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LETTER TO EDITOR
Year : 2017  |  Volume : 18  |  Issue : 2  |  Page : 140-141

Epidermoid cyst containing molluscum bodies in a 12-year-old Indian boy: A chance phenomenon or inducer?


1 Department of Dermatology, R. G. Kar Medical College, Kolkata, West Bengal, India
2 Arica Diagnostic Pvt. Ltd., Kolkata, West Bengal, India

Date of Web Publication27-Mar-2017

Correspondence Address:
Olympia Rudra
Department of Dermatology, R. G. Kar Medical College, 1, Khudiram Bose Sarani, Kolkata - 700 004, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2319-7250.193035

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How to cite this article:
Rudra O, Ghosh SK, Gangopadhyay A, Bhunia D, Maiti G, Ghosh A. Epidermoid cyst containing molluscum bodies in a 12-year-old Indian boy: A chance phenomenon or inducer?. Indian J Paediatr Dermatol 2017;18:140-1

How to cite this URL:
Rudra O, Ghosh SK, Gangopadhyay A, Bhunia D, Maiti G, Ghosh A. Epidermoid cyst containing molluscum bodies in a 12-year-old Indian boy: A chance phenomenon or inducer?. Indian J Paediatr Dermatol [serial online] 2017 [cited 2019 Dec 14];18:140-1. Available from: http://www.ijpd.in/text.asp?2017/18/2/140/193035

Sir,

A 12-year-old otherwise healthy boy presented to us with an untreated asymptomatic raised lesion on his shoulder since last 2 years. Initially, the lesion was small which gradually increased to attain the present size. There was no history of atopy. No similar history was present in the family. Cutaneous examination revealed a soft to firm, nontender sessile nodule of 1.5 cm diameter on his shoulder [Figure 1]a. The lesion was free from underlying structures. There was no erythema, scaling, or erosion on the surface of the lesion. However, a punctum was seen over the nodule. Rest of the cutaneous or systemic examination was noncontributory. Routine blood examinations were within normal limits. Screening for HIV was negative. Histopathological examination (HPE) of the excised nodule, stained by hematoxylin and eosin [Figure 1]b,[Figure 1]c,[Figure 1]d, revealed multiple big to small cystic structures in the dermis. The overlying epidermis was normal with irregular proliferation of rete pegs. The cysts were lined by single-layered granular cells of surface epithelium and contained keratin debris, hair shaft remnants, and eosinophilic globular structures suggestive of molluscum bodies. Molluscum bodies were also seen in the walls of the lining epithelium. There was a sparse inflammatory cell infiltrate consisting of eosinophils, lymphocytes, and histiocytes surrounding the cystic structures. Based on the clinical with HPE findings, a diagnosis of epidermoid cyst (EC) containing molluscum bodies was made.
Figure 1: (a) Sessile nodule with central punctum. (b) Cyst containing hair remnants and molluscum bodies, (H and E, ×100). (c) The presence of granular cell layer and scattered molluscum bodies both inside and within the cyst wall, (H and E, ×400). (d) High-power view showing multiple molluscum bodies and hair shafts (H and E, ×400)

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ECs are lesions that arise from the infundibular portion of the terminal hair follicles.[1] They are usually situated in the dermis and protrude in the epidermis. Although EC may become infected and culture showed growth of bacteria, both aerobic and anaerobic,[2] the occurrence of molluscum contagiosum (MC) within an EC is an extremely rare occurrence.[3]

We could find out that the coexistence of MC and EC was first reported way back in the year of 1973.[4] Since its original description, <20 cases have been described in the PubMed and Medline database and most of the previous cases are reported in middle-aged adults. An EC occurs due to plugging of pilosebaceous units.[3] It is an asymptomatic, slow-growing, mobile, dermal or subcutaneous nodule with a surface punctum through which cheesy material can be expressed. It commonly affects adult men or women. Chest, back, head and neck region are the most common sites of involvement.[2] On the other hand, MC is a viral infection caused by a poxvirus, subgenus molluscipox virus (MCV), which comprises four genetically distinct viral subtypes. It is characterized by shiny, pearly white, hemispherical, umbilicated papule over skin and mucosa. MC is more common among children. It is common in the head and neck region, followed by flexural areas and the genitalia.[5] Extensive lesions can occur in immunocompromised patients, especially in HIV, patients receiving immunosuppressive therapy, and in atopics.[5],[6] However, our patient was neither atopic nor had history of use of any topical or systemic medication. After entering through the basal epidermis, the MCV starts cellular proliferation and forms lobulated epidermal growths which further compress the papillae and, thus, fibrous septae develop between the lobules. Ultimately, cells at the center of the lesion get destroyed and appear as large hyaline bodies containing eosinophilic, cytoplasmic masses of virus material.[5] Spontaneous regression usually occurs within 1 year due to cell-mediated immune response. Antibody to the virus is present in almost 60% of patients, which suggest the role of humoral immunity in addition. Apart from these, ubiquitin-proteasome system also plays an important role in regression of the lesions. Apoptosis of the virus-infected cells occurs at the end of the regression.[6] Rarely, MCV may infect keratinocytes of the hair follicle infundibulum or inflamed comedones and abscesses.[7]

MC within EC in an immunocompetent individual is an extremely rare finding, and till date, only a few cases have been reported in the literature.

Various hypotheses have been proposed to describe the pathogenesis of occurrence of MC within EC. It can occur due to simultaneous infection of MCV at the time of EC formation or due to invasion of the virus into a preexisting cyst.[3],[7],[8] In addition, it might develop due to infection by MCV of a preexisting hair follicle followed by secondary cystic transformation.[7] The presence of epithelial lining in the cystic wall essentially ruled out the possibility of pseudocystic MC in the present case.

Furthermore, EC can be differentiated histopathologically from sebaceous duct cysts and dermoid cysts by the absence of sebaceous glands in its wall.[1] Surgical excision is the treatment of choice for EC [2] and MC is usually self-limiting. Different modalities of treatment have been suggested for persistent MC which may include curettage, topical trichloroacetic acid, salicylic acid, tretinoin, potassium hydroxide solution, imiquimod cream, and cryotherapy amongst others.[5] In our case, it is unlikely that MCV secondarily infected the already existing EC as there were no adjacent lesions. Rather, we presume that the epidermal cysts formed as a reactive phenomenon to the MCV or both MC and EC developed concurrently as it has already been reported. This probably allowed the MCV to evade the body's cell-mediated immune response and persist for such a long time in an otherwise immunocompetent host. We report here this case because of its extreme rarity and interesting clinical presentation. To the best of our knowledge, this type of cooccurrence has not yet been reported in Indian population. Moreover, such a combination is probably a hitherto unreported occurrence in pediatric population. In this report, we further seek to emphasize the importance of histological examination in the evaluation of cutaneous nodules.

Financial Support and Sponsorship

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Conflicts of Interest

There are no conflicts of interest.

 
  References Top

1.
Fullen DR. Cysts and sinuses. In: Busam KJ, editor. Dermatopathology a Volume in the Series Foundations in Diagnostic Pathology. 2nd ed. Philadelphia: Elsevier Saunders; 2010. p. 310-36.  Back to cited text no. 1
    
2.
Piggot C, Friedlander SF, Tom W. Poxvirus infection. In: Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Leffel DJ, Wolff K, editors. Fitzpatrick's Dermatology in General Medicine. 8th ed. New York: The McGraw-Hill; 2012. p. 2402-20.  Back to cited text no. 2
    
3.
Jung HM, Choi WJ, Sohn KM, Kim JE, Kang H. Atypical clinical presentation of molluscum contagiosum in an epidermal cyst. Indian J Dermatol Venereol Leprol 2015;81:548.  Back to cited text no. 3
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4.
Hodqes J, Fliecelmanm T, Schrodtg R, Owenl G. Molluscum contagiosum occurring in epidermal inclusion cysts. Arch Dermatol 1973;108:257-8.  Back to cited text no. 4
    
5.
Sterling JC. Virus infection. In: Burns T, Breathnach S, Cox N, Griffiths C, editors. Rook's Textbook of Dermatology. 8th ed. Singapore: Wiley-Blackwell; 2010. p. 33.1-33.81.  Back to cited text no. 5
    
6.
Weedon D. Weedon's Skin Pathology. 3rd ed. Edinburgh, UK: Churchill Livingstone Elsevier; 2010.  Back to cited text no. 6
    
7.
Kanitakis J. Molluscum contagiosum in an epidermoid cyst. Am J Dermatopathol 2011;33:638-40.  Back to cited text no. 7
    
8.
Phelps A, Murphy M, Elaba Z, Hoss D. Molluscum contagiosum virus infection in benign cutaneous epithelial cystic lesions-report of 2 cases with different pathogenesis? Am J Dermatopathol 2010;32:740-2.  Back to cited text no. 8
    


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