appearance at the sites of ino -

culation 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 toa 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 sometimespruritus and pain are noted. During secondary infection, an in-

creased acute inflammatory picture can be seen, during which

a scalingappears 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 wasdescribed 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 deter-

mined (17). Singh et al. (18) reported increased MC and Kaposis

sarcoma in an HIV-infected patient.

7/31/2019 1-Jurnal OL

2/3

Dermatologia Kliniczna 2009, 11 (4)Farajev Z.Q., Amirova I.A., Mahmudov F.R., Babazarov I.Z.Giant molluscum contagiosum

220

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 eosinophilicstructures 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 atnight 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 approxi-

mately 6-8 weeks, after which it subsides on its own.

Case report

A five-month-old girl was admitted to the Republic Derma-tological-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 nodulesin 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.

Discussion

GMC, characterized by more widely spreading focuses oflesion 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

in the described patient. An atypical course of CM in children

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

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

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

7/31/2019 1-Jurnal OL

3/3

221

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.

References

1. Juliusberg M.: Zur Kenntnis des virus des Molluscum contagiosum. Dtsch.

Med. Wochenschr., 1905, 31, 1598-1599.2. Myskowski P.L.: Molluscum contagiosum. New insights, new directions.

Arch. Dermatol., 1997, 133, 1039-1041.

3. Scholz J., Rosen-Wolff A., Burgert K., Reisner H., White M.I., Darai G.,

Postlethwaite R.: Epidemiology of molluscum contagiosum using geneticanalysis of the viral DNA. J. Med. Virol., 1989, 27, 87-90.

4. Porter C.D., Archard L.C.: Characterization by restriction mapping of three

subtypes of molluscum contagiosum virus. J. Med. Virol., 1992, 38, 1-6.5. Gottlieb S.L., Myskowki P.L.: Molluscum contagiosum. Int. J. Dermatol.,

1994, 33, 453-461

6. Yamashita H., Uemura T., Kawashima M.: Molecular epidemiologic analysisof Japanese patients with molluscum contagiosum. Int. J. Dermatol., 1996,

35, 99-105.

7. Katzman M., Carey J.T., Elmets C.A., Jacobs G.H., Lederman M.M.:Molluscum contagiosum and the acquired immunodeficiency syndrome:

Clinical and immunological details of two case. Br. J. Dermatol., 1987, 116,131-138.

8. Postlethwaite R.: Molluscum contagiosum: A review. Arch. Environ. Health,1970, 21, 432-452.

9. Emond R., Rouland Kh., Welsbi F.: Infection diseases. Practice, Moscow

1998, 366-369.10. Ivanov O.L.: Dermatologic-venereology diseases: Reference book. Practice,

Moscow, 2007, 169.

11. Kumar P., Chatura K.R., Jagannath V.K.: Giant molluscum contagiosumin an infant. Ind. J. Dermatol. Venerol. Leprol., 1999, 65, 290-291.

12. Hellier F.F.: Profuse mollusca contagiosa of the face induced by cortico-steroids. 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 virusinfected 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 withAIDS. 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