Efflorescence of facial molluscum contagiosum as a manifestation of immune reconstitution inflammatory syndrome in a patient with AIDS

ARTICLE

Auteur(s) : Claude Bachmeyer¹, Philippe Moguelet², Françoise Baud³, François-Xavier Lescure⁴

¹Service de médecine interne
²Service d’anatomo-pathologie
³Pharmacie
⁴Service des maladies infectieuses et tropicales, CHU Tenon (AP-HP), 4 rue de la Chine, 75020 Paris, France

Molluscum contagiosum (MC) is a self-limited disease due to a DNA virus of the poxviridae family. It is a frequent condition in children and is reported in immunocompetent adults in the genital areas, suggesting sexual transmission. MC is observed as high as 20% in HIV-infected adult patients in an advanced stage of the disease, with lower levels of CD4+ lymphocytes and higher viral loads [1]. Resolution of MC may be observed along with an increase of CD4+ lymphocytes under highly active antiretroviral therapy (HAART) [2]. We report here a case of efflorescence of facial MC as a manifestation of immune reconstitution inflammatory syndrome (IRIS) in a patient with AIDS.

A 55-year-old heterosexual man sought medical advice in February 2008 for the rapid onset of lesions on his face. He had been diagnosed as having AIDS in September 2007 when he presented with cryptococcal meningitis resolving under amphotericin B and 5-fluorocytosine for 2 weeks, then fluconazole at 400 mg/d initially and 200 mg/d as maintenance therapy. Diagnosis of chronic B hepatitis was also established (F2 metavir score). Cotrimoxazole was given as a prophylactic treatment of opportunistic infections. At this time his CD4 cell count was 13/mm³, his viral load, 16,300/mL. Antiretroviral treatment combining atazanavir, ritonavir, abacavir and lamivudine was started in November 2007 plus entecavir. Eight weeks later, the patient presented a rapid onset of more than 70 asymptomatic smooth, skin-coloured, 1-3 mm in diameter, papules, often with central umbilication, on the chin, cheeks and neck (figure 1). Diagnoses of MC and cutaneous cryptococcosis were suspected. Histologic examination from one lesion showed an inverted lobule of hyperplastic epidermis in the superficial dermis with intracellular eosinophilic inclusion bodies, consistent with MC. The CD4 cell count was 101/mm³, the viral load was undetectable. Topical treatment with cidofovir 1% twice daily resulted in a dramatic improvement within 1 month.

IRIS is characterized by the precipitation by HAART of clinically apparent infections in patients with latent infections within the initial weeks of treatment, including infections with mycobacteria, cytomegalovirus, Pneumocystis jirovecii and Cryptococcus Neoformans [3, 4]. The pathogenesis of IRIS is still disputed, but actually develops before the total reconstitution of the immune system. Indeed, HAART induces a rapid initial increase of memory CD4 cells as a result of redistribution from lymphoid tissues, leading to the recognition of previous antigenic tissue and development of manifestations of IRIS. Then, there is a steady increase of naïve T cells responsible for the later quantitative increase in the CD4 cell counts. The development of MC seems to be an uncommon presentation of IRIS. In a series of 44 patients who experienced 51 IRIS events, 4 (9%) had MC [3]. In another series of 44 patients who developed IRIS, 4 (9%) presented MC [4]. Of note, it is unclear how diagnosis of MC was established in these patients, and clinical diagnosis seems to be insufficient. Thus, only two well-established cases have been described to date. The first case consisted of an isolated lesion of MC involving the lower eyelid margin, which did not recur after biopsy [5]. The second case was multiple lesions on the neck, right eyelid, nose, pubic area, penis and scrotum, most lesions healing spontaneously after cryotherapy with liquid nitrogen on a few of the larger lesions [6]. Moreover, confirmed diagnosis is required since the centrally-umbillicated papules may mimic cutaneous lesions of fungal infectious caused by Cryptococcus neoformans, Histoplasma capsulatum, and Paracoccidioidosis brasiliensis. Most cases of IRIS are mild and spontaneous resolution is usual [3, 4]. As in our patient, topical cidofovir may be an effective option when it is difficult to wait for spontaneous resolution.

MC could be an underreported cutaneous manifestation of IRIS, but further studies are needed.

Acknowledgements

References

2 Calista D, Boschini A, Landi G. Resolution of disseminated molluscum contagiosum with highly active antiretroviral therapy (HAART) in patients with AIDS. Eur J Dermatol 1999; 9: 211-3.

3 Ratnam I, Chiu C, Kandala NB, Easterbrook PJ. Incidence and risk factors for immune reconstitution inflammatory syndrome in an ethnically diverse HIV type 1-infected cohort. Clin Infect Dis 2006; 42: 418-27.

4 Murdoch DM, Venter WD, Feldman C, Van Rie A. Incidence and risk factors for the immune reconstitution inflammatory syndrome in HIV patients in South Africa: a prospective study. AIDS 2008; 22: 601-10.

5 Albini T, Rao N. Molluscum contagiosum in an immune reconstituted AIDS patient. Br J Ophthalmol 2003; 87: 1427-8.

6 Pereira B, Fernandes C, Nachiambo E, Catarino C, Rodrigues A, Cardoso J. Exuberant molluscum contagiosum as a manifestation of the immune reconstitution inflammatory syndrome. Dermatol Online J 2007; 13: 6.