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Molluscum contagiosum folliculitis mimicking tinea barbae in a lung transplant recipient

2010; Elsevier BV; Volume: 63; Issue: 1 Linguagem: Inglês

10.1016/j.jaad.2009.04.017

1097-6787

Laurence Feldmeyer, Jivko Kamarashev, Annette Boehler, Sarosh R. Irani, Rudolf Speich, Lars E. French, Günther F.L. Hofbauer,

Herpesvirus Infections and Treatments

To the Editor: Viral folliculitis is an infrequent condition; in particular, folliculitis caused by molluscum contagiosum virus (MCV) has rarely been described.1Krishnamurthy J. Letter: viral sycosis.Arch Dermatol. 1974; 109: 578Crossref PubMed Scopus (11) Google Scholar, 2Schwartz J.J. Myskowski P.L. Molluscum contagiosum in patients with human immunodeficiency virus infection. A review of twenty-seven patients.J Am Acad Dermatol. 1992; 27: 583-588Abstract Full Text PDF PubMed Scopus (193) Google Scholar, 3Weinberg J.M. Mysliwiec A. Turiansky G.W. Redfield R. James W.D. Viral folliculitis. Atypical presentations of herpes simplex, herpes zoster, and molluscum contagiosum.Arch Dermatol. 1997; 133: 983-986Crossref PubMed Google Scholar, 4Jang K.A. Kim S.H. Choi J.H. Sung K.J. Moon K.C. Koh J.K. Viral folliculitis on the face.Br J Dermatol. 2000; 142: 555-559Crossref PubMed Scopus (44) Google Scholar Most cases of folliculitis caused by MCV develop in patients with acquired or iatrogenic immunosuppression. A 61-year-old man presented with multiple, flesh- to red-colored papules 2- to 5-mm in diameter, some of them umbilicated, symmetrically disseminated on the chin and cheeks. A physical examination revealed papules with a central cavity of heterogeneous size (Fig1). His medical history included a bilateral lung transplant 2 years earlier for lung emphysema related to an alfa-1-antitrypsin deficiency. At presentation, the patient was under maintenance immunosuppressive therapy with cyclosporine (blood trough levels of 180-220 μg/mL), mycophenolate mofetil (2 g/day), and prednisolone (0.1 mg/kg/day). Because of recurring bouts of rejection, he was undergoing a cycle of extracorporeal photopheresis on a monthly basis. He received intravenous human immunoglobulin as part of cytomegalovirus prophylaxis at a dose of 0.35 g/kg every 8 weeks in the year before admission. His complete blood cell count showed chronic anemia (10.3 g/dl) and chronic leukocytosis (9800/μL) with lymphopenia (700/μL). On admission, our differential diagnosis included tinea barbae—which is by far the most frequent diagnosis for such a clinical presentation in the general population—an infectious granulomatous process, bacterial peri-/folliculitis, and chronic herpes folliculitis. Microbiologic, mycologic, and viral smears were negative. Subsequently, a punch biopsy of a lesion on the chin was performed, showing a follicle-associated lobulated endophytic epithelial hyperplasia with numerous typical large intracytoplasmic eosinophilic inclusions (Fig 2). Repeated cryotherapy achieved a regression of the lesions. No recurrence was observed at 12 months of follow-up. Viral folliculitis of the face is a little-published entity. In particular, folliculitis caused by MCV has been infrequently reported. Molluscum contagiosum (MC) is a common opportunistic infection of immunocompromised HIV patients. Extensive MC has been reported in patients receiving chemotherapy or corticosteroids and in those with congenital or acquired immunodeficiencies.2Schwartz J.J. Myskowski P.L. Molluscum contagiosum in patients with human immunodeficiency virus infection. A review of twenty-seven patients.J Am Acad Dermatol. 1992; 27: 583-588Abstract Full Text PDF PubMed Scopus (193) Google Scholar A deficiency in either the function or number of T lymphocytes is common in all of these patients. Our patient presented with chronic lymphopenia, which provides no evidence for a lymphocyte dysfunction but indicates a quantitative deficiency. In immunocompromised patients, MC often has an atypical presentation. Lesions are often multiple, in atypical localizations (like the face), and of different sizes; they also tend to be progressive, refractory to therapy, and rapidly recurring.5Mansur A.T. Goktay F. Gunduz S. Serdar Z.A. Multiple giant molluscum contagiosum in a renal transplant recipient.Transpl Infect Dis. 2004; 6: 120-123Crossref PubMed Scopus (36) Google Scholar In conclusion, we report an atypical presentation of MC illustrating the challenge of an atypical presentation of a common pathogen in immunosuppression. Folliculitis in an immunosuppressed individual should be addressed with a wide differential diagnosis, especially if refractory to antibacterial and antiinflammatory treatments.