Extensive exuberant giant molluscum contagiosum with ulceration in a female with acquired immunodeficiency syndrome with a CD4 count of 54 cells/mm³ – an interesting case report with a brief review of the literature

INTRODUCTION

The skin is involved in 90% of cases of human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) in all stages of the disease. The skin is also the first organ to be affected in HIV/AIDS. Very often, the cutaneous manifestations may also be a marker of undetected HIV infection. The cutaneous manifestations may also be related to the CD4 levels. Molluscum contagiosum (MC) is a common cutaneous manifestation of HIV infection. MC is caused by the MC virus (MCV), a pox virus that can be sexually transmitted. In humans, there are 2 types of poxvirus that cause infection: MCV-1, the most common type, and MCV-2, which is exclusively involved in the context of HIV infection. Giant MC, defined as lesions >1 cm in diameter, is seen more often in AIDS patients and is a marker of low CD4 counts.^[1] The ability of HIV to progressively deplete the CD4 cells is the immune mechanism by which viral disorders predominate in HIV. This is because the CD4 cells are a very important part of the cell-mediated immunity arm of the body’s defense in combating obligate intracellular pathogens such as MV and the herpes virus. MC usually presents clinically with dome-shaped pearly white papules with central umblication, but in the event of HIV infection, these classical features may not be seen, and the diagnosis can be missed. We are reporting a rare and interesting case of extensive exuberant and giant MC in an AIDS patient with a low CD4 count.

CASE REPORT

A 49-year-old female, an accredited social health activist worker by profession and separated from her husband for the past 20 years, presented with a history of multiple skin-colored, pruritic but painless raised lesions on the inner aspect of the right thigh 2 months ago. Within a period of 1 week, she noticed similar lesions on the inner aspect of the left thigh. She took over-the-counter systemic and topical medications, including ayurvedic powders, but with no relief. She had also consulted multiple physicians without relief. During the next 2–3 weeks, the lesions became confluent and spread to the posterior thigh and buttocks. Last week, she noticed that some large lesions had ruptured to form raw areas and ulcers, which were painful and had yellowish discharge. She was subsequently referred to our tertiary care center. The patient was a diabetic and hypertensive on drugs. There was no history of tuberculosis (TB), weight loss, chronic diarrhea, or any systemic illness. She denied premarital or extramarital contact. There was no history of genital ulcers. There was no history of blood transfusion or I/V drug abuse.

On examination, there were multiple confluent and some discrete skin colored to hyperpigmented papules, plaques, and nodules, some with ulceration, distributed on the anteromedial aspect of both thighs [Figure 1], posterior thighs, and buttocks. Some of the papules and plaques on the posterior thigh and buttocks had central umbilication [Figure 2]. There were two well-defined oval punched out ulcers of 3 cm × 2 cm on the inferior aspect of the right medial thigh, with regular margins, floor with clean granulation tissue, the base non-indurated, non- tender, and non-bleeding [Figure 3]. We had differentials of giant MC, blastomycosis-like pyoderma, cutaneous cryptococcus, talaromyces, and histoplasmosis. An ophthalmological examination showed evidence of cytomegalovirus (CMV) retinitis. The other systems were within normal limits.

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Figure 1:

Papules, plaques, nodules with ulceration on both thighs

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Figure 2:

Papules and plaques with central umblication (arrow) on the posterior thighs and buttocks.

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Figure 3:

Well-defined punched-out ulcers on the inferior part of the right thigh.

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The relevant investigations done on the patient have been depicted in Table 1. The blood hemogram showed anemia (8.5 mg%) and an elevated erythrocyte sedimentation rate (95 mm). Liver function and renal function tests were normal. Urine examination was normal. Stool and sputum cultures were negative for organisms. Serological tests for syphilis, Hepatitis B surface antigen, and anti-hepatitis C virus were negative. Dark field examination of the smear from the ulcers was negative for Treponema. IgG and IgM tests for HSV-1 and 2 were negative. The retro test was positive for HIV-1. CD4 count was 54 cells/mm³. HIV plasma RNA content was not measured due to a lack of facilities. IgG for CMV was positive (>200). Chest X-ray was normal, and investigations for TB were negative. Ultrasound of the abdomen demonstrated fatty liver and a calcified fibroid. Pus culture and sensitivity from the ulcers demonstrated heavy mixed growth. A skin biopsy from an umblicated papule and the edge of the ulcer demonstrated similar findings. There was an epidermal defect with the underlying stratum granulosum and spinosum cells showing inclusion bodies [Figure 4]. High power showed the keratinocytes in the stratum granulosum and spinosum packed with intracytoplasmic eosinophilic bodies (Henderson– Paterson bodies) diagnostic of MC [Figure 5]. The patient was treated with broad-spectrum antibiotics, co-trimoxazole (for pneumocystis pneumonia prophylaxis), and I/V ganciclovir for CMV retinitis. The patient is at present being worked for starting antiretroviral therapy (ART) after CMV treatment.

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Figure 4:

Skin biopsy showing epidermal defect (arrow) with intracytoplasmic eosinophilic bodies in the epidermal keratinocytes, H&E ×100. H&E: Hematoxylin and Eosin.

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Figure 5:

High power showing intracytoplasmic eosinophilic bodies (arrows) in the stratum granulosum and stratum spinosum, H&E ×400. H&E: Hematoxylin and Eosin.

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DISCUSSION

Our HIV patient with low CD4 count presented with skin lesions with a biopsy diagnosis of MC. The MCs in our patient were giant, extensive, exuberant, and in addition, there were large ulcers, which are the highlights of this case. Ulceration in MCs is very rare, and we could come across only very few case reports. The low CD4 count could explain this atypical and rare presentation in our case. Another interesting feature in our case is that the patient had only CMV retinitis as systemic involvement, with no other involvement, in spite of very low CD4 counts. Profound immunosuppression in AIDS can radically modify the clinical presentations of many common dermatoses.^[2,3] Giant MC is a common presentation in the context of HIV with very low CD4 counts.^[3,4] The protean manifestations of MC in HIV/AIDS range from lichen planus-like papules to carcinoma-like presentations. A brief review of literature on the atypical presentations of MC in HIV, along with treatment, is given in Table 2.

The various presentations range from nodules, verrucous plaques, cutaneous horn-like lesions, basal cell carcinoma-like lesions, and even tumor-like lesions. In comparison, our patient had extensive ulcerative lesions, which are very rare in the literature. The diagnosis is usually established by impression smears or skin biopsy. Skin biopsy is mandatory in many cases, as cutaneous cryptococcosis, talaromyces, and histoplasmosis may present with MC-like lesions.^[4,5] The crux of the problem is the treatment of extensive and giant MC in HIV/AIDS. Most case reports have shown that starting ART will cause resolution of MC in most cases.^[6,7] Other anecdotal reports are ART along with 5% imiquimod, 20% KOH, external radiation, 10% TCA, topical acyclovir, and excision.^[6-9] Recently, extensive MC in a pediatric HIV case has shown excellent response to paclitaxel.^[10] In conclusion, a strong clinical acumen is required to diagnose atypical manifestations of common dermatoses in HIV/AIDS.

CONCLUSION

HIV infection presents with a wide variety of atypical cutaneous viral infections when the CD4 counts are very low. Atypical presentations of molluscum contagiosum may be missed if a strong clinical suspicion is not entertained.