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Indian Journal for the Practising Doctor

Fulminant Ocular Molluscum Contagiosum

Author(s): Untoo RA, Shaheen N, Lone IA, Sheikh S

Vol. 5, No. 6 (2009-01 - 2009-02)

Untoo RA, Shaheen N, Lone IA, Sheikh S

Dr.R.A.Untoo (Associate Professor), Dr Nusrat Shaheen(Registrar), Dr Imtiyaz A Lone (Lecturer), Dr Sheikh Sajjad (Asssistant Professor), Department of Ophthalmology, SKIMS Medical College Bemina Srinagar

Correspondence: Dr. Nusrat Shaheen, C/O Dr. Tahir Saleem Khan, R/o Bazar, Batamolo, Srinagar (Kashmir). [Cell 9906533994; Email: [email protected],tariqsgr(at)gmail.com]

ISSN: 0973-516X

Abstract:

Molluscum contagiosum is a common skin disease caused by pox virus which affects the top layer of skin by causing small, flesh-coloured or pink, dome-shaped growths that often becomes red or inflamed. Here, we present a case of ocular Molluscum contageosum in rampant form in a HIV negative patient.

Introduction

Molluscum contagiosum is a common and generally benign viral infection of the skin caused by Molluscipox virus, a member of the Poxviridae family. The virus was first described by Bateman in the beginning of the 19th Century, who also later assigned the name to it1. The virus is distinct from other poxviruses in that it causes spontaneously regressing, umblicated tumours of the skin rather than pox like vesicular leions The virus is found world wide with higher distribution in tropical countries. The disease is transmitted primarily through direct skin contact with an infected individual, although fomites also have been suggested as another source of infection2.

The average incubation period of the disease is between 2 and 7 weeks with a range extending out to six months. The disease is endemic with a higher incidence within institutions and communities where overcrowding, poor hygiene and poverty favour its spread2. The worldwide incidence of the disese is estimated to be between 2% and 8%3. Over the last three decades the incidence of infection has been increasing, mainly as a sexually transmitted disease, because of the concurrent HIV infection; it has been reported that between 5% and 20% of HIV patients have symptomatic MCV4,5,6. The disease is more common in children with the lesion involving face, trunk, and extremeties. In adults, the lesions are most commonly found near the genital region. The clinical appearance of Molluscum contagiosum in most cases is diagnostic. Though it can not be cultured in the laboratory, the histological examination of a curetted or biopsied lesion can also aid in the diagnosis in cases that are not clinically obvious. Other modalities by which the virus can be demonstrated are electron microscopy, immunohistochemical methods using polyclonal antibody and in-situ hybridization for MCV DNA.7,8

Treatment of the molluscum contagiosum in non-atopic and immune-competent individuals is not mandatory as it is a self-limited disease in such individuals. However when treatment is deemed appropriate, multiple local therapeutic options are available in the form of cryoablation, evisceration, curettage, tape stripping, podophyllin and podofilox suspension, cantharidin (0.9% solotion of collodion and acetone), 10% iodine solution and 50% salicylic acid plaster, tretinoin 0.1% cream, 10% KOH solution, pulsed dye laser, imiquimod 5% cream and cidofovir 3% cream. In immunocompromised patients with widespread and potentially disfiguring lesions, the usual local destructive therapies are ineffective. However such patients may be benefited from antiviral and immune modulatory medications.

Case report

A twenty year old, married, female presented in our Ophthalmology Department with a history of raised skin lesion in the right lower lid. These lesions got increased in number as well as size, and were painless. Initially vision was normal but with increased size they caused mechanical ptosis and hampered vision. The second eye got involved in the next three months in a similar way. There was associated history of itching and watering.

Systemic examination revealed similar few isolated skin lesions all over the body. Examination (with retractors) revealed vision of 6/36 and 6/24 in the right and the left eye respectively. Upper lid examination of both eyes showed multiple dome-shaped vesicles with umblication varying from 1-2mm to more than 15 mm. Lid margins were swollen. Examination of the lower eye lid showed similar lesions with varying diameter of 1-2mm to 10 mm (Fig. 1). On squeezing, white cheesy material could be expressed. Examination of the anterior segment was possible with retractors only. It was normal in both the eyes.

All investigations including HIV serology were within the normal range, except complement levels of C3 and C4.[C3: 77.9 (range 84 -193 dl); C4: 19.9mg/dl (range 20 -58 dl)]

All the skin lesions were excised by using wet-field cautery in multiple sittings over a period of one and a half months under cover of topical and systemic antibiotics over two months. The patient developed mild cicatricial ectropion of the upper lid. However, there was not significant lagophthalmos. (Fig. 2)

Fig 1: Extensive Molluscum Lesions

Extensive Molluscum Lesions

Fig 2: Complete recovery

Complete recovery

Discussion

Molluscum contagiosum is a common skin disease caused by a virus which affects the top layer of the skin, leading to hyperplasia and hypertrophy of the epidermis.

The name molluscum contagiousum implies that the virus develops growths that are easily spread by the skin contact. The virus belongs to the poxvirus family and enters the skin through the break of hair follicles. It does not affect internal organs8.

Molluscum are usually small fleshcolored or pink dome-shaped growths that often become red or inflamed. They may appear shiny and have a small indentation in the centre. Because they can spread by skin-to-skin contact, molluscum are usually found in areas of skin that touch each other such as the folds in the arm or the groin. They are also found in clusters on the chest, abdomen, and buttocks and can involve the face and eyelids. The disease is endemic with a higher incidence within institutions and communities where overcrowding, poor hygiene, and poverty potentiate its spread. Over the last 30 years, its incidence has been increasing, mainly as a sexually transmitted disease, and it is particularly rampant as a concurrent infection with HIV infection4,9. The worldwide incidence is estimated to be between 2% and 8%10. Less than 5% of the children in the United States are believed to be infected. Between 5% and 20% of patients with HIV have symptomatic MCV I, MCV II, MCV III, and MCV IV. All subtypes cause similar clinical lesions in genital and nongenital regions. Studies show MCV I to be more prevalent (75%-90% ) than MCV II, MCV III, and MCV IV, except in immunocompromised individuals11,12. There are, however, regional variations in the predominance of a given subtype and differences between individual subtypes in different countries. The novel genes of the MCV genome that may interfere with immune recognition and host defense mechanisms include:

  1. A major histocompatibility complex Class I heavy chain homologue that inhibits presentation of MCV–specific peptides.
  2. A chemokine homologue that may inhibit inflammation.
  3. Glutathione peroxidase homologue that may protect the virus and infected cells and oxidative damage by peroxide which may form in response to infection.

These features of the virus may explain the paucity of inflammatory and immune response seen in the lesions of immuno-competent patients13,14.

The average incubation time is between 2 and 7 weeks with a range that may extend up to 6 months.

Molluscum contagiosum is a self limiting disease, which if left untreated, will eventually resolve in immunocompetent host but may be protracted in atopic and immunocompromised individuals14.

The decision whether treatment is necessary depends on the needs of the patient, recalcitration of their disease, and the likelihood of treatment to leave pigmentary alteration or scarring. Most of the common treatments consist of Cryosurgery, Evisceration, Curettage, Tape stripping, Podophyllin and podofilox, Cantharidin, Iodine solution and salicylic acid plaster, Tretinoin, Cimetidine, Potassium hydroxide, Pulsed dye laser, Imiquimod, and Cidofovir etc. Traumatents have recently been added to the option.

Wet-field cautery was used in this patient and after 6 months the patient has no recurrence.

References

  1. Postlethwaite R. Molluscum contagiosum: A review. Arch Environ Health 1970;21:432-452. (2)
  2. Billstein SA, Mattaliano VJ. The “nuisance” sexually transmitted disease: Molluscum contagiosum, scabies, crab lice. Med Clin North Am 1990; 74: 1487-1505. (3)
  3. Becker TM, Blout JH, Douglas J, Judson FM. Trends in molluscum contagiosum in the United States, 1966-1983.Sex Transm Dis 1986; 13:88-92.(4)
  4. Lombardo PC. Molluscum contagiosum and the acquired immunodeficiency syndrome. Arch Dermatol 1985; 121:834-835.(5)
  5. Shwartz JJ, Mykowski PL: Molluscum contagiosum in patients with human immunodeficiency virus infection. J Am Acad Dermatol 1992;27:583. (6)
  6. Penneys NJ, Mutsuo S, Mogollon R. The identification of molluscum infection by immunohistochemical means. J Cutan Pathol 1986;13:97-101.(7)
  7. Thompson CH. Identification and typing of molluscum contagiosum virus in clinical specimens by polymerase chain reaction. J Med Virol 1997;53:205- 211.(8)
  8. Hanson D, Dayna GD. Dermatology Online J. 2007; 9(2): 2.(9)
  9. Guttlieb SL, Myskowki PL. Molluscum contagiosum. Int J Dermatol 1994; 33:453-461(11)
  10. Yamashita H, Uemera T, Kawashima M .Molecular epidemiologic analysis of Japanese patients with molluscum contagiosum. Int J Dermatol 1996;35:99-105. (12)
  11. Bateman F. Molluscum contagiosum. In: Shelley WB, Crissey JT, eds. Classics in Dermatology, Springfield IL; Charles C Thomas,1953, p20.(13)
  12. Beugett JI, Daniel G. Recent advances of MCV research. Arch Viriol (Supp); 1997;13:35. Fitzpatrick`s Dermatology in General Medicine, Vol 1 and 2 by Irwin et al
  13. Nakamaru J, Muraki Y, Yamada M, Hatano Y, Nii S. J Med Virol 1995;46(4):339-48.
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