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 Zambia HIV National Guidelines
 


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 Guide Editors
 Editor In Chief
    Joel E. Gallant, MD, MPH

Pharmacology Editor
    Paul Pham, PharmD, BCPS

Zambia Guideline Team
   Peter Mwaba MMed PhD FRCP
   Alywn Mwinga MMed
   Isaac Zulu MMed MPH
   Velepie Mtonga MMed
   Albert Mwango MBChB
   Jabbin Mulwanda MMed FCS
 

 

 

Diagnosis>Organ System>
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Molluscum contagiosum

Ciro R. Martins, M.D. & David Kouba, M.D.
02-14-2008

  • In one study from Lusaka in pre-HAART era, extensive molluscum contagiosum was a uncommon skin finding in HIV+ pts but was often refractory to treatment.
  • DDx in Zambia is same as noted below - consider checking cryptococcal antigen to rule out disseminated cryptococcosis.
  • Treatment in Zambia is primarily with HAART, with expected improvement of lesions with immune reconstitution.

REFERENCES

Zambia Information Author: David Riedel, M.D.

PATHOGENS

  • 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

CLINICAL

  • 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.

DIAGNOSIS

  • 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.

TREATMENT

Uncomplicated molluscum

  • 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
Giant molluscum

  • 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 Comments

DrugRecommendations/Comments
Imiquimod Should be titrated to mild irritation/erythema. Response varies, and 3 nights weekly dosing may not be frequent enough.

FOLLOW UP

  • Localized, stable infections should be followed every 3-6 mos.
  • Giant molluscum should be routinely debulked/treated to prevent progression/relapse.

Pathogen Specific Therapy

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