Dermatology: Practical and Conceptual Observation | Dermatol Pract Concept 2016;6(3):15 71 DERMATOLOGY PRACTICAL & CONCEPTUAL www.derm101.com Introduction Molluscum contagiosum is a double-stranded DNA virus, which is the cause of benign, infectious disease of the skin that is characterized by dome-shaped papules with a central dell or depression clinically [1]. In patients with altered or impaired immunity such as atopic dermatitis, after long term corticosteroid and immunosuppressive therapy use, sarcoid- osis, leukemias, Wiskott-Aldrich syndrome and especially with acquired immune deficiency syndrome, atypical lesions of molluscum contagiosum may occur, often reaching a large size on an unusual site that can also mimic a wide spectrum of other conditions [2]. The presence of giant molluscum con- tagiosum in immunocompetent patients is rare, and in some reviews it was reported to be a clue for HIV infection in both the pediatric patient group and adult patients [3]. This rare infection must be kept in mind in patients who have solitary pink nodular lesions for a short time, especially on face and anogenital region. Case report A 27-year-old male was admitted to our outpatient clinic with a 4-month history of a 1.5 cm in diameter, asymptom- atic, pink nodular lesion on left temporal region (Figure 1). He had no systemic disease or drug use history. In dermato- Isolated giant molluscum contagiosum mimicking epidermoid cyst Tugba K. Uzuncakmak1, Burce C. Kuru1, Ebru I. Zemheri2, Ilkin Zindanci1, Zafer Turkoglu1, Mukaddes Kavala1 1 Department of Dermatology, Istanbul Medeniyet University School of Medicine, Goztepe Research and Training Hospital, Instanbul, Turkey 2 Department of Pathology, Istanbul Medeniyet University School of Medicine, Goztepe Research and Training Hospital, Istanbul, Turkey Key words: dermoscopy, epidermoid cyst, molluscum contagiosum Citation: Uzuncakmak TK, Kuru BC, Zemheri EI, Zindanci I, Turkoglu Z, Kavala M. Isolated giant molluscum contagiosum mimicking epidermoid cyst. Dermatol Pract Concept 2016;6(3):15. doi: 10.5826/dpc.0603a15 Received: June 15, 2016; Accepted: June 18, 2016; Published: July 31, 2016 Copyright: ©2016 Uzuncakmak et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: None. Competing interests: The authors have no conflicts of interest to disclose. All authors have contributed significantly to this publication. Corresponding author: Tugba Kevser Uzuncakmak, MD, Istanbul Medeniyet University, Goztepe Research and Training Hospital, Dermatology, Istanbul, Turkey. Tel. 0 +90- (530) 6640226. Email: drtugbakevser@gmail.com Molluscum contagiosum is a benign cutaneous viral infection which is caused by double- stranded DNA poxvirus. It affects mainly children and young adults and usually presents with single or multiple umblicated papules or nodules on face, arms, legs and anogenital regions. It may present in atypical size and clinical appearance in patients with altered or impaired immunity and rarely in immuncom- petent patients. Herein we present an immuncompetent young adult patient with isolated giant mol- luscum contagiosum, which was mimicking epidermoid cyst clinically. ABSTRACT mailto:drtugbakevser@gmail.com 72 Observation | Dermatol Pract Concept 2016;6(3):15 a disease of childhood, rarely it can be seen in adults. Due to the characteristic appearance of the lesions, diagnosis is gen- erally made without laboratory testing. Specific treatments or therapies are usually not administered for molluscum contagiosum infection in immunocompetent individuals, as lesions will resolve within time. Dermoscopic examination may be helpful in atypical cases. Dermoscopy of MC reveals a central pore or umbi- lication in association with polylobular white to yellowish amorphous structures, which are surrounded by linear, fine, corona-like telangiectasias [5,6] This apperance may change in atypical cases, especially in atypical localizations. Histopat- hologic examination is mandatory in these cases. Giant MC is a rare nodular variant of molluscum conta- giosum, which is 0.5-1 cm or more in diameter. This clinical presentation may mimic basal cell carcinoma, furuncle, intra- dermal nevus, amelanotic melanoma, kerathoacanthoma and viral warts [2,3]. These lesions are rare in healthy children or adults and may accompany altered immunity, such as atopic dermatitis, corticosteroid and immunosuppressive therapy, sarcoidosis, leukemias, Wiskott-Aldrich syndrome and acquired immune deficiency syndrome. Atypical lesions of molluscum contagiosum may occur often and reach large size with extensive distribution on unusual body parts [3,4,7]. In our patient there was no systemic disease, drug usage, immundeficiency or atopic dermatitis history. There are only a few case reports of giant molluscum contagiosum occurring in immunocompetent patients in the literature [2,7]. Most of these patients are children without immunodeficiency. There are also only a few case reports of molluscum contagiosum on the scalp in immunocompetent patients—one newborn and one elderly patient. Our patient was a young immuno- competent adult patient. Cryotherapy, 10% KOH application, trichloroacetic acid, imiqumod, systemic cimetidin, intralesional 5-FU and bleom- logical examination a white material output was detected. Dermoscopic examination revealed white-yellow structure- less area in the center of the of lesion and increased linear vascularity on the periphery (Figure 2). Excisional biopsy was offered with preliminary diagnosis of epidermoid cyst and isolated giant molluscum. Histopathologically epidermal hyperkeratosis, acanthosis, widespread viral cytopathic effect and intracytoplasmic inclusion bodies were seen (Figure 3). He was diagnosed with isolated giant molluscum with his clinical and histopathological findings. His laboratory tests for immunsuppresssion, including complete blood counting, immunoglobulins and HIV serology were totally normal. No recurrence was detected on the 6-month control visit. Discussion Molluscum contagiosum (MC) is a common infectious dis- ease of the skin characterized by pearly dome-shaped papules with a central dell or depression located on the face, arms, legs and anogenital region, caused by the molluscum contagiosum virus [1]. The virus replicates in the epidermis and enters the skin from a small skin defect leading to impaired skin bar- rier function or from contaminated items, such as towels or clothes. Specific lesions of MC are usually smaller than 5 mm and less than 20 in number [1-4]. Although it is known to be Figure 1. A 1.5 cm diameter, asymptomatic, pink tumoral lesion on left temporal region. [Copyright: ©2016 Uzuncakmak et al.] Figure 2. White-yellow structureless area in the center of the le- sion and increased linear vascularity on the periphery. [Copyright: ©2016 Uzuncakmak et al.] Figure 3. Epidermal hyperkeratosis, acanthosis, widespread viral cy- topathic appearance and intracytoplasmic inclusion bodies. [Copy- right: ©2016 Uzuncakmak et al.] Observation | Dermatol Pract Concept 2016;6(3):15 73 3. Leung AKC, Davies HD. Molluscum contagiosum—an over- view. Current Pediatric Reviews 2012;8:346-49. DOI: 10.2174/ 157339612803307732 4. Zalaudek I, Giacomel J, Cabo H, et al. Entodermoscopy: a new tool for diagnosing skin infections and infestations. Dermatology. 2008;216(1):14-23. PMID: 18032894. DOI: 10.1159/000109353. 5. Mun JH, Ko HC, Kim BS, Kim MB. Dermoscopy of giant mollus- cum contagiosum. J Am Acad Dermatol. 2013 Dec;69(6):e287-8. PMID: 24238183. DOI: 10.1016/j.jaad.2013.04.065. 6. Basu S, Kumar A. Giant molluscum contagiosum—a clue to the diagnosis of human immunodeficiency virus infection. J Epidemiol Glob Health 2013;3:289–91. PMID: 24206800. DOI: 10.1016/j. jegh.2013.06.002. 7. Matsuda, LD Bloch M. Arnone M. Vasconcelos Dde M, Nico MM. Giant molluscum contagiosum: does it affect truly immunocom- petent individuals? Acta Derm Venereol 2005;85(1):88–9. PMID: 15849008. DOI: 10.1080/00015550410023536. ycin and total excision are the main treatment options [1,2]. We chose total excision surgery in our patient to exclude epidermoid cyst histologically. We present this case to present giant molluscum in diffe- rential diagnosis of soft, slowly growing tumoral lesions with atypical presentation. References 1. Pérez-Díaz CE, Botero-García CA, Rodríguez MC, et al. Giant molluscum contagiosum in an HIV positive patient. Int J In- fect Dis 2015 Sep;38:153-5. PMID: 26255893. DOI: 10.1016/j. ijid.2015.07.021. 2. Karadag AS, Karadag R, Bilgili SG, Calka O, Demircans YT. Giant molluscum contagiosum in an immunocompetent child. J Pak Med Assoc 2013;63:778-9. PMID: 23901686.