A Rare case of giant molluscum contagiosum lesion

presenting as lid tumor in an immunocompetent adult.

Author: Dr. Giri NileshJunior resident dept of ophthalmology Dr. PDMMC

Introduction Lid masses are commonly encountered cases in ophthalmology

OPD and the diagnosis of the underlying pathology can be easily made based on detailed history and detailed local examination of the mass, and the line of management can be decided.

We report a very interestingly unusual presentation of a single, solitary, giant, non-umbilicated lesion on R.E. upper eyelid of a immunocompetent, middle-aged male patient causing mechanical ptosis, the mass could be easily separated from overlying skin during complete excision biopsy which showed a never described before whitish brain like appearance consisting of multiple lobes and gyri, which histopathologically proved to be molluscum contagiosum (M.C) lesion.

CASE SCENARIO A 35 y/o male patient, farmer by occupation, was referred from skin VD OPD to ophthalmology OPD with c/o:

Mass over RE Upper Eyelid since 1 year for excision of mass ? Wart.

Pt was a/a 1 yr back when he started developing mass over RE upper eyelid which was gradual in onset, painless, and progressively increasing in size.

Since last 3 to 4 months the size of the mass increased relatively rapidly to current size.

No h/o traumaNo h/o pain or redness in the massNo h/o discharge from the massNo h/o redness in the eyeNo h/o similar complaints in LENo h/o similar compaints elsewhereNo h/o sudden change in the appearance or contour of the mass.

No h/o similar complaints in the pastNo h/o HTN/ TB/ DM/ BA or any other major illness in the pastNo h/o ocular surgery in the past.Patient is a tobacco chewer since 15 yrs, denies any other addiction.

d/d on history:Chalazion, Lipoma,

Meibomian gland adenoma,

Neurofibroma, Meibomian gland

Carcinoma, Sebaceous cyst, Dermoid cyst,

Foreign body granuloma.

PARAMETER RE (ocular examination)

LE

V/A (U/A) 6/18 6/18(P)

(With Pin Hole) 6/9 6/9

Lids :Upper eyelid Single, well defined Mass ms 1.3 x 1.2x 0.4

cm.4 mm nasally from lateral canthus , 3 mm above lid margin. Rest eyelid: within normal limits.

Normal

Lower lid Normal Normal

PAH Reduced (by 0.2 cm ) due to mechanical ptosis caused by the U.L. mass.

Normal

Conjunctiva Normal Normal

Cornea clear Clear

Anterior chamber Normal depth Normal depth

Pupil NSRL NSRL

General & systemic examinations: Within normal limits, physician fitness taken.

ON OCULAR EXAMINATION:

On detailed local examination: Right eye upper eyelid shows a single, solitary, non-tender, well

defined mass 1.3 x 1.2 x 0.4 cm firm in consistancy, non tender, Smooth, with well defined margins, with no punctum.

The overlying skin was tense, shiny. Getting under the mass was not possible.

D/D on examination

1)Chalazion (due to tarsal location of the swelling)2) lipoma (universal tumor, firm consistency)3) Meibomian gland adenoma (tarsal location)4) Neurofibroma (appearance, soft to firm, brown)

We rule out on examination:Meibomian gland Ca.(no extension)Sebaceous cyst (no punctum or inflammation)Dermoid cyst.(location)Foreign body granuloma.(no scar)

MANAGEMENT:•Decision was made to perform an excisional biopsy of the mass.•Under all aseptic precautions and local anaesthetic infiltration, excisional biopsy was performed by following steps:

1) A chalazion clamp was applied around the mass for hemostasis.2) A skin incision was made along the lid crease, the skin was undermined over the mass which was unexpectedly easy in view of its adherence to mass on preoperative examination and the mass was easily separated from the underlying orbicularis muscle.

INTRAOPERATIVE PICTURESHOWING INTERESTINGLY BRAIN LIKE GYRI AND SULCI.

The mass was removed in toto. primary skin closure was done

using vicryl 4-0 The excised mass was

white in color and, interestingly, had brain like appearance morphologically. It had multiple lobes and gyri like corrugations over its surface as shown in Fig

Histopathological evaluation of the mass revealed….

Histopathological evaluation showed typical epithelial hyperplasia and intracytoplasmic inclusion bodies and gave us the diagnosis of molluscum contagiosum.

Courtesy: dept of pathology Dr PDMMC

A Brief overview of molluscum contagiosum (M.C.)

•It is a benign, self-limiting, epidermal, contagious viral infection.•Causative virus: A DNA pox virus , the molluscipox virus and has features intermediate between the orthopox and parapox groups.•PCR identified two main types, MCV-1 and MCV-2, with two much rarer types, MCV-3 and MCV-4.It infects humans, causing characteristic skin papules, more seen in children.Painless papular eruptions with multiple umbilicated cutaneous lesions of 5 to 8 mm and very rarely >10 mm ( giant M.C. lesion)Can occour in any body area except palms and soles (atypical, if present).Rare sites include eyelids, lips and mouth.•The age of peak incidence is reported as between 2 and 5 years, A later incidence peak in young adults is attributable to sexual transmission with lesions more common in the genital area. Higher incidence has been noted in immunocompromised states suggesting role of cell mediated immunity.•Cells at the core of the lesion show the greatest distortion and are ultimately destroyed, and appear as large hyaline bodies (molluscum bodies) some 25 µm in diameter, containing cytoplasmic masses of virus material {pathognomic}

Treatment options for molluscum contagiosum lesions:.

Destroy the infected epidermal cells by Stimulating an immunological response Act directly against the virus (Cidofovir) Surgical removal of molluscum contagiosum by curettage has been used for

many years Cryotherapy/ Photodynamic therapy

What made this case unique?? Age ( adult) solitary lesion(no crops) Unusual ( rare ) location Absence of umbilication Size of the lesion (>1o mm) Immunocompetent status.

What did we learn?? Solitary giant MC, although a rare condition in immunocompetent patients, should be suspected even if central umbilication is not found in the lid tumor.

Complete excision of the mass is an easy and effective mode of treatment and

White brain like appearance of the removed tissue may further point towards the diagnosis of MC.

Only one such case with similar brain like appearance has been published in the Indian Journal of Ophthalmology and that too was reported in pediatric age group.

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