ABSTRACT

CORRESPONDING AUTHOR:
Dr. Komal Singh Likhar,
HIG-12, B Peoples Medical College Campus,
Bhanpur, Bhopal-462037,
Madhya Pradesh, India.
Email: dr.komallikhar@yahoo.com

ABSTRACT: Molluscum contagiosum is a virus-induced dermatologic condition causing characteristic pearly lesions on the surface of skin. The lesion is common in children. In adults, it is usually a sexually transmitted disease. Molluscum contagiosum may be found anywhere on the body, although it rarely occurs on the palms and soles. Dermatosis of nipple due to molluscum contagiosum is rare. If it occurs, it is accompanied by lesions in other sites. Isolated involvement of nipple by the virus is unusual and has been reported only once in previous literature to the best of our knowledge. Here, we report this unusual case of isolated molluscum contagiosum of nipple in 18years young antenatal female.

KEYWORDS: Molluscum Contagiosum, Nipple, Inclusions.

INTRODUCTION: Molluscum contagiosum is a contagious skin infection caused by molluscum contagiosum virus (MCV) that causes raised, pearl like nodule or papules on the skin with umbilicated centre which may get ulcerated. These growths are called as molluscum bodies or condyloma subcutaneum.¹ The virus belongs to the family Poxviridae. Molluscum contagiosum virus is a double-stranded DNA poxvirus. Lesion is common in children and adolescence. It frequently occurs on the face, trunk and extremities of children and adolescents. It is also commonly encountered on the genitals of young adults as a result of sexual contact. Many cases are associated with HIV infection. However, molluscum contagiosum of the areola or nipple is rare. We present a woman who developed a solitary molluscum contagiosum lesion on her left areola.

CASE SUMMARY: A 18years old young antenatal female presented with a small papulo-nodular swelling over right nipple. She was apparently well till 1 month ago when she noticed a small painless nodular swelling on tip of right nipple with whitish discharge. On examination, a small papulo-nodular lesion was noted on nipple measured 1.7x1cm. The swelling was pinkish, non-tender and associated with whitish discharge. General physical and systemic examination was normal. She had no other lesions or lumps in the breast and there was no history of any similar lesions elsewhere on her body. There was no lymphadenopathy anywhere particularly axilla.

She gave history of two months pregnancy. All the preliminary investigation including HIV was normal as per her last test done two months prior to the presentation. A clinical diagnosis of pyogenic granuloma was made. The lesion was excised under local anaesthesia and sent for histopathology examination in pathology department.

On gross examination the received specimen consists of a single skin covered nodular greyish white soft tissue piece measures 1.7x1.0x0.5cms with greyish white cut surface.

Microscopic examination revealed verrucous hyperplastic keratinised epidermis showing downward growth in the form of lobules having round eosinophilic Molluscum bodies (Henderson Patterson bodies). Large numbers of intracytoplasmic inclusions were also observed in keratinocytes. The keratinous material was seen in the centre of lobules. The diagnosis of Molluscum contagiosum was made.

DISCUSSION: MC is caused by a virus Molluscum contagiosum virus which is a member of the family Poxviridae (genus Molluscipoxvirus). It is the principal poxvirus causing human disease. Spread is mainly by direct skin-to-skin contact and occurs predominantly in children, adolescents, sexually active adults, in individuals with impaired cellular immunity and in association with HIV and HPV infections.²

In immunocompetent hosts, MC is a benign, self-limited skin infection. However, in patients with underlying immune dysregulation, which is characterized by a T helper 2 (Th2) cytokine switching pattern within the skin, the lesions may be more diffuse, remain for longer periods of time, and may be more resistant to therapy. This most probably reflects the local deficits in cellular immune reactions within the skin, which are mediated primarily by a T helper 1 (Th1) cytokine pattern. Antibody to pox virus may be seen in 60% patients with skin lesions but are less frequent in AIDS patients.^3,4

Non-sexual transmission in healthy adults has been reported and typically occurs at a site of trauma or other cutaneous injury. It has predilection for head and neck, flexural areas and genital areas. Sexually transmitted lesions in adults are usually seen on the lower abdomen and genitalia. There was no known predisposing factor in this patient.

The characteristic lesion is commonly described as a firm, fleshy, dome shaped umbilicated waxy papule measuring 2-8 mms in diameter and MC is easy to recognize clinically. Papules of MC are usually asymptomatic, but they can be pruritic or tender to touch. Extensive lesions are noted in patients with AIDS.⁵

The nipple is an extremely unusual site of involvement and forms an important differential diagnosis for dermatoses of the nipple, including malignant nipple lesions. Dermatoses of the nipple and areola are quite rare. Infectious dermatoses at this site commonly include viral warts, molluscum contagiosum and scabies. Gross appearances of these lesions are very similar; therefore the differential diagnosis is of great clinical importance. Early lesions of dermatoses are scaly and erythematous, with possible etiologies ranging from eczema or inflammatory skin disorders, to Paget's disease of the nipple. The management implications are widely varied for this range of disorders, from topical applications to surgical interventions.⁶

N Kumar reported a similar case in 45years old female who presented with 10 months history of a nodular nipple lesion which ulcerated after local application of caustic pencil. There was no associated breast lump. Cytology smears revealed nucleate and anucleate squames in an inflammatory background. Characteristic intracytopalsmic and extracytopalsmic molluscum bodies were seen.⁷

N marwah also reported this rare case in 30years old female who presented with small, popular, non-painful lesion on the nipple of right breast.⁸

It is a self limiting condition, most cases gradually resolve without treatment. It is a common practice to consult pharmacist who act as a first line health care provider to many patients in cities as well as rural areas in Africa. Caustic pencil for warty lesions is often prescribed by pharmacists. This should never be used on the breasts because the tissue is so sensitive and takes so long to heal. In this patient ulceration of nipple is a complication that precluded a correct clinical diagnosis.

CONCLUSION: This case is very rare as the isolated nipple is an unusual site of presentation for Molluscum contagiosum and the definitive diagnosis of molluscum contagiosum is made by visualizing molluscum bodies by microscopy. The lesions of molluscum contagiosum are usually self-limited. However, a variety of treatment options exist to facilitate the resolution of the skin lesions.

BIBLIOGRAPHY:

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5.    Fornatora ML, Reich RF, Gray RG, Freedman PD. Intraoral molluscum contagiosum: a report of a case and a review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2000; 92: 318–320. [PubMed].
6.    Parlakgumus A, Yildirim S, Bolat FA, Caliskan K, Ezer A, Colakoglu T, Moray G. Dermatoses of the nipple. Can J Surg. 2009; 52: 160–161.[PubMed].
7.    Neeta Kumar, Patricia Okiro, Ronald Wasike Cytological diagnosis of molluscum contagiosum with an unusual clinical presentation at an unusual site. J Dermatol Case Rep. 2010 December 31; 4 (4): 63–65.Published online 2010 December 31. doi: 10.3315/jdcr.2010.1055 PMCID: PMC3157818.
8.    Nisha Marwah, Sumiti Gupta, Sunita Singh, Divya Sethi. Molluscum contagiosum of nipple. Medical Journal of Dr. D.Y. Patil University. July-December 2012; Vol. 5 Issue 2. pg1 61-62.


    Figure 1: Photomicrograph showing large intracytoplasmic inclusions (molluscum bodies)in lower epidermis (H&E;100x).

Figure 1

Figure 2: Photomicrograph showing large intracytoplasmic rounded eosinophilic inclusions (H&E;1000x).

Figure 2

Figure 3: Photomicrograph showing similar histologic changes under high power (H&E;400x) (2).

Figure 3

Figure 4: Photomicrograph showing similar histologic changes under high power (H & E; 400x)

Figure 4