INFECTION:

MOLLUSCUM CONTAGIOSUM
Molluscum contagiosum (MC) is a benign but nonetheless
frequently troublesome viral infection that
most often affects young children. It is characterized
by smooth, dome-shaped, discrete, opalescent papules
with a central core that occasionally develops
surrounding areas of scale and erythema (molluscum
dermatitis). Patients and families are bothered by
this infection because of its often prolonged course,
as it may MOLLUSCIPOXVIRUS persist for months to years. MC is a greater
concern in immunocompromised individuals and
those with atopic dermatitis, in whom the extent and
duration of infection may be more extreme. Sexually
transmitted disease occurs in adults but is extremely
unlikely in children.

- Epidemiologi
MC virus (MCV) infection occurs worldwide and
appears specific to humans. The prevalence of MCV
infection has risen significantly in the past several
decades, with an 11-fold increase noted in one US
study of patient visits for this disorder over a twodecade
span.75 This rise appears to parallel the overall
increase in sexually transmitted diseases. Although
a prevalence rate of less than 5% in US children
is often cited,76 the rate varies by location, and it is
thought that subclinical infection may be more common
than overt disease. A representative Australian
study documented an overall seropositivity rate of
23%, which supports the view that subclinical or mild
unrecognized disease exists in the population. HIVinfected
individuals are at higher risk for extensive
prolonged disease, and individuals with atopic conditions
appear more likely to have increased numbers
of lesions and experience a more prolonged disease
course.76
Transmission may occur via direct skin or mucous
membrane contact, or via fomites. Bath towels, swimming
pools, and Turkish baths have all been reported
as sources of infection, and individuals involved in
close contact sports (e.g., wrestling) also appear at
higher risk.77,78 Autoinoculation and koebnerization
also play a role in the spread of lesions. Recent reports
also document the possibility of vertical transmission
from mother to neonate during the intrapartum
period.79
Etiologi :
E MCV is a large, brick-shaped poxvirus that replicates
within the cytoplasm of cells. It shares a number

of genomic similarities with other poxviruses, and

approximately two-thirds of the viral genes are similar
to those of vaccinia and variola virus.80 There are
four subtypes of MCV, but they all appear identical
clinically. Ninety-eight percent of disease in the United
States is caused by MCV genotype 1 and it is the main
cause of MC in children.80,81 MCV-2 is primarily seen
in adults and immunocompromised individuals, with
sexual contact being the most common mode of transmission.
Serial transmission of the virus has not yet
been achieved in culture. An incubation period of 27
weeks has been observed.
Virus replicates within the cytoplasm of epithelial
cells, and infected cells replicate at twice the baseline
rate. There are many MCV genes that may contribute to
an impaired immune response to this virus, including (1)
a homolog of a major histocompatibility class 1 heavy
chain, which may interfere with antigen presentation;
(2) a chemokine homolog that may inhibit inflammation;
and (3) a glutathione peroxidase homolog that may protect
the virus from oxidative damage by peroxides.82,83
Gejala Klinis :CLINICAL FINDINGS
CUTANEOUS LESIONS. MC often presents with
extremely small pink, pearly, or flesh-colored papules
that then enlarge, occasionally reaching sizes of
up to 3 cm (giant molluscum). As they enlarge, a
dome-shaped, opalescent morphology may become
more apparent. The lesions may have a central dell or
umbilication (Fig. 195-12), within which a white curdlike
substance can be seen that can be expressed with
pressure. Most patients develop multiple papules,
often in intertriginous sites, such as the axillae, popliteal
fossae, and groin. Genital and perianal lesions can
develop in children and are only rarely associated with
sexual transmission in this population.75
Lesions may be grouped in clusters or appear in a
linear array. The latter often results from koebnerization
or development of lesions at sites of trauma.
Erythema and eczematous changes may occur around
lesions; this is termed molluscum dermatitis. Papules
may become erythematous (Fig. 195-12B), which is
believed to be an immune response to the infection.
Patients with acquired immunodeficiency syndrome
may develop large and extensive lesions involving
both genital and extragenital sites.82 (see Chapter 198)
Pemeriksaan Khusus:SPECIAL TESTS
Diagnosis is usually straightforward. Evaluation of the

central contents using a crush preparation and Giemsa

staining can be carried out when necessary (eFig. 19512.1 in online edition), and histopathologic evaluation
can be performed as needed. Some clinicians recommend
that an adult with new-onset MC infection. undergo evaluation for HIV infection and/or other
causes of an immunocompromised state.84
Histopathologic examination reveals a hypertrophied
and hyperplastic epidermis. Above the basal
layer, enlarged cells containing large intracytoplasmic
inclusions (Henderson-Paterson bodies) can be seen
(Fig. 195-13). These increase in size as the cells reach
the horny layer.TA
Diagnosa Banding:ND
The differential diagnosis includes verrucae, pyogenic
granulomas, amelanotic melanoma, basal cell carcinomas,
and appendageal tumors. Fungal infections
caused by Cryptococcus, histoplasmosis, and Penicillium
must be considered in immunocompromised
hosts (Box 195-5).
Komplikasi:
T Although many patients are asymptomatic, pruritus is
sometimes a significant problem, particularly in those
patients with underlying atopic dermatitis. Chronic
conjunctivitis and punctate keratitis may develop in
patients with eyelid lesions. Secondary bacterial infection
can occur, particularly if patients scratch their
lesions.H
Prognosis :
Spontaneous clearance occurs, but often over a prolonged
period of months to years. Most families prefer
treatment if lesions persist more than a month or two.
In patients with HIV, MC infection is usually indicative
of a more advanced state of HIV, with higher viral load
and lower CD4+ T-cell count.84
Penatalaksanaan :TREATMENT
It is important to discuss the risks and benefits of individual
therapies with families before embarking on
treatment for this essentially benign condition, which
will generally resolve without complication in the
immunocompetent individual (Table 195-3). For some
children, no treatment is the best option as the childs
native immune response may clear the MC without
additional intervention. Many experts use cantharidin
0.7% or 0.9% liquid for treatment of MC. This extract of
the blister beetle, Cantharis vesicatoria, induces vesiculation

at the dermoepidermal junction when applied

topically to the skin. It must be applied with care and
washed off 26 hours later. Use on the face or genital
areas is not recommended, and families must be counseled
regarding the small risk of extreme reaction or
scarring.
Other traditional therapies have included curettage
and cryotherapy; however, both of these treatments
are painful. The use of topical anesthetic agents may
ameliorate some of the associated pain, but patients
generally find topical cantharidin treatment the most
efficient and least painful. Other topical therapeutic
modalities include retinoid creams, imiquimod cream,
salicylic acid, trichloroacetic acid, cidofovir, and silver
nitrate paste and tape stripping. Oral cimetidine has
also been used with some success.85 However, a 2009
Cochrane Database analysis of treatments for MC,
which identified only 11 therapeutic studies of high
quality, found that no single intervention is convincingly
effective for the treatment of MC.86
Pencegahan :PREVENTION
Prevention of spread may be enhanced by avoiding
trauma to the sites of involvement as well as avoiding scratching, with the use of antipruritics
as necessary.
Autoinoculation may be decreased by treating all existing
lesions.
Figure 195-13 Molluscum contagiosum. Histopathology
(skin biopsy, H&E) shows downgrowth of infected epidermal
cells bearing large eosinophilic cytoplasmic inclusion
bodies (Henderson-Paterson bodies).

Box 195-5 Differential Diagnosis

of Molluscum Contagiosum
Most Likely
Verrucae
Consider
Pyogenic granuloma
Papular granuloma annulare
Epidermal inclusion cyst
Sebaceous hyperplasia
Always Rule Out
Appendageal tumors
Basal cell carcinoma
Amelanotic melanoma
Cryptococcosis/histoplasmosis/penicilliosisGENESIS