Molluscum contagiosum is a common viral skin infection in children with atopic diathesis and not rare in HIV patients. We report a 45-year-old psoriasis patient who developed eruptive mollusca contagiosa during an antipsoriatic treatment with efalizumab. Copyright (C) 2008 S. Karger AG, Basel

Alexander Vasilevic Kuznetsov

J&ouml

Lim KS

Michael Flaig

Papp KA

Peter Weisenseel

Vozmediano JM

Wachi K

English

Weisenseel, Peter

Kuznetsov, Alexander Vasilevic

Flaig, Michael J.

Prinz, Jörg Christoph

Universität München: Elektronischen Publikationen

Disseminated eruptive giant mollusca contagiosa in an adult psoriasis patient during efalizumab therapy

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Disseminated Eruptive Giant Mollusca Contagiosa in an Adult Psoriasis Patient during Efalizumab Therapy

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Fax +41 61 306 12 34E-Mail karger@karger.chwww.karger.com Case Report  Dermatology 2008;217:85–86  DOI: 10.1159/000128282  Disseminated Eruptive Giant Mollusca Contagiosa in an Adult Psoriasis Patient during Efalizumab Therapy  Peter Weisenseel    Alexander Vasilevic Kuznetsov    Michael Flaig    Jörg Christoph Prinz  Department of Dermatology, Ludwig Maximilian University,  Munich , Germany whitish papules occurred on the face and neck of the patient. The papules increased in number and size and were resistant to topical application of steroids and vitamin D analoga. Simultaneously, the psoriasis flared up. The patient presented at our  department with more than 50 flesh- coloured partly umbilicated papules and nodules of up to 1 cm in diameter ( fig. 1 ) that were diagnosed as disseminated giant mollusca contagiosa (MC).  Laboratory routine parameters, in-cluding complete blood cell count, blood chemistry and urine analysis, were unre-markable except for a minor acidocytosis. An HIV test was negative. Histopathology of a nodule (shave bi-opsy,  fig. 2 ) showed an exophytic tumour with epidermal hyperplasia and central impression forming a pouch containing keratinocytes filled with clustered intra-cellular deposits. Therapy and Outcome  Efalizumab treatment was interrupted; a therapy with methotrexate 15 mg once a week as well as narrow-band UVB treat-ment was initiated sparing the MC-affect-ed regions. The MC were gradually re-moved with a pair of forceps. After some minor relapses, a complete and stable re-mission of the MC was achieved. The pso-riasis was kept under control. Key Words  Efalizumab   Mollusca contagiosa   Biological agent   Psoriasis  Abstract  Molluscum contagiosum is a common viral skin infection in children with atopic diathe-sis and not rare in HIV patients. We report a 45-year-old psoriasis patient who devel-oped eruptive mollusca contagiosa during an antipsoriatic treatment with efalizumab.  Copyright © 2008 S. Karger AG, Basel  Case Report   We report a 45-year-old female patient who was referred to our department be-cause of a psoriasis flare-up and the devel-opment of skin papules following retreat-ment with efalizumab. She had been suf-fering from recalcitrant psoriasis vulgaris for 20 years and had a long history of dif-ferent treatment modalities including ex-tensive (repeat) UV therapy and therapy with fumaric acid esters. Complete remis-sion was achieved after efalizumab 1 mg/kg/week s.c. had been administered for 12 weeks. After the remission had been sus-tained by efalizumab treatment for anoth-er 3 months, the drug was discontinued on advice of the physician. Two months later, the patient had a severe psoriasis relapse and the efalizumab treatment regimen was resumed. Three weeks later, eruptive  Received: October 16, 2007  Accepted: November 23, 2007  Published online: April 29, 2008  Dr. Peter Weisenseel, MD  Department of Dermatology, Ludwig Maximilian University  Frauenlobstrasse 9–11,  DE–80337 Munich (Germany)  Tel. +49 89 5160 6010, Fax +49 89 5160 6312E-Mail peter.weisenseel@med.uni-muenchen.de  © 2008 S. Karger AG, Basel1018–8665/08/2171–0085$24.50/0  Accessible online at:www.karger.com/drm  Comment  MC is a common epidermotropic pox virus infection in children. The virus is transferred by direct skin contact. In pa-tients with regular immune function, the virus induces an effective antiviral re-sponse which prevents the manifestation of MC or leads to a complete remission of MC. As contact with the virus and mount-ing of a virus-specific immune response usually occur during childhood, MC in-fections are rarely found in adults. Predis-posing factors in adults with MC are atop-ic dermatitis and a suppressed immune system. MC infections are therefore com-mon in patients with HIV infection or transplant patients. In contrast to patients with atopic der-matitis, psoriasis patients hardly experi-ence bacterial or viral skin infections. The low rate of skin infections in psoriasis pa-tients is attributed to the activation of an-timicrobial defence mechanisms in in-flamed skin. However, immunosuppres-sive systemic antipsoriatic therapy can predispose patients to skin infections. Ac-cordingly, MC has been reported in pso-riasis patients during immunosuppressive therapy such as methotrexate  [1] or during infliximab treatment in combination with other immunosuppressive drugs  [2, 3] . Efalizumab is a CD11a antibody ap-proved for the treatment of recalcitrant moderate to severe psoriasis vulgaris. Efa-lizumab inhibits T-cell activation and par- Weisenseel/Kuznetsov/Flaig/Prinz Dermatology 2008;217:85–8686ticularly T-cell transmigration from blood vessels into the skin  [4] . The rate of infec-tions or malignant tumours during efali-zumab treatment for psoriasis vulgaris is generally not increased  [5, 6] . Therefore, efalizumab is considered as a safe long-term treatment regimen. The exacerbation of MC under efali-zumab therapy reported here might indi-cate that under certain conditions efali-zumab might assist viral infections to de-velop and defeat the immune system. While MC lesions in childhood normally measure 1–4 mm, giant-shaped MC of more than 5 mm in diameter can be found in HIV-positive patients and patients un-der immunosuppressive therapy  [7] . Al-though case reports provide only little  evidence in general, they may prove ne c-essary to raise the awareness of unantici-pated adverse events in this new class of psoriasis drugs. This first published case of MC during efalizumab treatment dem-onstrates that biological agents do not only offer new and effective treatment options for chronic inflammatory diseases, but may also confront us with atypical or un-expected infections.  Fig. 1.  a Umbilicated papules and nodules on the face and neck.  b Detail, left cheek.  Fig. 2. Histology – exophytic tumour with epidermal hyperplasia and central impres-sion forming a pouch containing keratino-cytes filled with clustered intracellular de-posits.  References  1 Lim KS, Foo CC: Disseminated molluscum contagiosum in a patient with chronic plaque psoriasis taking methotrexate. Clin Exp Dermatol 2007; 32: 591–593.  2 Wachi K, Prasertsuntarasai T, Kishimoto M, Uramoto K: T-cell lymphopenia associated with infliximab and cyclophosphamide. Am J Med Sci 2005; 330: 48–51.  3 Cursiefen C, Grunke M, Dechant C, Antoni C, Jünemann A, Holbach LM: Multiple bilat-eral eyelid molluscum contagiosum lesions associated with TNFalpha-antibody and methotrexate therapy. Am J Ophthalmol 2002; 134: 270–271.  4 Jullien D, Prinz JC, Langley RG, Caro I, Dummer W, Joshi A, Dedrick R, Natta P: T-cell modulation for the treatment of chronic plaque psoriasis with efalizumab (Raptiva): mechanisms of action. Dermatology 2004;  208: 297–306.  5 Papp KA, Camisa C, Stone SP, Caro I, Wang X, Compton P, Walicke PA, Gottlieb AB: Safety of efalizumab in patients with moder-ate to severe chronic plaque psoriasis: review of clinical data. Part II. J Cutan Med Surg 2005; 9: 313–323.  6 Leonardi CL, Toth D, Cather JC, Langley RG, Werther W, Compton P, Kwon P, Wetherill G, Curtin F, Menter A: Review of malignan-cies observed during efalizumab (Raptiva  ) clinical trials for plaque psoriasis. Dermatol-ogy 2006; 213: 204–214.  7 Vozmediano JM, Manrique A, Petraglia S, Romero MA, Nieto I: Giant molluscum con-tagiosum in AIDS. Int J Dermatol 1996; 35:  45–47. 

AB: Safety of efalizumab in patients with moderate to severe chronic plaque psoriasis: review of clinical data. Part II.

Foo CC: Disseminated molluscum contagiosum in a patient with chronic plaque psoriasis taking methotrexate. Clin Exp Dermatol

Holbach LM: Multiple bilateral eyelid molluscum contagiosum lesions associated with TNFalpha-antibody and methotrexate therapy.

Menter A: Review of malignancies observed during efalizumab (Raptiva  ) clinical trials for plaque psoriasis. Dermatology

Nieto I: Giant molluscum contagiosum in AIDS.

Tcell modulation for the treatment of chronic plaque psoriasis with efalizumab (Raptiva): mechanisms of action. Dermatology

Uramoto K: T-cell lymphopenia associated with infliximab and cyclophosphamide.

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Disseminated eruptive giant mollusca contagiosa in an adult psoriasis patient during efalizumab therapy

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