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Ciro R. Martins, M.D. & David Kouba, M.D.
09-29-2009
- In one study from Lusaka in pre-HAART era, extensive molluscum contagiosum was an uncommon skin finding in adult HIV+ pts but was often refractory to treatment.
- Common finding in HIV+ children.
- DDx in Zambia is same as noted below - consider checking cryptococcal antigen to rule out disseminated cryptococcosis.
- Treatment in Zambia is primarily with ART, with expected improvement of lesions with immune reconstitution.
Zambia Information Author: David Riedel, M.D.
- Molluscum contagiosum virus, Type I (MCV I)
- Molluscum contagiosum virus, Type II (MCV II)
- MCV I and MCV II are poxviruses of genus Molluscipox; clinical manifestations indistinguishable
- Transmission is by skin-to-skin contact, and to lesser degree by fomites.
- Clinical presentation: 2-4 mm, firm, umbilicated, pearly papules with waxy surface. Usually asymptomatic although pruritus and dermatitis may sometimes occur.
- In AIDS pts, typical lesions commonly found on face/neck or may be disseminated. Lesions may also spread within plaques of atopic dermatitis; these lesions may be either smooth and umbilicated or more verrucous or hyperkeratotic. This feature more common in AIDS pts.
- Larger, coalescent, fungating lesions (giant molluscum) can also occur in AIDS pts, usually around the head and neck.
- Dx: largely presumptive based on clinical appearance . If Dx is in question, Bx with histopathology is definitive.
- Histopathology: Molluscum bodies (Henderson-Patterson Bodies) visible in cytoplasm of epithelium.
- Rapid diagnosis: curette a lesion and smear on glass slide to see characteristic cytoplasmic inclusions on H&E. Special stains are not necessary.
- DDx in the immunosuppressed host also includes disseminated cryptococcosis, histoplasmosis.
- DDx in all pts includes: warts, nevi, papular granuloma annulare, pyogenic granuloma.
- Uncomplicated molluscum primarily a cosmetic problem. No permanent cure, but can be easily controlled with local destructive methods and immunomodulatory agents.
- Local destructive methods: curettage, cryotherapy, electrocauterization, KOH solution, trichloroacetic acid (TCA), cantharidin (blister beetle extract), photodynamic therapy (PDT) or 0.5% podophyllotoxin cream should all be considered first line agents.
- Immunomodulatory agents: imiquimod cream: apply 3 nights/wk. If no irritation results, frequency of administration can be increased to qhs. This can be used as secondary, adjunct to destructive measures.
- Treat while disease limited to avoid spread.
- Treatment of HIV with HAART should improve severity and frequency of outbreaks.
- Newer therapies include BIW application of 12%salicylic acid gel
- Very difficult to treat; recalcitrant to all known therapies, with possible exception of HAART.
- Various destructive modalities such as TCA, PDT, and aggressive curettage should be attempted in conjunction with topical immunomodulatory therapy.
| Drug | Recommendations/Comments |
| Imiquimod | Should be titrated to mild irritation/erythema. Response varies, and 3 nights weekly dosing may not be frequent enough. |
- Localized, stable infections should be followed every 3-6 mos.
- Giant molluscum should be routinely debulked/treated to prevent progression/relapse.
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