Case report Giant hyperplastic molluscum contagiosum 
Giant hyperplastic molluscum 
contagiosum 
M. Wiederkehr and R. A. Schwartz 
SUMMARY 
Molluscum contagiosum (MC) is a common vira! infection of the skin in healthy children. Unfortunately, it 
may be seen in exuberant form in children and adults with leukemia or other types of immunodeficiency, 
including the acquired immunodeficiency syndrome. It usually appears as a solitary or small group of 
papules which are characteristically flesh colored, slightly translucent and umbilicated. We report a case 
of a 40-year-old AIDS patient with multiple keratotic, papillomatous projections on his anterior neck, 
some resembling cutaneous horns. A skin biopsy specimen revealed the presence of numerous mollus-
cum bodies. 
Introduction 
Molluscum contagiosum (MC) is a common vira! 
infection of the skin and mucous membranes of healthy 
children (1,2). Unfortunately, it may be seen in exuber-
ant form in children and adults with leukemia or other 
types of immunodeficiency, including the acquired 
immunodeficiency syndrome (2-4). It usually appears 
as a solitary or small group of papules which are char-
acteristically flesh colo red, slightly translucent and um-
bilicated (1, 4-6). Our patient was remarkable in that he 
had MC, some in the form of multiple hyperplastic cu-
taneous horns. 
Report oj a case 
A 40 year-old Black man was seen for multiple 
growths of the face and neck of one year's duration. 
The patient had a history of AIDS with a CD4 count of 
22. He was not on antiretroviral therapy. One year prior 
to our examination, he had developed "growths" on 
his face and neck. They were non-painful, non-pruritic, 
and slowly but continuously growing. Occasionally, one 
would rupture and extrude a white, foul-smelling sub-
stance. A dermatologist previously excised severa! of 
these lesions. Three months earlier, he had developed 
a red, scaly rash around his nose extending to his 
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Giant hyperplastic molluscum contagiosum 
cheeks, eyebrows, and forehead. 
On physical exam, the patient appeared cachectic, 
but in otherwise no distress. Multiple keratotic papillo-
matous projections were present on the patient's man-
dible and anterolateral neck. Severa! smaller dome 
shaped umbilicated papules were also present, prima-
rily on the forehead. Additionally, the patient had scaly 
erythematous patches on his nasolabial folds extend-
ing to his cheeks, glabellar and forehead region, as well 
as scales in his scalp and eyebrows. The rest of the skin 
exam was normal except for a few scattered dome 
shaped papules on upper chest. Shave excision of one 
of the keratotic lesions on his anterior neck was per-
formed . Skin biopsy specimen revealed numerous 
molluscum bodies in the dermis. A diagnosis of mol-
luscum contagiosum was confirmed; the patient began 
treatment w ith liquid nitrogen. 
Discussion 
Molluscum contagiosum usually appears as tiny 1-2 
mm papules which are smooth, dome shaped and 
pearly white or skin colored. They tend to develop cen-
tral umbilication as they enlarge, reaching a diameter 
of 1.5 centimeter or more in some patients. They are 
often 3 to 5 mm in diameter when first noted by the 
patient, with smaller ones sometimes also evident. There 
may be hundreds of nodules, especially if the patient is 
immunocompromised. An associated erythema some-
times surrounds molluscum contagiosum (7). Atypical 
MC may arise from follicular involvement (8), manipu-
lation of which may produce secondary abscess forma-
tion (9). On the eyelid, MC may produce unilateral re-
fracto1y conjunctivitis, and may be evident as a con-
junctival or even corneal nodule (10). 
MC is a cutaneous infection by the molluscum 
contagiosum virus, a pox virus of double stranded DNA 
200-300 nm in diameter (2). One of the largest viruses 
in size, its incidence is worldwide, attacking humans, 
other primates and the kangaroo. The virus has not been 
grown in tissue culture or eggs. It has two distinct vira! 
types based on DNA analysis, labeled MCV-1 and MCV-
2 (2 ,11). There is no predominance of either type in 
genital infection, nor is there a morphological differ-
ence clinically between the two types. MCV-2 was not 
seen in patients under 15 years of age in one study of 
90 patients (11). 
MC is transmitted by fomites , close physical contact 
and by autoinoculation. It is worldwide in distribution, 
and is most prevalent in children of school age (12). It 
has been associated with close contact sports, especially 
Figure 1. 40-year-old AIDS patient with giant 
hyperplastic molluscum contagiosum on 
anterior neck. 
wrestling (12). It is also a sexually transmitted disease 
03,14). 
Molluscum contagiosum may resemble a number 
of other disorders. Its pearly quality with central um-
bilication suggests a basal celi epithelioma or a trichoe-
pithelioma (15). A giant MC may resemble a keratoa-
canthoma or a warty dyskeratoma. Benign appendageal 
tumors such as syringomas and hydrocystomas may 
require distinction at times, as may ectopic sebaceous 
glands (12,16). On the eyelids, MC may be mistaken for 
a chalazion, a lid abscess, or a granuloma (11). More 
importantly, in patients with AIDS, a deep fungal infec-
tion, especially cryptococcosis, may resemble MC (17). 
In our patient the cutaneous horn formation also sug-
. gested human papilloma virus infection. 
The therapeutic approach to molluscum 
contagiosum in patients with AIDS is often challeng-
ing. Initiating highly active antiretroviral therapy 
(HAART) may indirectly help treat the condition. 
Cryosurgery is good modality in immunocompetent 
patients, however, it is often unsuccessful in AIDS pa-
tients. In addition, chemical destruction and other meth-
ods can also be used successfully such as retinoic acid, 
phenol, salicylic acid, lactic acid, imiquirnod, cidofovir, 
and cantharidin (2,13,17-24). The humoral response to 
MC may be affected by the patient's immunological sta-
tus (25), with or without therapy. 
Case report 
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Case report 
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Giant hyperplastic molluscum contagiosum 
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Giant hyperplastic molluscum contagiosum 
AUTHORS' 
ADDRESSES 
24. Edwards L. Imiquimod in clinical practice. J Am Acad Dermatol 2000; 43: S12-7. 
25. Watanabe T, Nakamura K, Wakugawa M et al. Antibodies to molluscum contagiosum virus in the 
general population and susceptible patients. Arch Dermatol 2000; 136: 1518-22. 
Michael Wiederkehr, MD, pathologist, Dept Pathology, New Jersey 
Medical School, Newark, New Jersey 
Robert A. Schwartz, MD, MPH, Professor & Head, Dermatology, New 
Jersey Medical School, 185 South Orange Avenue, Newark, New Jersey 
07103-2714 
On behalf of Dermatovenereological Society of Slovenia and Society for 
Clinical Microbiology and Hospital lnfections (Slovenian Medical Society), 
we cordially invite you to attend and to actively participate in the 
8th Alpe-Adria-Danube Congress on Sexually Transmitted Diseases 
and Sexually Transmitted Diseases and lnfections of the Skin 
Kranjska Gora, Slovenia, November 15-17, 2002 
In the course of this meeting special lectures will cover key topics on Sexually 
Transmitted Dieseases and lnfections of the Skin followed by series of oral 
communications and poster presentations. We look forward to receive a large 
number of abstracts on the current research work done on this field and also 
on the epidemiology of STDs and infections of the skin in the Alpe Adria 
Danube Reg ion. The meeting will provide you with the opportunity to exchange 
the experiencies and ideas on recent developments related to all aspects of 
STDs. The Organizing Committee will endeavour to organize a meeting of 
high scientific standard in the hospitable atmosphere of Kranjska Gora. 
We look forward to welcoming you in November 2002 . 
Ca s e r e p o rt 
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