Molluscum Contagiosum in a 12-Year-Old Child – Report of a Case and Review of Literature

Abstract

Molluscum contagiosum (MC) is an infection of the skin and mucous membrane caused by a DNA virus from the poxvirus family. It usually affects any part of the body and presents as pearly, flesh colored dome shaped nodule with a central umbilication. Clinical diagnosis can be supplemented with histopathology for the confirmed diagnosis of MC. This article presents a case of 12-year-old male child afflicted with MC along with a review of the literature on MC.

Full text

Journal of International Oral Health 2015; 7(1):63-66
63
Molluscum contagiosum in a 12-year-old … Nandhini G et al
Case Report
Received: 20
th
August 2014 Accepted: 10
th
November 2014 Conicts of Interest: None
Source of Support: Nil
Molluscum Contagiosum in a 12-Year-Old Child – Report of a Case and Review of Literature
G Nandhini
1
, K Rajkumar
2
, K Sudheer Kanth
3
, Priyadharsini Nataraj
4
, Pavithra Ananthakrishnan
5
, M Arunachalam
6
Contributors:
1
Reader, Department of Oral Pathology, SRM Dental College,
Chennai, Tamil Nadu, India;
2
Professor & Head, Department
of Oral Pathology, SRM Dental College, Chennai, Tamil Nadu,
India;
3
Reader, Department of Oral Pathology, Mamata Dental
College, Khammam, Telangana, India;
4
Lecturer, Department
of Oral Pathology, SRM Dental College, Chennai, Tamil Nadu,
India;
5
Tutor, Department of Oral Pathology, SRM Dental College,
Chennai, Tamil Nadu, India;
6
Post-graduate Student, Department
of Oral Pathology, SRM Dental College, Chennai, Tamil Nadu,
India.
Correspondence:
Dr. Nandhini G. 186/2, Nallantha Flats, 4
th
Avenue,
Anna Nagar West, Chennai - 600 040, Tamil Nadu, India.
Phone: +91-9840192610. Email: drnandhuguna@gmail.com
How to cite the article:
Nandhini G, Rajkumar K, Kanth KS, Nataraj P, Ananthakrishnan P,
Arunachalam M. Molluscum contagiosum in a 12 year old
child – Report of a case and review of literature. J Int Oral Health
2015;7(1):63-6.
Abstract:
Molluscum contagiosum (MC) is an infection of the skin and
mucous membrane caused by a DNA virus from the poxvirus
family. It usually aects any part of the body and presents as pearly,
esh colored dome shaped nodule with a central umbilication.
Clinical diagnosis can be supplemented with histopathology for the
conrmed diagnosis of MC. This article presents a case of 12-year-
old male child aicted with MC along with a review of the literature
on MC.
Key Words: Henderson–Paterson bodies, mollusca, molluscum
contagiosum, pearly nodule
Introduction
Molluscum contagiosum (MC) is a common and self-limiting
viral infection of the skin and mucous membrane, caused by
molluscipox virus gene of the poxvirus family. MC infection
usually aects children and also adults who are sexually active
and those who are immunocompromised. Clinically MC
appears as small bumps, which are called as “mollusca” on the
skin or mucous membrane.
1
The clinical appearance of MC in most cases is diagnostic
and, histopathology examination can be used as an aid in the
diagnosis of cases that are not clinically obvious.
Here, we report a case of MC in a male child with its clinical
and histopathological ndings.
Case Report
A 12-year-old male child reported to the Oral Medicine
Department with a complaint of sudden eruptive papules in
the right side of the face for the past 2 months. History revealed
that the papules were noticed by his parents 2 months ago,
which were small in size and not associated with any pain or
discomfort.
Extra-oral examination revealed two large papules measuring
4 mm in diameter and three small papules measuring 2 mm in
diameter, which were seen on the right side of the skin of the
face near the angle of the mouth. The surface of the lesions
appeared smooth, round, blanched and pinkish with a dimple
in the middle, and they were soft in consistency and non-tender
(Figure 1).
Routine blood investigations revealed no abnormality in any of
the parameters. HIV 1 and HIV 2 testing were also done, which
was found to be negative. Fluorescent antinuclear antibody
testing was done to check for autoimmune infection, and was
found to be negative. On the basis of clinical examination,
provisional diagnosis of MC was made, along with the
dierential diagnosis of Herpes simplex infection. Under local
anesthesia, the two larger lesions were surgically excised, and
the biopsied tissues were xed in 10% formalin and sent for
histopathological examination (Figure 2).
Microscopic examination of the excised tissue by routine
hematoxylin and eosin (H and E) staining revealed hyperplastic
epidermis in the form of lobules invaginating into the dermis
(Figure 3). The basal layer showed enlarged basophilic nuclei
and mitotic gures. Progressing toward the center of the lobule,
the spinous cells showed cytoplasmic vacuolization and large
intra-cytoplasmic, basophilic viral inclusions called Molluscum
bodies or Henderson-Paterson bodies, which compress the
keratinocyte nucleus (Figure 4).
Along with H and E, special stains such as Gram’s, Giemsa, and
Papanicolaou (Figure 5) were also done to demonstrate the viral
inclusion bodies within the host cell. Correlating the clinical
and histopathological ndings the lesion was diagnosed as MC.
Since MC is self-limiting condition, the smaller lesions were
allowed to resolve spontaneously and the patient was reviewed
after a month, and showed no recurrence or scarring in the
excised area.

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Journal of International Oral Health 2015; 7(1):63-66
Molluscum contagiosum in a 12-year-old … Nandhini G et al
Discussion
MC is a supercial, viral infection, which is characterized
by single, discrete or multiple papular or nodular lesions on
the skin and mucous membrane. MC was first described
by Bateman in year 1817.
2
MC is caused by Molluscum
contagiosum virus (MCV), which is a DNA virus belonging
to the poxvirus family. MCV is of four types; MCV I to MCV
IV of which MCV I is most prevalent and MCV II is usually
seen in adults.
1
MC is a common infection in children between the ages of
1-12 years. It is also seen in sexually active adults and those
who are immunocompromised, such those with HIV.
MCV is transmitted either via direct contact with infected
people or indirectly through infected fomites. The virus
also spreads through sexual contact or by autoinoculation.
Traumatic inoculation such as that caused by tattoos can
also transmit the virus.
3
The incubation period usually
varies from 2 to 8 weeks, and sometimes may extend upto
6-18 months.
2
Figure 1: Multiple smooth, round, and pinkish papules on the
skin of the face near the angle of the mouth.
Figure 2: Gross picture of the excised specimens.
Figure 3: Lobular hyperplasia of epidermis resulting in a cup
shaped invagination into the dermis (H and E, ×4).
Figure 4: Henderson–Paterson/molluscum bodies appearing
eosinophilic in the spinous layer and basophilic in the granular
layer (H and E, ×20).
Figure 5: Special stains used to demonstrate molluscum
bodies; (a) Molluscum bodies appearing basophilic with gram
stain (×10), (b) molluscum bodies appearing eosinophilic
with giemsa stain (×10), (c) molluscum bodies appearing
eosinophilic with papanicolaou stain (×10).
C
B
A

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Journal of International Oral Health 2015; 7(1):63-66
Molluscum contagiosum in a 12-year-old … Nandhini G et al
In children, MCV lesions are frequently seen in the skin of the
face, neck, armpits, arms and hands;
4
and mucous membrane of
lips, tongue and buccal mucosa.
2
In sexually active adults and
immunocompromised individuals such as those with AIDS,
the lesions are commonly seen in the genital, abdomen and
the inner part of the thigh.
In children and immunocompetent adults, the lesion is
self-limiting, but in patients with HIV the lesions are more
extensive and cause disgurement. Studies have suggested
that in patients with severe immunodeciency MC may be
used as a cutaneous marker and could be a rst indicator of
HIV infection.
5
Clinically the lesion begins as a painless, small papule, which
later becomes raised to a pearly, esh colored dome shaped
nodule with a central depression like a small pit or umblication.
These dome shaped nodules are called as “mollusca.” The
central pit contains central plug of waxy, cheesy, white material
in which virus is present. The papules or nodules can be either
solitary or multiple, and they measure about 2-5 mm and
sometimes grow to as large as 10 mm.
MCV lesions are generally painless, but they may itch or
become irritated. Scratching or picking the papules or nodules
can lead to secondary bacterial infection or can cause scarring.
Scratching or picking the papules or nodules can also cause the
spread of the virus to the neighboring skin in a process called as
autoinoculation. Children usually develop widespread cluster
of lesion due to autoinoculation.
The dierential diagnosis for MC in HIV patients includes
Basal cell carcinoma, Keratocanthoma, Darier’s disease,
Epithelial nevi, Atopic dermatitis, Cryptococcosis, and
Histoplasmosis.
5
Diagnosis of the lesion is presumptively based on the
distinctive, central umblication of the dome shaped lesion, and
the lesion can be further conrmed by biopsy and examining
it under the miscroscope.
Histological section stained with H and E reveals inverted
lobular hyperplasia of the epidermis in the form of a cup shaped
nodule with central cellular and viral debris. The inverted
epidermis exhibits acanthosis, and the basal layer shows
enlarged basophilic nuclei and mitotic gures. Progressing
upward, the keratinocyte cells of the spinous and granular layer
exhibit intra-cytoplasmic, eosinophilic, granular viral inclusions
called Molluscum bodies or Henderson–Paterson bodies.
These intra-cytoplasmic inclusion bodies were rst described
by Hendrson and Paterson in the year 1841.
6
Ultrastructural
studies of the molluscum bodies show membrane bound
sacs that contain MCV. These inclusion bodies measure
approximately 35 µ in diameter and are formed by the
virus within the cytoplasm of the cell. Initially, the virion is
formed as a small particle in the cytoplasm of the cells of the
suprabasal layer, and they increase in size from the spinous
to the granular layer. In the granular layer, these inclusion
bodies compress the nucleus to the periphery of the infected
cells. Near the granular cell layer the staining reaction of the
molluscum bodies changes from eosinophilic to basophilic.
The stratum corneum in the center of the lesion disintegrates
and releases the molluscum bodies into the central crater.
Usually the dermis is relatively unremarkable, but when the
contents of the lesion are discharged into it, the dermis shows
inammatory reaction composed of histiocytes, lymphocytes,
neutrophils, and occasional foreign body giant cells. The large
brick-shaped Molluscum bodies can also be demonstrated
microscopically by squash preparation. This is a technique,
wherein the cellular material within the central umblication
is extracted manually by an incision with a 16 gauge needle,
and flattened between two microscopic slides to release
the virions, and stained with 5-7 drops of Giemsa stain and
observed under microscope to see the inclusion bodies.
7
Gram, Wright, 10% KOH, and, Papanicolaou stains can also
use to stain the smear to demonstrate the inclusion bodies. In
our case, instead of the smear, the excised tissue sections were
stained with geimsa, gram, and papanicolaou to demonstrate
the inclusion bodies.
Studies have shown that most patients with MCV produce
anti-cellular antibodies and virus-specic antibodies of the
immunoglobulin M class, and they can be demonstrated by
immunouorescence.
8
MCV can be detected and categorized
by polymerase chain reaction assay in skin lesions.
MC lesions spontaneously resolve when left untreated within
6-18 months in children and immunocompetent adults. In
immunocompromised and HIV infected adults the lesions can
get protracted if left untreated. Treatment is recommended for
aesthetic reasons and to prevent autoinoculation based on the
patient’s age, immune status, and site of lesion.
An easy home treatment is to gently scrub the aected area
either with betadine surgical scrub or retin-A 0.025% gel for
5 min daily until the lesions resolves. The most common,
quick, and ecient method to remove individual lesions is by
cryosurgery using liquid nitrogen, dry ice, or frigiderm.
9
Other
methods include curettage with or without electrodessication,
10
or by pulsed laser surgery
11
or by the use of adhesive tape.
12
Surgical removal of the individual lesions may result in
scarring. An eective method is to remove the lesions by using
sharp instruments such as sharp tooth pick, scalpel, or the
edge of a glass slide to eviscerate the central core.
10
Topical
agents such as trichloro acetic acid, potassium hydrochloride,
cantharidium, 10% benzyl peroxide, imiquimod, retinoid

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Journal of International Oral Health 2015; 7(1):63-66
Molluscum contagiosum in a 12-year-old … Nandhini G et al
and similarly, essential oils like Australian lemon myortie
and tea tree oil with organically bound iodine can be used
over the bumps.
2
Extensive lesions can also be treated by
antiviral drugs such as cidofovir, either applied topically or
administered by intralesional injections.
13
Diphencyprone
is a contact immunotherapy, which produces complete
or partial regression in generalized MC in HIV patients.
14
The complications of MC include irritation, inammation,
secondary bacterial infections, and cellulitis in patients who
are HIV infected. The prognosis in healthy patients after
treatments is usually eective, although lesions can cause
disguring and scarring in generalized lesions.
Conclusion
Though clinical appearance of the lesion is sucient for the
diagnosis, microscopic examination of the excised tissue can
be an adjuvant aid in the diagnosis of MC, and routine H and E
stain can be supplemented with special stains like geimsa, gram,
and papanicolaou to demonstrate the molluscum bodies.
References
1. Basak S, Rajurkar MN. Molluscum contagiosum - An
update. Indian Med Gaz 2013;CXLVII(7):276-8.
2. Bateman F. Molluscum contagiosum. In: Shelley WB,
Crissey JT, (Editors). Classics in Dermatology, Springeld,
IL: Charles C Thomas; 1953. p. 20.
3. Molina L, Romiti R. Molluscum contagiosum on tattoo.
An Bras Dermatol 2011;86; 352-4.
4. A.D.A.M. Medical Encyclopedia [Internet]. Atlanta, GA:
A.D.A.M.; 2013.
5. Schwartz JJ, Myskowski PL. Molluscum contagiosum in
patients with human immunodeciency virus infection.
A review of twenty-seven patients. J Am Acad Dermatol
1992;27(4):583-8.
6. Brown ST, Nalley JF, Kraus SJ. Molluscum contagiosum.
Sex Transm Dis 1981;8:227-34.
7. Eleftheriou LI, Kerr SC, Stratman EJ. Diagnosis of
atypical molluscum contagiosum: The utility of a squash
preparation. Clin Med Res 2011;9(1):50-1.
8. Shirodaria PV, Matthews RS, Samuel M. Virus-specic
and anticellular antibodies in molluscum contagiosum.
Br J Dermatol 1979;101(2):133-40.
9. Janniger CK, Schwartz RA. Molluscum contagiosum in
children. Cutis 1993;52(4):194-6.
10. Epstein WL. Molluscum contagiosum. Semin Dermatol
1992;11(3):184-9.
11. Hammes S, Greve B, Raulin C. Molluscum
contagiosum: Treatment with pulsed dye laser. Hautarzt
2001;52(1):38-42.
12. Arndt KA. Manual of Dermatologic Therapeutics, 5
th
ed.
Boston: Little Brown; 1995. p. 339-40.
13. Zabawski EJ Jr. A review of topical and intralesional
cidofovir. Dermatol Online J 2000;6(1):3.
14. Chularojanamontri L, Tuchinda P, Kulthanan K,
Manuskiatti W. Generalized molluscum contagiosum in
an HIV patient treated with diphencyprone. J Dermatol
Case Rep 2010;4(4):60-2.