A 10-year-old female child seropositive for HIV (acquired perinatally) presented to our dermatology outpatient department with a swelling on left cheek, which had gradually increased in size over a period of 6 months. In addition, she also complained of multiple skin coloured to white lesions over face, neck, lower abdomen, both hands and lower extremities since 6 months. Patient didn't have any other systemic complaints. There was no history of tuberculosis, herpes zoster, diarrhoea, or any other opportunistic infections. One-year back, patient had been started on anti-retroviral therapy (ART) (zidovudine, lamivudine, nevirapine [ZLN]) in a government ART centre on account of her low CD4 count (222 cells/mm3 [normal: 448-1611 cells/mm3]). However she had poor compliance and her CD4 count was consistently low (ranging between 172 and 224 cells/mm3) during the year.
On examination there was a single, well defined, lobulated, tumoral swelling 5 cm x 6 cm x 7 cm in size on the left cheek [Figure 1]. Skin overlying the swelling was thinned out with surface showing evidence of ulceration, haemorrhagic crust with slough. Swelling was freely mobile over underlying structures. Multiple, discrete, pearly white, umbilicated papules were present over cheek, forehead, upper eyelids, nose, lower extremities and buttocks. There was no lymphadenopathy. Systemic examination including central nervous system examination was normal. A differential diagnosis of giant molluscum contagiosum, keratoacanthoma, squamous cell carcinoma and cryptococcosis was considered.
On investigations, she had anemia (Haemoglobin: 7.6 g/dl [Normal: 9-11 g/dl]) and CD4 count was 251 cells/mm3. Other investigations including total leukocyte count, liver function tests and renal function tests were normal. Viral load estimation could not be done as the patient's parent refused to do the same due to financial constraints at that time. A punch biopsy of the tumoral swelling on left cheek revealed acanthosis with keratinocytes showing intracytoplasmic eosinophilic inclusion bodies, which were becoming basophilic in the granular layer. Thus a diagnosis of giant molluscum contagiosum was made.
After correction of anemia, complete excision of the giant molluscum contagiosum was done followed by split thickness skin grafting. The cut surface of the excised lesion showed multiple gyri like corrugations corresponding to the marked acanthosis seen on histopathology. At the base of the excised lesion, multiple pearly white papules could be seen [Figure 2]. On histopathological examination [Figure 3], there was marked acanthosis, keratinocytes showing intracytoplasmic eosinophilic to basophilic inclusions which were extruding out with keratinous debris. The epidermal ridges extended deep into the dermis surrounded by a dense lymphohistiocytic infiltrate with multiple giant cells and few plasma cells/neutrophils. Within the infiltrate, occasional degenerated molluscum bodies were seen. The infiltrate also extended into the subcutaneous fat resulting in septal panniculitis with extensive fibrosis. One-month later, there was complete healing at the site of skin grafting with minimal scarring [Figure 4]. Rest of the lesions were treated with topical 10% trichloroacetic acid (TCA) application resulting in gradual resolution. The patient was continued on ART (ZLN) with thorough counselling regarding compliance with medication. Her CD4 count improved to 676 cells/cmm after 10 months and had undetectable viral load. One-year later, on follow up, there has been no recurrence of lesions.