A rare case of ocular molluscum contagiosum in paediatric age group

Challapalli Himabindu¹*,  Jayashree S Shah²

¹Post Graduate, ²Professor and Head, Department of Ophthalmology,
Sri Siddhartha Medical College, SSAHE, Tumkur,
Karnataka, India

* Corresponding author

Abstract
Molluscum contagiosum is a viral skin infection caused by poxvirus which commonly affects eyelid margins seen as pink pearly umbilicated tumor. Molluscum contagiosum usually present as single lesion in school going children who are healthy, while multiple lesions are seen in immunosupressed patients. A 2 year old healthy male child, presented to OPD with multiple painless swellings on both upper and lower eye lid margins since 7 months. Histopathological report confirmed the diagnosis of excised tissue as molluscum contagiosum with Henderson Peterson bodies. The case was investigated and treated with acyclovir 3% ointment on which lesions are were resolved after 6 months.
Keywords: Molluscum contagiosum, Histopathology, confocal microscopy, eyelid tumors
Introduction
Molluscum contagiosum is a infection of skin and mucosal tissues caused by DNA poxvirus group, transmits through direct contact with infected people, autoinoculation and fomites. [1] This was reported most commonly in about 4.5% of children under 10 years old. A cross- sectional surveys with meta-analysis among children shown overall prevalence of 8.28% (95% CI 5.1-11.5) with a higher frequency in geographical areas with warm climates.[2] Clinically presents as pale or skin coloured waxy and umblicated nodules on eyelid margins.[3] Molluscum contagiosum lesions can also be transmitted vertically by contact with Molluscum contagiosum virus in the birth canal.[4] In this case, lesions are typically located on the scalp and have a circular arrangement. In addition to the oral mucosa, other sites of atypical location include the areola or nipple, palms and soles, lips, conjunctiva, eyelids. Clinical presentation of periocular lesions described as erythematous,inflamed, giant, nodular umbilicated, or pedunculated. Periocular presentation will also be associated with conjunctivitis. [5] Due to hypersensitivity reaction with viral proteins from lid margins secondary follicular conjunctivitis will occur. General measures are advised to patients to prevent the spread of MCV, and advised not to rub or scratch the lesions. Active treatments can be classified as antiviral, immuno-modulatory, mechanical, chemical.

Case presentation
A 2 year old male patient presented with multiple painless lesions on upper and lower lids of both eyes since 7 months, similar lesions noticed on nose and forehead also. [Figure-1] No history of fever. On ocular examination: Slit lamp examination showed thickened upper and lower lid margins with loss of eyelashes on lower lids and about 10-15 multiple lesions of skin coloured dome shaped papulonodular lesions with central umblication of 1-2 mm diameter present on upper and lower lid margins of both eyes. No similar complaints in the past and no relevant birth or family history, medical, surgical history. As per age child was fully immunized. Anterior segment appears to be normal. No history of human immunodeficiency virus. For Schirmer's test and tear film break up time (TBUT) child was not co-operative. On histopathological examination it was concluded as molluscum contagiosum with Henderson Peterson bodies with lobular arrangement of stratified squamous epithelium extending into dermis [Figure 2 &3]. On topical application of 3% acyclovir ointment lesions were resolved after 6 weeks.

Figure-1: Clinical photograph showing thickened upper & lower lid margins with loss of eyelashes on lower lids and about 10-15 multiple lesions of skin coloured dome shaped papulonodular lesions with central umblication of 1-2 mm diameter present on upper and lower lid margins of both eyes.

Figure-2: Histopathological section showing intracytoplasmic  eosinophilic bodies called Henderson Peterson bodies (40X)

Figure-3: Histopathological section studied shows lobular arrangement of stratified squamous epithelium extending into dermis. (10X)
Discussion
Molluscum contagiosum is a viral skin infection caused by double stranded DNA Poxvirus. Usually affects children with peak incidence between 2-4 years. Replication of virus takes place in the cytoplasm of host epithelial cells. Commonly infection is transmitted by with infected individuals, fomites or autoinoculation. Also common in immunosupressed individuals and presents with multiple lesions. Incubation period for MCV is about 2 weeks. MCV presents with small, round, hard papules on eyelids. A central depression forms when lesions reach about 3 - 5mm due to cellular damage and typically with whitish lesions of caseous material. Diagnosis can be made clinically when these characteristic molluscum lesions are present on eyelids. Histopathologically molluscum contagiosum shows increased number of T lymphocytes and macrophages in epidermis and dermis around the lesions along with mollusum bodies. In Autoimmune deficiency syndrome (AIDS) patients lesions will be on face which are large, numerous.[6] These can also be seen in children with atopic dermatitis leukemia, immunodeficiency. Pustular eruptions can occur occasionally at the site of molluscum contagiosum lesions. Although it is not caused to the secondary bacterial infection but immune reaction to molluscum contagiosum virus and is treated with antibiotic which leads to atrophic scar. Eyelid molluscum contagiosum lesion usually presents with chronic unilateral irritation and mild discharge and may lead to follicular conjunctivitis, epithelial keratitis and pannus due to virus entry in tear film.[7] Differential diagnosis of lid lesions include chalazion, basal cell carcinoma, papilloma, sebaceous cyst, wart. Molluscum cotagiosum should be differentiated from conditions like ectopic sebaceous gland, basal cell carcinoma, trichoepithelioma, syringoma, keratocanthoma and warty dyskeratomia.[8]
Conclusion
Molluscum contagiosum lesions are usually self limiting which lasts for about 9-10 months or can spread to distal sites. It is very important that one should avoid shared baths or towels till infection fades. In conditions like follicular conjunctivitis or keratitis or pannus treatment of eyelid lesions is indicated on basis of cosmetic reason. Surgical techniques include, destruction of lesion with cautery, cryotherapy with liquid nitrogen incision at margin of lesion with or without application of carbolic acid cautery, tincture iodine cautery, or laser [9] and photodynamic therapies.[10] We should not over treat iatrogenically and create scars.
Acknowledgement: NIL
Financial support and sponsorship: NIL
Conflict of interest: NIL
References
1.   Raizada VN, Prabha C. Molluscum contagiosum .Indian J ophthalmology. 1979; 2:57-58.
2.   Olsen JR, Gallacher J, Piguet V, Francis NA. Epidemiology of molluscum contagiosum in children: a systematic review. Fam Pract. 2014;31(2):130-136. doi :10.1093/fampra/cmt075
3.   Charteris DG, Bonshek RE, Tullo AB. Ophthalmic molluscum contagiosum: clinical and immuno pathological features. Br J Ophthalmol. 1995;79:476-91.
4.   Mira-Perceval Juan G, Alcala Minagorre PJ, Betlloch Mas I, Sanchez Bautista A. (Molluscum contagiosum due to vertical transmission). An Esp Pediatr. 2017; 86(5): 292- 293. doi:10.1016/j.anpedi.2015.12.014
5.   Schornack MM, Siemsen DW, Bradley EA, Salomao DR, Lee HB. Ocular manifestations of molluscum contagiosum. Clin Exp Optom. 2006;89(6):390-393.
6.   Lid abscess with extensive molluscum contagiosum in a patient with AIDS- Biswas Jyotirmay Indian Journal of Ophthalmology 1997,45;4:234-236.
7.   Duke Elder S-viral keratoconjunctivitis in System of ophthalmology, Henry Kimpton London 1965; 8(1): 249-295.
8.   Molluscum contagiosum in Principles and practice of ophthalmology by Peyman Sanders first edition 1987; 347.
9.   Molluscum contagiosum in Pediatric Ophthalmology by P.K. Mukharjee first edition, 2005; 50, 132, 756.
10. Karabulut GO, Ozturker C, Kaynak P, Akar S, Demirok A. Treatment of Extensive Eyelid Molluscum Contagiosum with Physical Expression Alone in an Immunocompetent Child. Turk J Ophthalmol. 2014; 44: 158-160.
Address for correspondence:
Dr. Challapalli Himabindu
Department of Ophthalmology, Sri Siddhartha Medical College, SSAHE, Tumkur, Karnataka , Email: chhimabindu183@gmail.com