Virtual Grand Rounds in Dermatology

21 year old woman with atypical molluscum

presented by

David Elpern MD

Williamstown, MA, USA

on August 10, 2005

Dermatologist, The Skin Clinic, Williamstown, MA, USA

Abstract	The patient is a 21 yo woman with atypical molluscum. She has congenital neutropenia and has recently been diagnosed with hypogammaglobulinemia.
Patient	21-year-old woman
Duration	6 months
Distribution	Buttocks
History	This 21 yo woman has a 6 month history of molluscum. Most are on buttocks and they are painful when she sits. She has a hereditary form of neutropenia. Her mother has neutropenia, too. The patient had over 20 episodes of pneumonia in her late teens and was eventually diagnosed with hypogammaglobulinemia. She receives IvIg every three to four weeks. Aldara was poorly tolerated. She is well otherwise, has a four month old child, but appears to have bronchiectasis. The child has not been evaluated at this time.
Physical Examination	Scores of dome shaped papules with central umbilication on buttocks. Range in size from 2 - 8 mm in diameter
Images
Laboratory Data	nil
Histopathology	nil
Diagnosis
Reasons Presented	The management of molluscum in this patient poses a therapeutic challenge. The one case report in the literature reported similar problems. I tried liquid nitrogen, but the patient found this very painful. Electrodessication and curretage under EMLA is a possibility. I wonder if more frequent IvIg might help. There are some reports of WHIM Syndrome: warts, hopogammaglobulinemia, recurrent bacterial infections and 'myelokathesis': an unusual congenital syndrome with congenital neutropenia, and I am wondering if our patient has a variant of this. Molluscum has not been reported with WHIM syndrome.
Questions	How would you approach this patient?
References	1. Ben-Amitai D, Metzker A, Hodak E, Cohen I, Garty BZ. Department of Dermatology, Children's Medical Center of Israel, Petah Tikva. Molluscum contagiosum in a patient with common variable hypogammaglobulinemia. Isr J Med Sci. 1994 Sep;30(9):707-9. 2. Gulino AV. Metabolism Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland 20892, USA. gulinov@mail.nih.gov WHIM syndrome: a genetic disorder of leukocyte trafficking. Curr Opin Allergy Clin Immunol. 2003 Dec;3(6):443-50. PURPOSE OF REVIEW: WHIM syndrome (the association of warts, hypogammaglobulinemia, recurrent bacterial infections, and 'myelokathexis') is a rare congenital form of neutropenia associated with an unusual immune disorder involving hypogammaglonulinemia and abnormal susceptibility to warts. In this review, we describe the clinical, laboratory and genetic features of WHIM syndrome. RECENT FINDINGS: The identification of chemokine receptor CXCR4 as the causative gene of WHIM syndrome yields new interest in the study of this disease as a model for the comprehension of CXCR4 biology in humans and highlights the importance of the chemokine network for inducing effective immune responses and governing leukocyte trafficking. SUMMARY: CXCR4 participates in several biological processes (bone marrow hematopoiesis, cardiogenesis, angiogenesis, neurogenesis) and is implicated in different clinical pathologic conditions (WHIM, HIV infection, tumor metastatization, autoimmunity). Pharmacologic agents that modulate CXCR4 expression/function are already available and promise a wide range of future clinical applications.
Comments from Faculty and Members	Benjamin Barankin M.D., Department of Dermatology, University of Alberta, Edmonton, Canada on Aug 9, 2005 Good case and great pictures. I would try cantharone/cantharidin applied for 20-30 minutes under tape occlusion, and then washed off with soap & water. Works great in our peds cases. You may need to retreat since her molluscum are so large. Melvin Gorelick MD, Monterey, CA, USA on Aug 9, 2005 I have had good luck with application of cantharone to mollusca in children and adults. It is normally painless both in application and in process. I apply it with a wooden cotton swab stick just to the very top of the lesions. Anthony Benedetto MD, FACP Clinical Assistant Professor Department of Dermatology, University of Pennsylvania School of Medicine, Philadelphia, PA and Medical Director Dermatologic SurgiCenter Philadelphia, PA, USA on Aug 9, 2005 Another attempt with liquid nitrogen cryotherapy should be given. This time when the area has thawed and as the pain begins to escalate, immediately apply LMX4 cream. Pain should remitt within less than 5 seconds. Topical anesthetics work much faster in the post thaw period of cryotherapy than they do in the pre treatment period. Rick Sontheimer MD, Professor and Vice-Chairman, Dept. of Dermatology University of Oklahoma Health Sciences Center Oklahama City,OK, USA on Aug 9, 2005 As immunosuppressed pts can have disseminated fungal infections (eg, crypto) that at times can present clinically as atypical molluscum lesions, I would first obtain a confirmatory biopsy. Khaled El-hoshy M.D., Troy, Michigan, USA on Aug 11, 2005 I would bx to R/O crypto. Cantharidin paint 1 hour & wash off. Repeat as needed q 7-14 days. Check sexual partner[s]. Shahbaz Janjua MD, Lalamusa, Pakistan on August 14, 2005 It is really an interesting case of molluscum with underlying hypogammaglobulinemia and neutopenia. Local application of the tincture of iodine should resolve most of the lesions in two weeks. Repeated IVIG may be tried to prevent the recurrence. In my opinion immunocompromised persons are susceptible to get both fungal and viral infections. Gabriela Frias, MD, Mexico City, Mexico on Aug 14, 2005 I treat many immunocompromised patients, after transplantation, and I have learned to be cautious. Topical Microcyn with transfer factor has been the best results in our cases. Khalifa Shaquie MD, PhD, Professor of Dermatology, College of Medicine, University of Baghdad, Baghdad, Iraq on August 15, 2005 The usual therapy of molluscum is through puncturing the lesions by sharpened orange stick immersed in 15% phenol.This could be repeated every five days until cure,usually once is enough.The mechanism of action is to disturb the internal enviroment of molluscum.5% iodine could be used in a similar manner.However,sometimes just puncturing might be enough.The other technique of therapy is to puncture the lesions by heated hair diathermy needle. Abbas N. Alshammari M.D., Doha, Qatar om Aug 20, 2005 I agree with Prof.Sontheimer to exclude the possibility of deep fungal especially cryptococcus infection since both may present similarly with the same patient criteria.

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