Giant molluscum contagiosum mimicking a lid abscess: “Appearances can be deceptive”!!

Yamini Priya; Anupama Janardhanan

doi:10.4103/PAJO.PAJO_20_19

Users Online: 225

CASE REPORT

Year : 2019 | Volume : 1 | Issue : 1 | Page : 12

Giant molluscum contagiosum mimicking a lid abscess: “Appearances can be deceptive”!!

Yamini Priya, Anupama Janardhanan
Department of Ophthalmology, St. John's Medical College, Bengaluru, Karnataka, India

Date of Submission	10-Sep-2019
Date of Acceptance	24-Sep-2019
Date of Web Publication	16-Oct-2019

Correspondence Address:
Dr. Anupama Janardhanan
G-13, Tucker AWHO Enclave, Gondhale Nagar, Hadapsar (PO), Pune - 411 028, Maharashtra
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/PAJO.PAJO_20_19

Abstract

Giant molluscum contagiosum (MC) is a rare nodular presentation of molluscum lesions. A diameter measuring more than half to 1 cm qualifies to be called as a giant MC. It has a strong predilection toward immunocompromised patients. A 45-year-old retropositive male presented with a large left upper eyelid swelling. After clinical evaluation, it was presumed to be a chronic lid abscess. On excision biopsy surprisingly, no purulent matter was obtained. A nodular mass was discovered which was confirmed to be giant MC on histopathology. No recurrence was found on follow-up. In immunosuppressed patients, MC has a chronic course and can rarely become large as a giant MC. CD4 lymphocytopenia and a phenomenon known as immune reconstitution inflammatory syndrome probably contribute to its pathogenesis. Giant MC must be kept in mind while evaluating an immunosuppressed patient coming with large lid swellings.

Keywords: CD4, giant molluscum contagiosum, immune reconstitution inflammatory syndrome, lid swelling

How to cite this article:
Priya Y, Janardhanan A. Giant molluscum contagiosum mimicking a lid abscess: “Appearances can be deceptive”!!. Pan Am J Ophthalmol 2019;1:12

How to cite this URL:
Priya Y, Janardhanan A. Giant molluscum contagiosum mimicking a lid abscess: “Appearances can be deceptive”!!. Pan Am J Ophthalmol [serial online] 2019 [cited 2023 Mar 23];1:12. Available from: https://www.thepajo.org/text.asp?2019/1/1/12/269298

Introduction

Immunocompromised condition makes a patient susceptible to a wide array of diseases. Molluscum contagiosum (MC) is one of the opportunistic skin infections caused by a double-stranded DNA virus from the family Poxviridae.^[1],[2]

It has a worldwide incidence of 8%. In human immune deficiency virus (HIV) infection, it increases to 18%.^[3] Three age groups are affected: children, sexually active healthy adults, and immunocompromised individuals.^[2],[3]

A fascinating entity called giant MC is a rare nodular form which measures approximately more than 1 cm in diameter.^[1],[4],[5] Highly deceiving to a physician's eyes, this variant does not have the classic pearly white, umblicated appearance. They can be solitary or present as multiple chronic lesions usually refractory to the treatment.^[6]

A peculiarity of molluscum virus is its inability to grow on a viral culture media.^[3] With regard to immunocompromised patients, it has been known to cause infection when CD4 count falls below 100 cells/μL. Furthermore, it has been speculated to be a part of immune reconstitution inflammatory syndrome (IRIS) that occurs in patients with HIV.^[3],[5],[7] Amid of conflicting literature, we came across an interesting case.

Case Report

A 45-year-old male farmer suffering from human immunodeficiency infection presented to our outpatient department with a complaint of multiple swellings of varied sizes over the face and eyelids and mainly a large walnut-sized swelling over the left upper eyelid for 1 month. He was recently started on Antiretroviral therapy (ART) for 3 months. There was no history of fever or similar swellings over the body. However, he was on a short course of oral antibiotics previously [Figure 1].

Figure 1: Clinical Picture showing the large abscess like swelling along with adjacent small lesions

Click here to view

Examination of the large swelling revealed erythematous, firm, lobulated, minimally fluctuant, nontender mass of 1.5 cm × 1.4 cm with glistening appearance and suspected pus pointed on its surface. Surrounding skin had multiple irregular pigmented papular lesions lined over the face and both eyelids.

A provisional diagnosis of chronic left upper eyelid abscess was made. On diagnostic and cosmetic grounds, the patient was admitted for surgical excisional biopsy. Prior to the initiation of ART, the patient had a CD4 count of 96 cells/μL. Investigations at the time of admission showed a CD4 count of 124 cells/μL along with iron deficiency anemia.

On the operating table following the skin incision, there was no evidence of any purulent material. Hence, blunt dissection was done between the skin and the capsule of the mass to procure the specimen in toto. Gross examination of the specimen appeared to have an astonishing corrugated appearance with multiple gyri [Figure 2]. There were absolutely no characteristics of a chronic abscess. After subjecting the specimen to histopathology, to our surprise, it revealed areas of hyperkeratosis with multiple intracytoplasmic inclusion bodies Henderson–Paterson bodies characteristic of MC infection.

Figure 2: Picture showing pathological specimen. On gross examination showing convoluted lobules with gyri

Click here to view

Few other significantly sized surrounding lesions were curetted and electrocauterized. ART was continued all throughout. No other specific medical therapy was given. The patient on 1 week follow-up showed a small linear scar at the surgical site with a cosmetically acceptable appearance and a smile of relief [Figure 3] and [Figure 4].

Figure 3: Clinical appearance on one week follow up with a thin healed scar and improved mechanical ptosis

Click here to view

Figure 4: Close up picture showing regression of surrounding lesions and electrocautery scars on contralateral side

Click here to view

Discussion

Bateman was the first person to describe MC virus in 1981.^[8]

In children, it is a communicable skin disease that subsides without any residual effects. Common ocular presentation in healthy adults is follicular conjunctivitis and epithelial keratitis with typical papular lid lesions.^[2],[3] Hypersensitivity reaction to viral proteins shed from the lid lesions into the tear film is taken to be the underlying mechanism of conjunctival involvement.^[6]

Very few cases have been reported of giant MC and fewer involving lid.^[5],[9] It can occur in patients with leukemia, sarcoidosis, and Wiskott–Aldrich syndrome, and very rarely, in healthy individuals.^[4]

Direct transmission of the virus is through skin defects and indirectly through sharing fomites.^[1],[4] Pox virus uses microtubule cytoskeleton within the human cells for locomotion into the cell at the time of infection and to establish the spread of infection.

In HIV individuals, there is a role of CD4 cells in determining the onset and severity of molluscum infection. Incidence increases to 33% when CD4 cell count drops below 100 cells/μL.^[3]

Usually, antiretroviral therapy is sufficient to resolve MC. However, IRIS seen in HIV patients may provoke development and sudden spread of giant MC. Patients with low CD4 count at the time of starting ART as seen in our patient have been known to develop IRIS. It manifests in two forms: clinical worsening of preexistent (paradoxical IRIS) or emergence (unmasking IRIS) of a pathogen. It is highly likely that our patient showed a form of unmasking IRIS.^[5],[7]

Ratnam et al. in their study found that 4 of 199 HIV patients developed MC as a part of IRIS phenomenon with a median of 8 weeks for appearance of MC lesions from the beginning of ART. Other immunogenic factors causing giant MC (GMC) are impaired natural killer cell function, reduced Langerhans cells, and altered blastogenic responses to antigens.^[3],[5],[7]

As seen in our case, atypical presentation warrants an accurate histopathology evaluation that shows typical brick-shaped eosinophilic viral inclusion bodies.^{[1],[2],[4],[6]}

Spontaneous resolution of giant lesions does not occur in immunocompromised patients.^[1],[2] Various treatment options for GMC include cryotherapy, 10% potassium hydroxide application, trichloroacetic acid, imiquimod, systemic cimetidine, 5-fluorouracil, and total excision.^{[1],[2],[5],[6]} Immunosuppressants are expensive.

Medical treatment around the eye is also challenging with its share of complications; therefore, surgical excision is a preferred method for eradication of large lesions around the eye.^[1],[6] In our case, even on 2-month follow–up, there was no recurrence.

Conclusion

Giant MC can be a rare ocular presentation of MC in HIV patients. IRIS may be the underlying cause for its presentation. This case has helped us in keeping a broad variety of differential diagnosis in mind while diagnosing a lid swelling. Identifying the infection on time has prevented chronicity and cosmetic disfigurement to the patient. Future research is warranted for understanding MC occurring in IRIS and the role of immunity and ART in its pathogenesis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgment

The authors would like to thank the Department of Pathology, St. John's Medical College, Bengaluru.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Nigwekar S. Ocular molluscum contagiosum – A case report. Pravara Med Rev2009;1:27-9.
2.	Pérez-Díaz CE, Botero-García CA, Rodríguez MC, Faccini-Martínez ÁA, Calixto OJ, Benítez F, et al. Giant molluscum contagiosum in an HIV positive patient. Int J Infect Dis 2015;38:153-5.
3.	Sisneros SC. Recalcitrant giant molluscum contagiosum in a patient with advanced HIV disease – Eradication of disease with paclitaxel. Top HIV Med 2010;18:169-72.
4.	Karadag AS, Karadag R, Bilgili SG, Calka O, Demircans YT. Giant molluscum contagiosum in an immunocompetent child. J Pak Med Assoc 2013;63:778-9.
5.	Vora RV, Pilani AP, Kota RK. Extensive giant molluscum contagiosum in a HIV positive patient. J Clin Diagn Res 2015;9:WD01-2.
6.	Schornack MM, Siemsen DW, Bradley EA, Salomao DR, Lee HB. Ocular manifestations of molluscum contagiosum. Clin Exp Optom 2006;89:390-3.
7.	Gupta A, Sharma YK, Ghogre M, Misra S, Pawar S. Giant molluscum contagiosum unmasked probably during an immune reconstitution inflammatory syndrome. Indian J Sex Transm Dis AIDS 2018;39:139-40.
8.	Bateman TA. Practical Synopsis of Cutaneous Diseases. 3^rd ed. London, (England): Longman Rees Orme Brown Green; 1814.
9.	Alrajeh M, Alessa D, Maktabi AM, Al Alsheikh O. Eyelid molluscum contagiosum presenting as a giant solitary ulcerating mass. Saudi J Ophthalmol 2018;32:338-40.