A 43-year-old, HIV-positive woman comes to the office due to lesions on her vulvar and perineal areas for the past 4 weeks. On examination, there are clusters of firm, shiny, round papules that are each 2-6 mm in diameter with central indentation. Microscopic examination of a lesion is shown in the image below: Which of the following is the most likely cause of this patient's presenting condition?

Question

A 43-year-old, HIV-positive woman comes to the office due to lesions on her vulvar and perineal areas for the past 4 weeks.  On examination, there are clusters of firm, shiny, round papules that are each 2-6 mm in diameter with central indentation.  Microscopic examination of a lesion is shown in the image below:  Which of the following is the most likely cause of this patient's presenting condition?

Quizplus · Accepted Answer

11ec160b_3847_e5f4_9249_e1bd27a1b52b_MD0001_00 This patient has molluscum contagiosum (MC), a benign skin condition caused by a poxvirus. MC is most common in young children, but older patients who are sexually active, participate in contact sports, or are immunocompromised (eg, HIV) are also at increased risk. MC classically presents as firm, shiny, dome-shaped, flesh-colored papules that often have a central umbilication. Lesions are nontender but may be pruritic. Affected areas in adults usually include the lower abdomen, genitalia, and upper thighs because sexual contact is the most common route of transmission. However, autoinoculation can lead to spread on any part of the body (except the palms and soles), and patients who are immunosuppressed are at increased risk for widespread disease. Microscopy of the lesions shows intracytoplasmic eosinophilic inclusion bodies (molluscum bodies) composed of poxvirus within keratinocytes in the epidermis. Lesions usually self-resolve within 6-12 months but typically last longer in immunocompromised patients. (Choice A) Genital herpes simplex virus causes acute episodes of painful vesicles and ulcers, which are not present in this patient. In addition, microscopy of herpes shows multinucleated cells. (Choice B) Human herpesvirus 8 in immunocompromised patients causes Kaposi sarcoma, which typically presents with nontender, discolored (eg, pink, purple, red) papules on the extremities, face, and genitalia. Biopsy shows whorls of spindle cell proliferation and extravasated red blood cells. (Choice C) Condyloma acuminata (due to human papillomavirus) are typically soft, verrucous anogenital lesions without a central indentation. Microscopy shows papillomatosis and perinuclear cytoplasmic vacuolation (koilocytosis). (Choice E) Syphilis, caused by Treponema pallidum, classically presents with a painless genital ulcer in its primary stage. Secondary syphilis can cause condyloma lata, which are pale papules and plaque-like genital lesions. Although the diagnosis is normally confirmed through serologic testing, microscopy would show spirochetes on darkfield examination rather than molluscum bodies in keratinocytes. Educational objective: Molluscum contagiosum is caused by a poxvirus and presents with small, firm, rounded, papules that often have a central umbilication. Adults who are immunocompromised (eg, HIV) or sexually active are at increased risk. Biopsy shows intracytoplasmic eosinophilic inclusion bodies of poxvirus in keratinocytes. __________ References: Molluscum contagiosum: an update and review of new perspectives in etiology, diagnosis, and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/31239742)

A 43-Year-Old, HIV-Positive Woman Comes to the Office Due to Lesions