Scattered Umbilicated Papules on the Cheek, Neck, and Arms.

Human monkeypox virus infection in an immunocompromised man: trial with tecovirimat

A patient with fever and umbilicated papules

Dear Editor: A 9-year-old girl presented with asymptomatic, rapidly growing, papular lesions in the posterior auricular area since the past 2 months. The medical history was noncontributory. There was no history of blood transfusion and no family history of HIV infection. No previous history of trauma or inflammation in the lesions was noted. The physical examination revealed a hyperkeratotic projection on the umbilicated papule in the posterior auricular area (Fig. 1). Under the clinical diagnosis of a cutaneous horn, a skin biopsy was performed and it revealed hyperkeratosis and an acanthotic epidermis with craters on low-power view of the skin specimen (Fig. 2A). Under high-power magnification, many epidermal cells were shown to contain eosinophilic hyaline intracytoplasmic inclusion bodies, which are the hallmarks of molluscum contagiosum (MC). The molluscum bodies increased in size as the infected cells moved toward the surface (Fig. 2B). The lesion was totally removed by skin biopsy and after 3 months follow-up, no recurrence was observed. Fig. 1 Hyperkeratotic projection on the umbilicated papule in the posterior auricular area. Fig. 2 (A) Hyperkeratosis and acanthotic epidermis with craters (H&E, ×40). (B) Under high-power magnification, many epidermal cells were shown to contain eosinophilic hyaline intracytoplasmic inclusion bodies, which are the hallmarks of molluscum ... MC is a poxvirus infection, occurring generally in children, but it may be found in people of all ages. Incidence of MC has risen significantly by up to 20% worldwide with the trend increasing in the United States and immunocompromised children such as HIV and leukemia patients are more commonly affected with MC1. MC lesions consists of papular eruptions of multiple, umbilicated lesions which are variable in number. The papules are small, discrete, waxy, skin-colored, dome-shaped, and usually 2~5 mm in size. The lesions of MC that occur in patients with HIV exhibit an extensive pattern with atypical morphology, such as giant molluscum, molluscum presenting as an abscess, molluscum without any umbilication, tender molluscum, and erythematous nodular types2. A cutaneous horn is the clinical description of a white or yellow, short or curved, dense protrusion from the skin surface consisting of cornified material. The important issue is not the horn itself, which is dead keratin, but rather the underlying condition. Cutaneous horns may be benign, like seborrheic keratosis and viral warts. However, approximately 50% of cutaneous horns arise from either premalignant (actinic keratosis and Bowen's disease) or malignant lesions (squamous cell carcinoma), thus an accurate diagnosis of the underlying disease is essential and an adequate amount of material from the base of the lesion is necessary to confirm the diagnosis3. MC presenting as a cutaneous horn has previously been reported as a penile horn in two adults and as a solitary firm horn-like projection on the left upper eyelid in one child. They all were HIV-positive3-5. This is an interesting case of MC presenting as a cutaneous horn in an immunocompetent patient. Therefore in an effort to establish an early diagnosis of MC, clinicians should be aware of such cases.

Penicilliosis is a systemic fungal infection caused by Penicillium marneffei. The infection is most commonly seen in Southeast Asia, Southern China, Hong Kong, and Taiwan. It is rarely seen among individuals of African descent. Here, we report a case of penicilliosis in an African man from Namibia who was studying in Malaysia. He presented with multiple umbilicated papules associated with cough, fever, loss of appetite, and weight. He also had urethral discharge and admitted to unprotected sexual intercourse with multiple partners. Histopathological examination of a skin papule showed the presence of multiple 2 to 4 microm intracellular yeast cells. Culture of the papule revealed Penicillium marneffei. The serology for human immunodeficiency virus (HIV) was positive. This case illustrates the need to recognize penicilliosis in any individuals staying or travelling to Southeast Asia and the need to look for underlying HIV infection in adults with umbilicated papules.

A 33-year-old Hispanic woman with newly diagnosed human immunodeficiency virus (HIV) infection, a CD4 T-lymphocyte count of 2, viral load of 730,000 copies/mL, candidal esophagitis, seizure disorder, a history of bacterial pneumonia, and recent weight loss was admitted with tonic clonic seizure. On admission, her vital signs were: pulse of 88, respiration rate of 18, temperature of 37.7 degrees C, and blood pressure of 126/76. Her only medication was phenytoin. On examination, the patient was found to have multiple umbilicated papules on her face, as well as painful, erythematous, large, punched-out ulcers on the nose, face, trunk, and extremities of 3 months' duration (Fig. 1). The borders of the ulcers were irregular, raised, boggy, and undermined, while the base contained hemorrhagic exudate partially covered with necrotic eschar. The largest ulcer on the left mandible was 4 cm in diameter. The oral cavity was clear. Because of her subtherapeutic phenytoin level, the medication dose was adjusted, and she was empirically treated with Unasyn for presumptive bacterial infection. Chest radiograph and head computed tomography (CT) scan were within normal limits. Sputum for acid-fast bacilli (AFB) smear was negative. Serologic studies, including Histoplasma antibodies, toxoplasmosis immunoglobulin M (IgM), rapid plasma reagin (RPR), hepatitis C virus (HCV), and hepatitis B virus (HBV) antibodies were all negative. Examination of the cerebrospinal fluid was within normal limits without the presence of cryptococcal antigen. Blood and cerebrospinal cultures for bacteria, mycobacteria, and fungi were all negative. Viral culture from one of the lesions was also negative. The analysis of her complete blood count showed: white blood count, 2300/microl; hemoglobin, 8.5 g/dL; hematocrit, 25.7%; and platelets, 114,000/microl. Two days after admission, the dermatology service was asked to evaluate the patient. Although the umbilicated papules on the patient's face resembled lesions of molluscum contagiosum, other infectious processes considered in the differential diagnosis included histoplasmosis, cryptococcosis, and Penicillium marnefei. In addition, the morphology of the ulcers, particularly that on the left mandible, resembled lesions of pyoderma gangrenosum. A skin biopsy was performed on an ulcer on the chest. Histopathologic examination revealed granulomatous dermatitis with multiple budding yeast forms, predominantly within histiocytes, with few organisms residing extracellularly. Methenamine silver stain confirmed the presence of 2-4 microm fungal spores suggestive of Histoplasma capsulatum (Fig. 2). Because of the patient's deteriorating condition, intravenous amphotericin B was initiated after tissue culture was obtained. Within the first week of treatment, the skin lesions started to resolve. Histoplasma capsulatum was later isolated by culture, confirming the diagnosis. The patient was continued on amphotericin B for a total of 10 weeks, and was started on lamivudine, stavudine, and nelfinavir for her HIV infection during hospitalization. After amphotericin B therapy, the patient was placed on life-long suppressive therapy with itraconazole. Follow-up at 9 months after the initial presentation revealed no evidence of relapse of histoplasmosis.

A 5 year old boy presented with a three month history of multiple mildly pruritic, dome shaped, skin coloured, shiny, centrally umbilicated papules (average diameter 1-5 mm) on his face...

Endoscopic diagnosis and terminology of erosions and similar mucosal lesions

A 43-year-old white man with molluscum contagiosum and a history of Wiskott–Aldrich syndrome presented to our clinic. He had previously finished six cycles of chemotherapy with R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone), and had achieved complete remission for diffuse large B-cell lymphoma. The patient had a 1.5-year history of molluscum contagiosum that had spread to the entire trunk and upper and lower extremities. Past therapies included liquid nitrogen cryotherapy, imiquimod, cantharidin, curettage, topical emollients (Dermasil), salicylic acid (Clear Away and Compound W), and trichloroacetic acid peel. Most recently, topical cidofovir had resulted in severe edema of the left arm. On physical examination, the patient had hundreds of umbilicated, flesh-colored to erythematous papules over his body(1, 2). A lesional biopsy of a 5-mm umbilicated papule from the left axilla showed epidermal cells and infundibular hair follicles with large intracytoplasmic molluscum inclusion bodies. Figure 1Open in figure viewerPowerPoint Disseminated molluscum-lower back Figure 2Open in figure viewerPowerPoint Disseminated molluscum-upper chest Laboratory results included a normal metabolic panel, complete blood count (CBC), and liver function tests (LFTs), as well as a negative human immunodeficiency virus (HIV) test. The patient's immunoglobulin E (IgE), IgG, and IgA were all normal. However, abnormally low laboratory values included an IgM of 17 mg/dL and absolute CD4 and CD8 counts of 203 and 41 µL, respectively. Initial therapy included topical imiquimod and oral acitretin 25 mg daily. Three months later, the patient showed slight improvement only and acitretin was discontinued. He had also been using salicylic acid (Compound W) and silver nitrate applications. Most recently, the plan included continuation of cantharidin toothpick treatment and imiquimod, and the potential addition of systemic interferons (γ or α) and topical or intravenous cidofovir.

Introduction. Ecthyma contagiosum is a zoonotic disease caused by the parapoxvirus that causes “sore mouth” in sheep and goats and orf in human. Case Presentation. A 61-year-old sheep farmer presented with a painful non-pruritic lesion on the left hand that had been present for approximately 5 weeks. Physical examination demonstrated a 1 cm pearly, umbilicated papule with raised borders. A biopsy showed an asymmetrical nodule with parakeratotic crust and acanthosis with thin epidermal strands extending deeply in the underlying dermis. Marked edema, capillary proliferation and extensive lymphocytic infiltration was also present. One red intranuclear inclusion was identified in an epidermal keratinocyte. A diagnosis of human orf (ecthyma contagiosum) was made. Conclusion. Infected sheep and freshly vaccinated sheep or goats are the reservoir for human infection. After an incubation period of 3–7 days, parapoxvirus infections produce 1–3 painful lesions measuring 1-2 cm in diameter. The natural history of the disease is complete resolution and no treatment is indicated. Prevention of echthyma contagiosum in ruminants through vaccination is thought to be the best way to control infection.

Molluscum contagiosum is a cutaneous viral infection presenting as multiple, umbilicated papules and vesicles. The cytology of molluscum contagiosum in an 11-year-old boy, which presented atypically as a solitary nodule over the right cheek, mimicking a skin adnexal tumor is reported here. Fine needle aspiration cytology plays a vital role in establishing the correct diagnosis of clinically unsuspected cases, and hence, the proper management of such lesions. The cytology of molluscum contagiosum is characterized by the presence of numerous large intracytoplasmic basophilic bodies that push the host nucleus to the periphery, giving a signet ring appearance to the superficial epidermal cells.

Patient: Female, 71-year-oldFinal Diagnosis: Molluscum contagiosumSymptoms: Mass • painMedication:—Clinical Procedure: Surgical excisionSpecialty: Dermatology • Infectious Diseases • Pathology • PodiatryObjective:Rare diseaseBackground:Molluscum contagiosum (MC) presents as skin-colored, dome-shaped, umbilicated papules or nodules on the skin and is caused by the MC virus. It predominantly occurs in school-aged children and mainly affects the face, neck, and central regions of the body but, rarely, the soles of feet are affected. Here, we describe the case of a 71-year-old woman with MC on the plantar heel.Case Report:A 71-year-old woman presented with a 3-mm, pale, pearly, round, verrucoid lesion along the plantar central aspect of the left heel, present for 1 week. Histopathological evaluation of the excisional biopsy revealed several clusters of hyperplastic keratinocytes containing lobulated, eosinophilic, intracytoplasmic inclusion bodies inverted into the dermal layer, which was diagnosed as MC.Conclusions:MC on the plantar heel is a rare, atypical presentation that needs to be differentiated from viral warts and other diseases.

Sebaceous hyperplasia (SH) is a benign proliferation of the sebaceous glands. Ultraviolet radiation is known to be the cofactor for the pathogenesis of SH. Frequently reported adverse events of 308-nm excimer laser are erythema, burning or pain, and itching sensation. However, the role of excimer laser as an aetiological factor of SH is rarely reported in the literature. A 59-year-old female presented with several elevated, umbilicated papules on the face. Papular eruption appeared abruptly after 11 weeks of treatment for vitiligo which includes 308-nm excimer laser therapy. The distribution of lesion was associated with the treated area. Total cumulative dose was 3,300 mJ/cm² over 16 sessions. Histopathologic findings showed enlarged sebaceous glands composed of numerous lobules around a centrally located, widened sebaceous duct. Chronic sun exposure clinically causes SH was proved in the previous animal studies. Thus, we introduce a rare case of eruptive SH in the patient treated with 308-nm excimer laser.

Cryptococcal infections occur in 6% to 13% of patients with acquired immunodeficiency syndrome (AIDS), most commonly infecting the central nervous system. Cutaneous lesions have been described morphologically as umbilicated papules, nodules, and violaceous plaques and can mimic molluscum contagiosum and Kaposi's sarcoma. Cutaneous lesions can present months prior to other signs of systemic infection. Cases of infection with cutaneous Cryptococcus and AIDS were reviewed and compared with cases reported in the literature. Among patients with Cryptococcus infection and AIDS seen at our institutions, 5.9% had skin lesions. All patients with cutaneous lesions had systemic involvement. Women were less commonly infected than men. There was no apparent predisposition associated with age, race, or human immunodeficiency virus infection risk factors. The median CD4 helper T-cell count was 0.024 X 10(9)/L (24/microL), and 44% (16/36) of the patients had previous opportunistic infections. Lesions were most commonly seen on the head and neck (78% [36/46]) and often mimicked molluscum contagiosum (54% [25/46]). The median serum and cerebrospinal fluid cryptococcal antigen titers were 1:32,768 and 1:512, respectively. Patients in our group did well with therapy (one death at 6 weeks, compared with 38% [13/34] mortality in the literature). There was no correlation between onset of lesions, number of lesions, CD4 helper T-cell count, or histopathologic characteristics. Disseminated Cryptococcus infection in AIDS presents with cutaneous lesions in up to 6% of cases. Clinicians need to be aware of the varied morphologic characteristics, since cutaneous lesions may present well in advance of other signs of systemic infection.

Sebaceous Glandhy Perplasia (SGH) is a common benign proliferative skin disorder, which most commonly involves the faces and usually appears as yellow, soft, umbilicated papules. But the clinical manifestations of SGH vary greatly. We presented a 40-year-old man with the flesh-colored to light brown linear plaque behind the right ear mimicking verrucous nevus clinically.

Histoid leprosy is extremely rare in children. Molluscum contagiosum-like lesions in the setting of histoid leprosy is a highly atypical presentation and may signify the process of "transepidermal elimination" in lesions with high bacillary load. A case of histoid leprosy with umbilicated papules and nodules mimicking molluscum contagiosum is reported in a 10-year-old Indian boy.