Molluscum Contagiosum of the Eyelids in Patients with Acquired Immune Deficiency Syndrome Michael R. Robinson, MD,1 Ira]. Udell, MD,2 Perry F. Garber, MD,2 Henry D. Perry, MD, 3 Barbara W. Streeten, MDI
BaCkground: Infection with molluscum contagiosum has been reported in patients with acquired immune deficiency syndrome (AIDS). Involvement of the eyelids by molluscum in patients with AIDS has rarely been mentioned. Methods: Two patients with AIDS presented with eyelid molluscum contagiosum. Detailed examination and follow-up was performed. Resufts: One patient had noted ocular irritation with epiphora for several weeks and showed a typical viral keratoconjunctivitis in both eyes. The other patient progressed to confluent masses involving the entire lower eyelid on one side. Removal of the lesions by surgery and cryotherapy was followed by recurrences in both patients within 6 to 7 weeks, the incubation period for this viral infection. Conclusion: Molluscum contagiosum can form confluent lesions on the eyelids in patients with AIDS, which may cause a keratoconjunctivitis. Local removal of molluscum eyelid nodules appears to be of limited long-term value in patients with T-cell immunodeficiency. Ophthalmology 1992;99:1745-1747
Infection with molluscum contagiosum and other cutaneous viral diseases has been reported in patients with the acquired immune deficiency syndrome (AIDS). I Molluscum contagiosum has been described as more confluent and resistant to conventional therapy in patients with AIDS, tending to recur after surgical removal of the lesions. 2-6 Involvement of the eyelids by molluscum in such patients has rarely been mentioned, and no ocular complications have been reported. We report two cases of eyelid involvement with mol-
Originally received: March 30, 1992. Revision accepted: July 2, 1992. IDepartment of Ophthalmology, State University of New York Health Science Center at Syracuse, Syracuse. Department of Ophthalmology, Long Island Jewish Medical Center, New Hyde Park. 3 Division of Ophthalmology, North Shore University Hospital, Manhasset. Reprint requests to Michael R. Robinson, MD, Rochester Eye Center, 30 N Union St, Rochester, NY 14607. 2
luscum contagiosum in patients with AIDS, one with keratoconjunctivitis.
Case Reports Case 1. Two months before examination, a 34-year-old man with Centers for Disease Control-defined AIDS noted the development of confluent nodules over his face, extremities, and groin. During the preceding 6 weeks, he had experienced epiphora and irritation of both eyes. On examination, his visual acuity was correctable to 20/20 in each eye. Along the lid margins of both the upper and lower lids, multiple umbilicated lesions, 2 to 5 mm in diameter (Fig I), characteristic of molluscum contagiosum, were discovered. Results of slit-lamp examination of both eyes showed a follicular conjunctivitis with follicles located on both the upper and lower tarsi (Fig 2). The patient had a diffuse punctate keratopathy located mainly across the palpebral fissure area and superior cornea with numerous subepithelial infiltrates for 360 0 along the limbus, more pronounced in the left eye. Case 2. A 39-year-old man, who tested positive for the human immunodeficiency virus (HIV), experienced a 7-month history of multiple nodules on the upper and lower lids of the left eye. Visual acuity without correction was 20/20 in each eye.
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Top left, Figure 1. Case 1. Multiple umbilicated molluscum lesions along the lid margins, as well as the adjacent skin. Top right, Figure 2. Case 1. Slit-lamp micrograph of subepithelial infiltrates and small vessels on the limbal cornea. Bottom left, Figure 3. Case 2. Multiple molluscum nodules on upper and lower eyelids with coalescence along the lateral lower lid. Bottom right, Figure 4. Case 2. Marked increase in size and number of molluscum nodules 3 months after surgical excision and cryotherapy with confluence of lesions along the whole lower lid border.
On external examination, multiple wart-like molluscum lesions, involving both upper and lower lids of the left eye, some of which appeared waxy and tended to coalesce laterally (Fig 3), were apparent. Results of slit-lamp examination showed follicular conjunctivitis in the left eye; the cornea was clear. He refused treatment of the eyelids and began receiving an experimental protocol using ansamycin. Four months later, he returned with a remarkable increase in lesions, both in size and in number, on the left eyelids (Fig 4). The lower lid lesions now formed a pearly, thickened, coalescent mass along the whole margin. A few nodules also were present in the right upper lid medially. The lesions were excised surgically along their edges, down to normal muscle. The deep tissue edges were frozen with nitrous oxide for approximately 20 seconds, using the freeze-thaw-freeze technique. In the outer left lower eyelid, the involvement was so extensive that a small skin flap had to be advanced from below. Small early lesions were frozen. Similar treatment was applied to the right upper eyelid. The patient did well initially with re-epithelialization of all the treated areas, but returned 8 weeks later with extensive recurrences between the treated areas (Fig 4).
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For several months, the patient had experienced abdominal pain and cramping, and a mass was now visualized on colonoscopy. Results of exploratory laparotomy showed immunoblastic lymphosarcoma, B-cell type. The patient has since died.
Histopathology Skin lesions from both cases were fixed in 10% neutralbuffered formalin, and a few lesions from case 2 were fixed in 2% glutaraldehyde for electron microscopy. The paraffin-embedded sections showed typical crater-like lesions of molluscum developing in lobules of epithelial cells, proliferating down into the dermis. The inclusions were seen as intracytoplasmic eosinophilic small bodies near the basal layer, becoming larger and more basophilic while pushing the cell nucleus to one side during the migration of the cells toward the surface. By electron microscopy, the cytoplasmic inclusion bodies were up to 35
Robinson et al . Molluscum in AIDS nm in diameter, containing myriad large viral particles, 300 X 250 nm. The particles were seen to change from an initial round shape to a more rectangular one. Their centers were filled with an electron-dense nucleoid, which on side view had a dumb-bell shape.
Discussion Patients with AIDS are infected with the HIV, a retrovirus that replicates and destroys T-helper cells. The loss ofThelper cells results in a profound defect in cell-mediated immunity, making patients susceptible to opportunistic infections. Mucocutaneous infections with viruses, including Herpes simplex, varicella-zoster, and condyloma acuminata, I are frequently encountered in patients with AIDS. Their course tends to be unusually aggressive and resistant to conventional therapy.2-6 A biopsy may be indicated since the lesions have been confused with warts, papillomas, and in the patient with AIDS, cutaneous Cryptococcosis and Histoplasma duboisii. 7- 8 Molluscum contagiosum is a benign, common viral disease of the skin, caused by a large DNA pox virus. The disease usually occurs in children with normal immunity and appears on the face and eyelids. In adults with normal immunity, the disease may be sexually transmitted, typically to the genitalia and groin area with fewer than 20 lesions, and resolves spontaneously within 3 to 12 months. 9,10 In patients with underlying immunodeficiencies, molluscum contagiosum has been characterized by occurrence of a large number of lesions, being more confluent, and also involving the extremities and face. 2-6 A number of patients with AIDS have been reported to have widespread, persistent molluscum contagiosum infection with several recurrences after therapy. Recurrences usually develop 6 to 8 weeks after removal of the lesions, which corresponds to the incubation period of the virus and was the interval in both of our cases. Spontaneous resolution of the lesions has not been observed in patients with AIDS. In individuals with normal immunity, spontaneous clearing may represent a cell-mediated rejection reaction. One histopathologic study revealed a dense, mononuclear cell infiltrate at the base of the lesion during the course of the disease. II Given the fact that patients with AIDS have a defect in their cell-mediated immunity, aggressive and recurrent molluscum contagiosum is not surprising. Secondary keratoconjunctivitis is a common complication of molluscum lid infection in patients with normal
immunity, but has not been previously reported in those patients with AIDS. Because some speculation has occurred that the keratitis represents an immunologic manifestation rather than a specific site of virus replication, one might wonder whether its absence in patients with AIDS could be related to the defective immunity. However, one of the present cases had typical viral-type infiltrates, punctate keratitis, and folliculosis, indicating that T-helper cells may not be necessary for these manifestations. Experience with the current cases suggests that surgery and cryotherapy, even when extensive, often will fail to be curative or helpful in treating molluscum contagiosum.
References 1. Hatcher VA. Mucocutaneous infections in acquired immune deficiency syndrome. In: Friedman-Kien AE, Laubenstein U, eds. AIDS: The Epidemic of Kaposi's Sarcoma and Opportunistic Infections. New York: Masson, 1984;245-51. 2. Katzman M, Elmets CA, Lederman MM. Molluscum contagiosum and the acquired immunodeficiency syndrome [letter]. Ann Intern Med 1985;102:413-4. 3. Lombardo Pc. Molluscum contagiosum and the acquired immunodeficiency syndrome [letter]. Arch Dermatol 1985; 121 :834-5. 4. Redfield RR, James WD, Wright DC, et al. Severe molluscum contagiosum infection in a patient with human T cell lymphotropic (HTLV-III) disease. J Am Acad Dermatol 1985; 13:821-4. 5. Sarma DP, Weilbaecher TG. Molluscum contagiosum and the acquired immunodeficiency syndrome [letter]. J Am Acad Dermatol 1985;13:682-3. 6. Kohn SR. Molluscum contagiosum in patients with the acquired immunodeficiency syndrome [letter]. Arch Ophthalmol 1987;105:458. 7. Rico MJ, Penneys NS. Cutaneous cryptococcosis resembling molluscum contagiosum in a patient with AIDS. Arch DermatoI1985;121:901-2. 8. Feuilhade de Chauvin M, Revuz J, Deniau M. Histoplasmose a Histoplasma duboisii. Lesions cutanees simulant des molluscum contagiosum. Ann Dermatol Venereol 1983; 110:715-6. 9. Lever WF, Schaumburg-Lever G. Histopathology of the Skin, 6th ed. Philadelphia: JB Lippincott, 1983;370-1. 10. Duke-Elder S, ed. System of Ophthalmology. Vol. XIII. The Ocular Adnexa. Pt. I: Diseases of the Eyelid. London: Henry Kimpton, 1974; 154-7. II. Steffen C, Markman JA. Spontaneous disappearance of molluscum contagiosum. Report of a case. Arch Dermatol 1980;116:923-4.
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BaCkground: Infection with molluscum contagiosum has been reported in patients with acquired immune deficiency syndrome (AIDS). Involvement of the eyelids by molluscum in patients with AIDS has rarely been mentioned. Methods: Two patients with AIDS presented with eyelid molluscum contagiosum. Detailed examination and follow-up was performed. Resufts: One patient had noted ocular irritation with epiphora for several weeks and showed a typical viral keratoconjunctivitis in both eyes. The other patient progressed to confluent masses involving the entire lower eyelid on one side. Removal of the lesions by surgery and cryotherapy was followed by recurrences in both patients within 6 to 7 weeks, the incubation period for this viral infection. Conclusion: Molluscum contagiosum can form confluent lesions on the eyelids in patients with AIDS, which may cause a keratoconjunctivitis. Local removal of molluscum eyelid nodules appears to be of limited long-term value in patients with T-cell immunodeficiency. Ophthalmology 1992;99:1745-1747
Infection with molluscum contagiosum and other cutaneous viral diseases has been reported in patients with the acquired immune deficiency syndrome (AIDS). I Molluscum contagiosum has been described as more confluent and resistant to conventional therapy in patients with AIDS, tending to recur after surgical removal of the lesions. 2-6 Involvement of the eyelids by molluscum in such patients has rarely been mentioned, and no ocular complications have been reported. We report two cases of eyelid involvement with mol-
Originally received: March 30, 1992. Revision accepted: July 2, 1992. IDepartment of Ophthalmology, State University of New York Health Science Center at Syracuse, Syracuse. Department of Ophthalmology, Long Island Jewish Medical Center, New Hyde Park. 3 Division of Ophthalmology, North Shore University Hospital, Manhasset. Reprint requests to Michael R. Robinson, MD, Rochester Eye Center, 30 N Union St, Rochester, NY 14607. 2
luscum contagiosum in patients with AIDS, one with keratoconjunctivitis.
Case Reports Case 1. Two months before examination, a 34-year-old man with Centers for Disease Control-defined AIDS noted the development of confluent nodules over his face, extremities, and groin. During the preceding 6 weeks, he had experienced epiphora and irritation of both eyes. On examination, his visual acuity was correctable to 20/20 in each eye. Along the lid margins of both the upper and lower lids, multiple umbilicated lesions, 2 to 5 mm in diameter (Fig I), characteristic of molluscum contagiosum, were discovered. Results of slit-lamp examination of both eyes showed a follicular conjunctivitis with follicles located on both the upper and lower tarsi (Fig 2). The patient had a diffuse punctate keratopathy located mainly across the palpebral fissure area and superior cornea with numerous subepithelial infiltrates for 360 0 along the limbus, more pronounced in the left eye. Case 2. A 39-year-old man, who tested positive for the human immunodeficiency virus (HIV), experienced a 7-month history of multiple nodules on the upper and lower lids of the left eye. Visual acuity without correction was 20/20 in each eye.
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Volume 99, Number 11, November 1992
Top left, Figure 1. Case 1. Multiple umbilicated molluscum lesions along the lid margins, as well as the adjacent skin. Top right, Figure 2. Case 1. Slit-lamp micrograph of subepithelial infiltrates and small vessels on the limbal cornea. Bottom left, Figure 3. Case 2. Multiple molluscum nodules on upper and lower eyelids with coalescence along the lateral lower lid. Bottom right, Figure 4. Case 2. Marked increase in size and number of molluscum nodules 3 months after surgical excision and cryotherapy with confluence of lesions along the whole lower lid border.
On external examination, multiple wart-like molluscum lesions, involving both upper and lower lids of the left eye, some of which appeared waxy and tended to coalesce laterally (Fig 3), were apparent. Results of slit-lamp examination showed follicular conjunctivitis in the left eye; the cornea was clear. He refused treatment of the eyelids and began receiving an experimental protocol using ansamycin. Four months later, he returned with a remarkable increase in lesions, both in size and in number, on the left eyelids (Fig 4). The lower lid lesions now formed a pearly, thickened, coalescent mass along the whole margin. A few nodules also were present in the right upper lid medially. The lesions were excised surgically along their edges, down to normal muscle. The deep tissue edges were frozen with nitrous oxide for approximately 20 seconds, using the freeze-thaw-freeze technique. In the outer left lower eyelid, the involvement was so extensive that a small skin flap had to be advanced from below. Small early lesions were frozen. Similar treatment was applied to the right upper eyelid. The patient did well initially with re-epithelialization of all the treated areas, but returned 8 weeks later with extensive recurrences between the treated areas (Fig 4).
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For several months, the patient had experienced abdominal pain and cramping, and a mass was now visualized on colonoscopy. Results of exploratory laparotomy showed immunoblastic lymphosarcoma, B-cell type. The patient has since died.
Histopathology Skin lesions from both cases were fixed in 10% neutralbuffered formalin, and a few lesions from case 2 were fixed in 2% glutaraldehyde for electron microscopy. The paraffin-embedded sections showed typical crater-like lesions of molluscum developing in lobules of epithelial cells, proliferating down into the dermis. The inclusions were seen as intracytoplasmic eosinophilic small bodies near the basal layer, becoming larger and more basophilic while pushing the cell nucleus to one side during the migration of the cells toward the surface. By electron microscopy, the cytoplasmic inclusion bodies were up to 35
Robinson et al . Molluscum in AIDS nm in diameter, containing myriad large viral particles, 300 X 250 nm. The particles were seen to change from an initial round shape to a more rectangular one. Their centers were filled with an electron-dense nucleoid, which on side view had a dumb-bell shape.
Discussion Patients with AIDS are infected with the HIV, a retrovirus that replicates and destroys T-helper cells. The loss ofThelper cells results in a profound defect in cell-mediated immunity, making patients susceptible to opportunistic infections. Mucocutaneous infections with viruses, including Herpes simplex, varicella-zoster, and condyloma acuminata, I are frequently encountered in patients with AIDS. Their course tends to be unusually aggressive and resistant to conventional therapy.2-6 A biopsy may be indicated since the lesions have been confused with warts, papillomas, and in the patient with AIDS, cutaneous Cryptococcosis and Histoplasma duboisii. 7- 8 Molluscum contagiosum is a benign, common viral disease of the skin, caused by a large DNA pox virus. The disease usually occurs in children with normal immunity and appears on the face and eyelids. In adults with normal immunity, the disease may be sexually transmitted, typically to the genitalia and groin area with fewer than 20 lesions, and resolves spontaneously within 3 to 12 months. 9,10 In patients with underlying immunodeficiencies, molluscum contagiosum has been characterized by occurrence of a large number of lesions, being more confluent, and also involving the extremities and face. 2-6 A number of patients with AIDS have been reported to have widespread, persistent molluscum contagiosum infection with several recurrences after therapy. Recurrences usually develop 6 to 8 weeks after removal of the lesions, which corresponds to the incubation period of the virus and was the interval in both of our cases. Spontaneous resolution of the lesions has not been observed in patients with AIDS. In individuals with normal immunity, spontaneous clearing may represent a cell-mediated rejection reaction. One histopathologic study revealed a dense, mononuclear cell infiltrate at the base of the lesion during the course of the disease. II Given the fact that patients with AIDS have a defect in their cell-mediated immunity, aggressive and recurrent molluscum contagiosum is not surprising. Secondary keratoconjunctivitis is a common complication of molluscum lid infection in patients with normal
immunity, but has not been previously reported in those patients with AIDS. Because some speculation has occurred that the keratitis represents an immunologic manifestation rather than a specific site of virus replication, one might wonder whether its absence in patients with AIDS could be related to the defective immunity. However, one of the present cases had typical viral-type infiltrates, punctate keratitis, and folliculosis, indicating that T-helper cells may not be necessary for these manifestations. Experience with the current cases suggests that surgery and cryotherapy, even when extensive, often will fail to be curative or helpful in treating molluscum contagiosum.
References 1. Hatcher VA. Mucocutaneous infections in acquired immune deficiency syndrome. In: Friedman-Kien AE, Laubenstein U, eds. AIDS: The Epidemic of Kaposi's Sarcoma and Opportunistic Infections. New York: Masson, 1984;245-51. 2. Katzman M, Elmets CA, Lederman MM. Molluscum contagiosum and the acquired immunodeficiency syndrome [letter]. Ann Intern Med 1985;102:413-4. 3. Lombardo Pc. Molluscum contagiosum and the acquired immunodeficiency syndrome [letter]. Arch Dermatol 1985; 121 :834-5. 4. Redfield RR, James WD, Wright DC, et al. Severe molluscum contagiosum infection in a patient with human T cell lymphotropic (HTLV-III) disease. J Am Acad Dermatol 1985; 13:821-4. 5. Sarma DP, Weilbaecher TG. Molluscum contagiosum and the acquired immunodeficiency syndrome [letter]. J Am Acad Dermatol 1985;13:682-3. 6. Kohn SR. Molluscum contagiosum in patients with the acquired immunodeficiency syndrome [letter]. Arch Ophthalmol 1987;105:458. 7. Rico MJ, Penneys NS. Cutaneous cryptococcosis resembling molluscum contagiosum in a patient with AIDS. Arch DermatoI1985;121:901-2. 8. Feuilhade de Chauvin M, Revuz J, Deniau M. Histoplasmose a Histoplasma duboisii. Lesions cutanees simulant des molluscum contagiosum. Ann Dermatol Venereol 1983; 110:715-6. 9. Lever WF, Schaumburg-Lever G. Histopathology of the Skin, 6th ed. Philadelphia: JB Lippincott, 1983;370-1. 10. Duke-Elder S, ed. System of Ophthalmology. Vol. XIII. The Ocular Adnexa. Pt. I: Diseases of the Eyelid. London: Henry Kimpton, 1974; 154-7. II. Steffen C, Markman JA. Spontaneous disappearance of molluscum contagiosum. Report of a case. Arch Dermatol 1980;116:923-4.
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