Eyelid molluscum contagiosum presenting as a giant solitary ulcerating mass

Abstract

Molluscum contagiosum is a benign viral cutaneous infection. It typically presents as an asymptomatic centrally umbilicated nodule 3–5 mm in diameter. Susceptible patients are children and adults receiving immunosuppressive therapy. We report a case of an eyelid molluscum contagiosum in a 5-year-old boy with no risk factors and a 2-week history of a large localized ulcerating mass of the left upper eyelid. The mass was totally excised, and diagnosis of molluscum contagiosum was confirmed in the histopathology study. Microscopic examination revealed enlarged keratinocytes, and acquired eosinophilic Henderson-Patterson inclusion bodies were also detected. Such ulcerating solitary lesions can be misdiagnosed as infected epidermal cysts, keratoacanthoma, or infected chalazions; therefore, molluscum contagiosum should be considered in the differential diagnosis. Complete excisional biopsy of the mass is diagnostic and curative.

Introduction

Molluscum contagiosum is a benign cutaneous viral infection that is caused by poxvirus. It is commonly seen in children, sexually active adults, and immunocompromised or immunosuppressed patients. It typically presents as asymptomatic, umbilicated papules that are 3–5 mm in diameter.¹

We describe a child who presented to King Khaled Eye Specialist Hospital’s emergency room in June 2017 with a 2-week history of a painful isolated left upper eyelid ulcerating mass. Few reports with molluscum contagiosum presenting as lid abscess or preseptal cellulitis are described in the literature. We report a solitary large ulcerating mass on the left upper eyelid in a healthy child.

Case report

A 5-year-old boy with a 2-week history of painful mass on his left upper eyelid presented on 21 June 2017. Prior to his presentation, he was seen by a general practitioner and was treated with an oral amoxicillin course. No umbilicated nodules or similar ulceration were detected on other parts of the patient’s body or those of his family. The child’s past medical, surgical, nutritional, social, and family history were unremarkable.

His height was 104 cm, weight was 15 kg, and growth and development chart were within normal limits. Ocular examination showed a localized single, tender mobile mass with a focal abscess on the left upper lid. A 1-cm-diameter opening with granulation tissue on the margins was observed, and there was no overlying skin over the mass (Fig. 1). Visual acuity was 20/20 in both eyes. Conjunctiva was quiet with no injection, clear cornea, deep and quiet anterior chamber with clear lens, and good red reflex. Fundus exam was normal.

Fig. 1.

Solitary ulcerating mass over the left upper lid.

Patient was admitted, and an assessment by a pediatrician was done. The child’s blood labs were within normal ranges and unremarkable. Surgical excision and curettage was done 1 day later, the granulation tissue surrounding the margin of the mass was removed and excisional biopsy of the mass was sent for histopathological study, and skin was closed with an absorbable 6-0 vicryl suture.

The patient was reevaluated 3 weeks postoperatively. The skin was clean and healed with no shortening or loss of anterior lamella. No recurrence of new lesions was noted in the 6-month follow-up.

Histopathology showed lobular hyperplasia into the dermis forming a cup-shaped lesion. The keratinocytes were enlarged, and acquired eosinophilic Henderson-Patterson inclusion bodies were detected, which were surrounded by mixed inflammatory cells (Fig. 2).

Fig. 2.

Low (a) Intermediate (b) and high (c) magnification views of a molluscum contagiosum show the area of ulceration, large lobules and thickening of the epidermis into the dermis with large eosinophilic, intracytoplasmic inclusion bodies. [Hematoxylin and eosin; a = ×20, b = ×40, c = ×100.]

Discussion

Molluscum contagiosum virus is a double-stranded DNA poxvirus that causes benign skin masses. It was first described by Bateman et al. in 1814.²

Giant or atypical lesion molluscum contagiosum may occur in diseases that cause immunosuppression, like the human immunodeficiency virus type 1 (HIV-1)³ or in patients using immunosuppressive therapy.⁴ Such patients are more prone to develop multiple, widespread lesions all over the body such as the face and genital region.⁵ Disseminated lesions are more frequently seen in children compared to adults.¹

The diagnosis of molluscum contagiosum is usually made based on clinical findings (typical central umbilication). Although in atypical presentation, as in our reported case, histopathological assessment is required, which reveal the typical appearance of intracytoplasmic inclusion bodies first described by Henderson⁶ and Paterson⁷ in 1841. Our patient was treated by surgical excision and curettage of the molluscum contagiosum lesion.

Few case reports with molluscum contagiosum presenting as lid abscess or preseptal cellulitis were reported in the literature. Ornek et al.⁸ reported a giant eyelid molluscum contagiosum presenting as preseptal cellulitis in a 5-year-old healthy girl with a negative HIV test. The child had multiple whitish nodules of molluscum contagiosum over her left lower eyelid and around the mouth, unlike our reported case, which had a single mass over the left upper lid with no similar masses detected on other parts of his body. Another report by Biswas et al. described extensive multiple nodules in a child who tested positive for HIV. Both of his parents had acquired immune deficiency syndrome.⁹

Conclusion

To the best of our knowledge, no similar case with a solitary large eyelid ulcerating mass in a healthy individual has been reported in the literature. Such solitary lesions can be misdiagnosed as keratoacanthoma, infected epidermal cyst, or infected chalazion. Therefore, molluscum contagiosum should be considered in the differential diagnosis. Complete excisional biopsy of the mass is diagnostic as well as curative.

Conflict of interest

The authors declared that there is no conflict of interest.