Molluscum Contagiosum: Widespread Lesions in an Immunocompromised Adult

Diagnosis: Molluscum Contagiosum

A 31-year-old male with HIV presenting with extensive dome-shaped papules with central umbilication on the face, neck, and trunk.

Clinical Presentation

Shiny, dome-shaped, skin-colored to pinkish papules ranging from 2-8mm with characteristic central umbilication. Lesions most numerous on the face, beard area, and neck. Some larger giant molluscum up to 15mm present on the cheeks.

Clinical History

Lesions first appeared 4 months ago and have been spreading rapidly. Patient diagnosed with HIV 2 years ago but non-adherent to antiretroviral therapy. CD4 count 85 cells/mm3.

Treatment

Urgent reinitiation of antiretroviral therapy in coordination with infectious disease. Cryotherapy with liquid nitrogen to accessible lesions in staged sessions. Curettage of larger lesions under local anesthesia. Topical imiquimod 5% cream for residual lesions.

Differential Diagnosis

• Verruca vulgaris • Basal cell carcinoma (small) • Milia • Cryptococcosis (immunocompromised) • Histoplasmosis (immunocompromised) • Folliculitis • Keratoacanthoma

Key Learnings

• Caused by Molluscum contagiosum virus (MCV) — a poxvirus • Pearly, dome-shaped papules with central umbilication are pathognomonic • Self-limited in immunocompetent patients (6-12 months), but may persist for years • Widespread or giant lesions in HIV → check CD4 count • Eczema molluscatum: molluscum in areas of atopic dermatitis • BOTE sign (beginning of the end): surrounding dermatitis/inflammation heralds spontaneous resolution • Histology: Henderson-Patterson bodies (eosinophilic cytoplasmic inclusions)

Tags: viral, poxvirus, immunocompromised, HIV, cryotherapy