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CASE REPORT
Year : 1997  |  Volume : 45  |  Issue : 4  |  Page : 234-236

Lid abscess with extensive molluscum contagiosum in a patient with acquired immunodeficiency syndrome


Vision Research Foundation, Chennai, India

Correspondence Address:
J Biswas
Vision Research Foundation, Chennai
India
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Source of Support: None, Conflict of Interest: None


PMID: 9567020

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How to cite this article:
Biswas J, Therese L, Kumarasamy N, Solomon S, Yesudian P. Lid abscess with extensive molluscum contagiosum in a patient with acquired immunodeficiency syndrome. Indian J Ophthalmol 1997;45:234-6

How to cite this URL:
Biswas J, Therese L, Kumarasamy N, Solomon S, Yesudian P. Lid abscess with extensive molluscum contagiosum in a patient with acquired immunodeficiency syndrome. Indian J Ophthalmol [serial online] 1997 [cited 2020 May 27];45:234-6. Available from: http://www.ijo.in/text.asp?1997/45/4/234/14994

Molluscum contagiosum is a common skin infection caused by a large DNA pox virus. Molluscum lesions can occur in children with normal immunity. In adults, this virus can be transmitted through sexual intercourse. In patients with acquired immunodeficiency syndrome (AIDS), such lesions can occur in the eyelid and conjunctiva and are characteristically larger in number and size, often confluent and resistant to therapy.[1][2][3] Dermal abscesses due to staphylococci, acid-fast bacilli, and cytomegalovirus have been reported in molluscum lesions in patients with AIDS indicating the tendency of such lesions to secondary infection.[4]

We report a case of extensive molluscum contagiosum of the eyelid with cellulitis caused by multiple organism infection in a child with AIDS.


  Case Top


A 4 year old boy was brought by his parents in October 1996 with complaints of painful swelling of the right eyelid with multiple nodular lesions for the last 6 months. The patient underwent cryopexy of the lesion without any benefit.

Both parents of the child had AIDS. Father had history of sexual exposure with multiple commercial sex workers and developed pulmonary tuberculosis. Both he and his wife had tested positive for human immunodeficiency virus type 1 (HIV-1) by enzyme-linked immunosorbant assay (ELISA), and this was confirmed by western blot test in February 1995. It is likely that his wife got the HIV infection from him. She developed pulmonary tuberculosis, oropharyngeal candidiasis, and extensive molluscum contagiosum. The child had tested positive for HIV-1 in March 1996 by ELISA, and this was confirmed by western blot test in an AIDS Care Centre. Systemic examination revealed pulmonary tuberculosis, oropharyngeal candidiasis, hepatomegaly, and gastroenteropathy. This child also developed extensive bacterial ulceration in the leg. Subsequently he developed multiple whitish papules and nodules with central umbilications typical of molluscum contagiosum over the right half of face, forehead, mouth, and also on the leg. The lesions varied in size between 1-15 mm in diameter.

Ocular examination revealed swollen eyelids on the right side with multiple molluscum lesions both on the upper and lower eyelids as well as the eyelid margins. There were multiple focal abscesses seen over the eye [Figure - 1]. The child was unable to open the eyelid on his own. On separating the eyelids, conjunctiva was found to be congested. Visual acuity was 6/6 in the right eye. Cornea was clear and fundus in this eye was normal. Left eye was normal in all respects. One molluscum lesion was excised under local anaesthesia and fixed in Karnovsky's fixative and on light microscopic study this lesion showed acanthotic epithelium. Within the epithelium, innumerable round and oval eosinophilic intracytoplasmic inclusion bodies consistent with molluscum bodies were seen [Figure - 2].

Electronic microscopic study showed multiple dumb-bell shaped virus particles within the inclusion bodies. A swab was taken from the purulent material that extruded on pressure. The material on direct smear examination revealed multiple polymorphonuclear leukocytes, plenty of gram positive cocci in single pairs, short chains and in clusters [Figure - 3]. Gram negative coccobacili and gram positive bacilli were also seen. Staphylococcus aureus, alpha-haemolytic streptococci, Corynebacterium xerosis, Candida lipolytica, and Bacteriodes intermedius grew on culture. Bacterial strains were sensitive to tetracycline, cefazoline and ciprofloxacin, and resistant to ampicilin and gentamycin. The child was seen by an internist and was advised cloxacillin 250 mg 8 hourly for 8 days. In addition, ciprofloxacin eye ointment was given twice daily in the right eye. After two weeks of therapy lid edema subsided. The child could open the right eye. The molluscum contagiosum lesions were too many to be removed.


  Discussion Top


Extensive molluscum contagiosum in the eyelid has been reported in patients with AIDS.[1][2][3] However, such a lesion in association with bacterial lid abscess has not been reported. Our patient, in addition to extensive molluscum lesions, also had mixed bacterial infections leading to cellulitis and closure of the eyelid. Secondary infection in the molluscum lesions in other parts of the body has been reported. Boudrean et al[4] reported presence of staphylococcus aureus, cytomegalovirus, and acid-fast bacilli in biopsy specimens of a patient who presented with multiple skin lesions, clinically suggestive of molluscum contagiosum. Patients with AIDS having profound defect in cell-mediated immunity are prone to develop mucocutaneaus infections with viruses, bacteria and yeasts. Although CD4 cell count has not been done in this case, presence of multiple organismal infection with extensive molluscum contagiosum indicate profound cell mediated immune deficiency.

Electrocautery, chemical cautery, cryotherapy, and surgical excision are the various treatment modalities described for molluscum lesions. But high recurrence rate has been observed in AIDS patients.[3] In this patient, control of secondary infection was important as continued closure of the eye could have lead to amblyopia.

Recent reports indicate that there is rapid increase in the number of AIDS cases in India. According to the report of National AIDS Control Organisation,[5] there were atleast 45,866 HIV positive patients in India as of September 1996. The actual number of HIV positive cases and AIDS patients are likely to be even more than officially reported. Ocular lesions are seen in 70% of patients with AIDS and can also be the initial manifestation.

Ophthalmologists and eye care personnel therefore should be aware of various ocular lesions, particularly external infections of the ocular adenexa occurring in patients with AIDS. Multiple, large and confluent molluscum contagiosum is one such presentation. Such lesions can be the only ocular presentation as in our case. Apart from taking care of the patients, they should also take adequate barrier precautions like wearing gloves and cleaning the equipment coming in direct contact with such open lesions to prevent spread of infection of HIV.


  Acknowledgment Top


We gratefully acknowledge Prof. Narsing A. Rao, A. Ray Irvine Ophthalmic Laboratory, Dobeny Eye Institute, Los Angeles, USA, for reviewing the pathology slides and performing electron microscopic study of the case[6].

 
  References Top

1.
Kohn SR. Molluscum contagiosum in patients with acquired immunodeficiency. Arch Ophthalmol 1987;105:458.  Back to cited text no. 1
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2.
Robinson MR, Udell IJ, Garber PF, Perry HD, Streeten BW. Molluscum contagioscum of the eyelids in patients with acquired immunodeficiency syndrome. Ophthalmology 1992;99;1745-47.  Back to cited text no. 2
    
3.
Charles NC, Friedberg DN. Epibulbar molluscum contagiosum in acquired immune deficiency syndrome. Ophthalmology 1992;99:123-36.  Back to cited text no. 3
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4.
Boudrean S, Hines HC, Hood AF. Dermal abscesses with staphyloccoccus aureus, cytomegalovirus and acid fast bacilli in a patient with acquired immunodeficiency syndrome. J Cutan Pathol 1988;15:53-57.  Back to cited text no. 4
    
5.
National AIDS Control Organization, Ministry of Health and Family Welfare, Government of India, New Delhi. Monthly Update, September 1996.  Back to cited text no. 5
    
6.
Ortiz R, Aaberg TM. Human immunodeficiency virus disease epidemiology and noscomial infection. Am J Ophthalmol 1991;112:335-42.  Back to cited text no. 6
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