Giant molluscum contagiosum (MC) is a peculiar
variant of the disease with the presence of multiple
or single lesions larger than 5 mm. In contrast to typical
molluscum contagiosum, dermoscopic features of
giant lesions have been poorly described, and none
of the reports included multiple giant lesions in an
immunocompromised patient. We present a patient
with acquired immunodeficiency syndrome diagnosed
with multiple giant molluscum contagiosum
along with the dermoscopic features of this entity

Ewa Iżycka-Świeszewska

Maria Hlebowicz

Marta Gesing

Martyna Sławińska

Małgorzata Sokołowska-Wojdyło

Michał Sobjanek

Monika Sikorska

Roman J. Nowicki

Tomasz Smiatacz

English

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ACTA DERMATOVENEROLOGICA CROATICA 233Acta Dermatovenerol Croat                              2020;28(4):233-235                            LETTER TO THE EDITORDermoscopic Features of Giant Molluscum Contagio-sum in a Patient with Acquired Immunodeficiency  SyndromeGiant molluscum contagiosum (MC) is a peculiar variant of the disease with the presence of multiple or single lesions larger than 5 mm. In contrast to typi-cal molluscum contagiosum, dermoscopic features of giant lesions have been poorly described, and none of the reports included multiple giant lesions in an immunocompromised patient. We present a patient with acquired immunodeficiency syndrome diag-nosed with multiple giant molluscum contagiosum along with the dermoscopic features of this entity.We examined a 40-year-old patient who had been diagnosed with acquired immunodeficiency syn-drome (AIDS) two months earlier. The disease defining AIDS was cerebral toxoplasmosis (initially presenting as a brain tumor several months earlier). Laboratory investigation showed a decreased CD4 cell count of 11 cells/mm3 and HIV viral load of 252 472 copies/mL. The patient was referred to the Department of Derma-tology due to multiple flesh-colored, asymptomatic nodules with superficial telangiectasia that had been observed on the face for several weeks (Figure 1, a). Dermoscopy of larger (>5 mm) skin lesions showed yellowish globules of different size and random distri-bution, separated by smaller, oval-shape white glob-ules and polymorphic vessels (Figure 1, b-d). Dermos-copy of smaller skin lesions showed the presence of a central yellow globule and white structureless area with irregular linear vessels of radial arrangement at the periphery (Figure 1, e). Histopathological exami-nation confirmed the diagnosis of molluscum conta-giosum (MC); special staining showed the details of the lesion (Figure 2, a-c).Antiretroviral therapy with Triumeq® (dolutegravir + abacavir + lamivudine) was initiated. After discuss-ing MC treatment options with the patient, we de-cided to delay the treatment and wait for the effect of antiretroviral therapy. Partial regression of MC lesions was observed after 5 months; laboratory investiga-tions showed a CD4 cell count of 99 cells/mm3 and a HIV viral load of 56 copies/mL. Along with continu-ation of antiretroviral therapy, the patient received treatment with topical imiquimod (Aldara®) for 12 weeks. Subsequently, a few lesions resistant to pre-vious treatment were treated with cryosurgery and the patient was instructed to apply imiquimod only to new-onset/regrowing lesions. Clinical evaluation Figure 1. (a) Clinical presentation: multiple, randomly distributed, flesh-colored, asymptomatic facial nodules. In contrast to larger (>5 mm) lesions, some of the smaller ones reveal the presence of central umbilication. (b-e) Dermoscopy of giant molluscum contagiosum shows the presence of large yellowish globules surrounded with white smaller globules/white structureless areas with polymorphic vessels (branched, dotted, linear irregular). Dermoscopy of two smaller lesions shows the presence of a central yellow globule and white structureless area with irregular linear vessels of radial arrangement at the periphery.ACTA DERMATOVENEROLOGICA CROATICA234after 2 months revealed a good clinical and aesthetic effect (Figure 3).MC is a viral disease caused by a DNA virus of the Poxviridae family (MCV-1 or MCV-2). The infection most commonly affects children and sexually active adults, and may be diagnosed based on physical examination in the majority of cases. Typical clinical presentation includes single to multiple, 2-5 mm, flesh-colored, asymptomatic nodules with central umbilication.Dermoscopy is a non-invasive diagnostic meth-od that allows skin examination with magnification, therefore improving the accuracy of dermatological diagnosis. It was primarily developed to detect mela-noma, but in recent years the role of this method in general dermatology has been constantly increasing. There have been several published reports that dem-onstrated the utility of dermoscopy in the diagnosis of MC. Most commonly observed structures include a central orifice and blood vessels arranged in punc-tiform, radial or mixed flower pattern (1). Giant mol-luscum contagiosum is an atypical variant of the dis-ease, with the presence of multiple or single lesions larger than 5 mm (2). The diagnosis of giant MC usu-ally indicates immunodeficiency and has been main-ly described in HIV-positive patients, but also in co-existence with leukemia, sarcoidosis, Wiskott-Aldrich syndrome, selective immunoglobulin M deficiency, atopic dermatitis, and after splenectomy, bone mar-row transplantation, and during immunosuppres-sive therapy (3). Giant MC may mimic other benign or malignant dermatoses, and the final diagnosis is usually based on histopathological examination. The list of differential diagnoses is long and includes basal cell carcinoma, keratoacanthoma, viral wart, varicella, intradermal nevi, pyogenic granuloma, lichen pla-nus, atypical mycobacterial infection, pneumocys-tosis, cutaneous cryptococcosis, and histoplasmosis (3). In contrast to typical MC, dermoscopic features of giant MC have been poorly described, and none of the reports included multiple lesions in immuno-compromised patient. Mun et al. described a pattern of multiple shiny white clods in giant MC observed in a 2-year-old girl in the perianal area (4). A different dermoscopic image – with prominent arborizing ves-sels and polylobular white structureless areas – was reported by Uzuncakmak et al., who described giant MC on the eyelid in a 25-year-old woman (2). Similar dermoscopic features of atypical MC (5 mm in size) were described by Zaballos et. al. (5).Figure 2. Histopathological picture: (a) Circumscribed intradermal tumor made of lobulated, endophytic, and mainly infun-dibular epidermal hyperplasia with papillomatosis. Some parts of the hyperkeratotic epidermis contain intracellular eosino-philic and basophilic inclusions (molluscum bodies) being released into the crypts. No inflammation is present (hematoxylin and eosin, ×40) (b) Blood vessels tightly surrounding inverted hyperplastic epidermal lobules, dilated in the periphery and the central part of the lesion (immunohistochemistry CD34, ×100). (c) Collagen fibers pressed and condensed between lob-ules of the tumor and highlighted molluscum bodies (Masson trichrome staining, ×100)Figure 3. Clinical presentation after treatment.Letter to the editor Acta Dermatovenerol Croat   2020;28(4):233-235235ACTA DERMATOVENEROLOGICA CROATICAThe course and treatment of MC differ in immuno-competent and in immunocompromised individuals. While the infection is usually mild and self-limiting in the former group, in the latter it may be extensive, symptomatic, and resistant to therapy. Treatment methods commonly applied in immunocompetent patients such as cryotherapy, curettage, and electro-cautery are not generally recommended in patients with severe immunodeficiency as they pose a risk of secondary infection or autoinoculation (6). Addition-ally, such treatment of multiple lesions is connected with pain and higher risk of postinflammatory chang-es/scarring (7). According to the literature, treatment with local immunomodulators – including imiquimod cream, interferon-a (IFN-a) injections and cidofovir – appears to be effective (6). Topical 5% imiquimod was most commonly used, and although not licensed for this indication it was shown to be effective in HIV-positive individuals, including treatment of giant MC lesions (7). Regardless of the topical treatment, previ-ous reports documented a correlation between im-munity status and the extension of MC lesions. There-fore, effective antiretroviral therapy may itself lead to resolution of MC [8].To sum up, the presented report introduced ad-ditional observations into the dermoscopic spectrum of giant MC. The observed dermoscopically large yel-lowish globules seem to correspond with the crypts and the surrounding white structures with the areas of lobulated, endophytic epidermal hyperplasia. The presence of vascular structures in dermoscopy cor-responds with the blood vessels tightly surrounding inverted hyperplastic epidermal lobules (Figure 2, b). Dermoscopic features od giant MC are different than those observed in small lesions. Interestingly, the dermoscopic appearance of smaller lesions observed in our patient seemed to be similar to MC eruptions described in immunocompetent patients (1). In case of clinical suspicion giant MC coexisting with smaller lesions, dermoscopic assessment of the latter may serve as a clue to diagnosis.References:1. Ianhez M, Cestari Sda C, Enokihara MY, Seize MB. Dermoscopic patterns of molluscum contagio-sum: a study of 211 lesions confirmed by histo-pathology. An Bras Dermatol. 2011;86:74-9.2. Uzuncakmak TK, Kuru BC, Zemheri EI, Zindanci I, Turkoglu Z, Kavala M. Isolated giant molluscum contagiosum mimicking epidermoid cyst. Der-matol Pract Concept. 2016;6:71-3.3. 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;38:153-5.4. Mun JH, Ko HC, Kim BS, Kim MB. Dermoscopy of giant molluscum contagiosum. J Am Acad Der-matol. 2013;69:e287-8.5. Zaballos P, Ara M, Puig S, Malvehy J. Dermoscopy of molluscum contagiosum: a useful tool for clini-cal diagnosis in adulthood. J Eur Acad Dermatol Venereol. 2006;20:482-3.6. Nguyen HP, Franz E, Stiegel KR, Hsu S, Tyring SK. Treatment of molluscum contagiosum in adult, pediatric, and immunodeficient populations. J Cutan Med Surg. 2014;18:299-306.7. Gardner LS, Ormond PJ. Treatment of multiple gi-ant molluscum contagiosum in a renal transplant patient with imiquimod 5% cream. Clin Exp Der-matol. 2006;31:452-3.8. Chatterjee S, Banerjee M, Bhattacharya S. Giant molluscum contagiosum: An unusual presenting complaint of paediatric HIV disease. Trop Doct. 2015;45:148-50.Martyna Sławińska1*, Maria Hlebowicz2*, Ewa Iżycka-Świeszewska3,4, Monika Sikorska1, Małgorzata Sokołowska-Wojdyło1, Tomasz Smi-atacz2, Marta Gesing2, Roman J. Nowicki1, Michał Sobjanek1 1Department of Dermatology, Venerology  and Allergology, Medical University of Gdańsk, Gdańsk, Poland2Department of Infectious Diseases, Medical University of Gdańsk, Gdynia, Poland3Department of Pathology and Neuropathology, Medical University of Gdańsk, Gdańsk, Poland4Department of Pathomorphology, Copernicus- Independent Public Healthcare Centre, Gdańsk, Poland *These authors contributed equally to the workCorresponding author:Martyna Sławińska MD, PhDDepartment of Dermatology, Venereology and AllergologyMedical University of GdańskSmoluchowskiego 17 Street80-214 Gdańskmslawinska@gumed.edu.plReceived: December 16, 2018Accepted: November 16, 2020Letter to the editor Acta Dermatovenerol Croat   2020;28(4):233-235

Dermoscopic Features of Giant Molluscum Contagio Contagiosum in a Patient with Acquired Immunodeficiency Syndrome

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Dermoscopic Features of Giant Molluscum Contagio Contagiosum in a Patient with Acquired Immunodeficiency Syndrome

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