AN INTERESTING CASE OF GIANT MOLLUSCUM WITH FLORID VERRUCA VULGARIS IN AN IMMUNOCOMPETENT PATIENT

Molluscum contagiosum and warts are two fairly common skin infections caused by DNA viruses i.e. poxvirus and human papilloma virus (HPV) respectively. Both the conditions are benign and mostly self-limited. However in immunocompromised individuals, these infections can have varied atypical presentations like larger, more extensive, recalcitrant and refractory lesions. These atypical presentations in a nonimmunocompromised individual are, however, quite rare. We present one such case with atypical presentation of molluscum contagiosum and warts (verruca vulgaris).


Introduction
Molluscum contagiosum (MC) is a benign viral infection of the skin caused by a DNA poxvirus (molluscum contagiosum virus).The disease is quite common in young children, though sexually active adults and immunocompromised individuals may also be affected.The incubation period is around 2-3 months [1].The characteristic lesions are white to pink, dome shaped, waxy, umbilicated papules usually 2-5 mm in size.Most of the lesions are benign and self-limited.In immunocompromised individuals, the infection may, however, assume atypical characteristics, such as large size of lesions (giant molluscum contagiosum when ≥1 cm) [1,2], widespread, chronic and recalcitrant lesions [1,3,4].Presence of giant molluscum in an immunocompetent host is an uncommon entity.Warts are a form of skin and mucous membrane infection caused by human papilloma virus (HPV) and have a universal occurrence.Extensive and refractory warts may be seen in immunocompromised individuals [5], thus underlining the role of immune system in eradication of the causative virus from the body.The occurrence of the atypical MC and verruca vulgaris in a non-immunocompromised individual is not so common, and we are reporting such a case, where excellent response to autoinoculation was found.

Case Report
A 20 year old male presented with multiple, discrete, dome shaped, umbilicated skin coloured papules and nodules ranging in size from 0.5 to 3 cm, mainly localised to the axillae, groins and genitalia (Figs.1A and B).The first skin lesion had appeared nearly one year back.The lesions were largely asymptomatic except for slight occasional pruritus.Upon compression, some of the nodules expressed white caseous material.Excision biopsy of one lesion revealed characteristic histologic features of large, eosinophilic intracytoplasmic inclusion bodies (molluscum bodies).The patient also presented with multiple hyperkeratotic papules and plaques with a rough, irregular surface ranging in size from 0.5cm to 2cm on the dorsal aspects of hands and feet (Fig. 2).The patient also reported recurrent episodes of tinea corporis and onychomycosis (Fig. 2).His face had diffuse erythema and telangiectasia at places on the malar area and nose.The patient was otherwise mentally and physically healthy with no other systemic complaint.The patient denied current use of any immunosuppressive drugs and the family history was noncontributory.General physical examination revealed an average built patient with no signs of pallor, icterus, cyanosis or clubbing.There was no significant lymphadenopathy.Systemic examination revealed no abnormality.www.odermatol.comSeveral laboratory tests were performed to investigate any underlying primary or secondary immunodeficiency.Human immunodeficiency virus (HIV) 1 and 2 serology was negative.Chest X-ray was normal.Sputum was negative for acid fast bacilli (AFB) and Mantoux test was negative.Erythrocyte sedimentation rate (ESR) was within normal limits.Antinuclear antibody (ANA) was positive at a low titre and anti-ds DNA was negative.Hepatitis B and C serology was negative.Serum cortisol levels were within normal limits.Measurement of the levels of major immunoglobulin classes: IgG (1234 mg/dl), IgA (735mg/dl), IgM (460mg/dl) and IgE (16.8IU/ml) were non-contributory.The absolute lymphocyte count (2764/mm 3 ) was within normal limits.The percentage and absolute numbers (in parentheses) for different lymphocyte subsets were determined as follows: CD3 -75% (2076/µl), CD4 -51% (1404/µl), CD8 -18% (588/µl).The CD4/CD8 ratio (2.4) was also within normal limits.Some of the giant molluscum lesions were successfully treated with extirpation followed by cauterisation of the base with potassium hydroxide.The hyperkeratotic lesions over hands and feet, diagnosed as verruca vulgaris, and most of the MC were, however, recalcitrant to treatment.Autoinoculation done for the same resulted in significant improvement in the lesions over a period of 2-3 months (Fig. 3).In addition, the patient also received oral levamisole (150mg twice weekly) and oral zinc sulphate (200mg once daily) for a period of 3 months.

Discussion
Molluscum contagiosum is a common viral infection of the skin caused by a large DNA virus (molluscum contagiosum virus).The infection is usually self-limited with lesions mostly disappearing within 6 to 12 months, but may take as long as 4 years.Giant molluscum contagiosum (>1cm in size) is an uncommon variant usually seen in immunocompromised states.Immunodeficient states are also typified by more widespread and recalcitrant forms of molluscum contagiosum.Occurrence of molluscum contagiosum in these forms is rare in immunocompetent individuals.Verruca vulgaris caused by human papilloma virus, although quite common, occurs more extensively, are usually recurrent and recalcitrant to treatment in immunocompromised hosts.Only a few cases of florid giant molluscum contagiosum occurring in immunocompetent patients have been reported.However, complete evaluation of the immune status was not carried out in most of them.Majority of these reported cases involved immunocompetent children.Giant molluscum contagiosum in immunocompetent adults appears to be even rarer.Dickinson A et al [6], Agarwal S et al [7], and Egawa K et al [8], reported cases of giant molluscum in immunocompetent adults.However none of these cases underwent complete evaluation of the immune status.Matsuda M et al [9], reported a case with concomitant giant molluscum contagiosum and verruca vulgaris.The immunocompetent status of the patient, however, could not be fully elucidated.In our patient, concomitant giant MC and verruca vulgaris, tinea corporis and onychomycosis was found, after ruling out any immunocompromised status.

Figure 2 .
Figure 2. Verrucae and onychomycosis on the hands.

Figure
Figure 1A and B. Molluscum contagiosum on groin and genitals (A) and axillae (B).