Multiple Molluscum Contagiosum Types 6, 11, 16, 18, 30, 31, 33, 35, 45, 51, and Lesions Ofthe Limbus in a Patient with 52 HPV (Fig 5)

Letters 393

lumen of the lacrimal sac. Histologically, we 5 Odrich MG, Jacobiec FA, Lancaster WD, Kenyon KR, Kelly LD. A spectrum of bilateral observed an inverted squamous cell papilloma squamous conjunctival tumors associated with with dysplastic change, marked mitotic human papillomavirus type 16. Ophthalmology

activity, and koilocytosis in the cells near the 1991; 98: 628-35. Br J Ophthalmol: first published as 10.1136/bjo.79.4.393 on 1 April 1995. Downloaded from 6 Manos MM, Ting Y, Wright DK, Lewis AJ, tumour surface (Figs 2, 3). The superficial Broker TR, Wolinsky SM. Use of polymerase epithelial tumour cells were positive for anti- chain reaction amplification for the detection of HPV antibody (Dako Corporation, USA) by genital human papillomaviruses. Cancer Cells immunohistochemical staining (Fig 4). Cells 1989; 7: 209-14. were also positive for a wide spectrum HPV fluorescein labelled DNA in situ hybridisation probe (Dako Corporation, USA) including Multiple molluscum contagiosum types 6, 11, 16, 18, 30, 31, 33, 35, 45, 51, and lesions ofthe limbus in a patient with 52 HPV (Fig 5). Cells were negative for a type HIV infection Figure 1 Ti weighted magnettc resonance image shows a lobular tumour within the lacrimal sac. 6/11 probe. Fluorescein staining of the nuclei of tumour cells was stronger in the superficial EDITOR,-In HIV infection, molluscum con- epithelial cells than the deeper cells. Follow tagiosum of the eyelids is quite common, but up at 10 months showed no clinical or radio- limbal molluscum contagiosum is rare. We logical evidence of any recurrence. report a documented case ofmultiple bilateral molluscum contagiosum of the limbus in an COMMENT HIV seropositive patient. Primary tumours of the lacrimal sac are rare.1 Most ofthem are benign, including adenomas CASE REPORT and papillomas. The latter may be exophytic A 40-year-old African (Zaire) man presented or inverted. Inverted papilloma can be readily with bilateral ocular foreign body sensation transformed into carcinoma, even in a young which had developed 1 month earlier, without adult. Anderson et al recently reported a 36- redness of the eyes or loss of vision. The year-old patient with transitional cell car- patient tested seropositive to HIV 4 years cinoma arising from an inverted papilloma.2 earlier and had not developed any AIDS reveals an Figure 2 Histological examination In our case, epithelial dysplasia that dis- defining illness so far. He had been treated by inverted squamous papilloma that originated and cryotherapy for over a sac. (Haematoxylin played cytoplasmic clearing along with repeated curettage from the wall ofthe lacrimal contagio- and eosin staining X 13.) nuclear pyknosis and koilocytosis suggested year for disseminated molluscum HPV infection as an aetiology, since koilo- sum lesions of the skin, localised mainly on cytosis in squamous papilloma is commonly the face, the trunk, and the genitalia. CD4 T found in lesions associated with HPV.3 Based lymphocyte count at the time of ophthalmic on the histopathological findings in this case, evaluation was 70X 106/litre. Visual acuity we conducted an immunohistochemical and was 20/20 in both eyes without correction. molecular biological investigation of HPV in Slit-lamp examination revealed multiple, con- the lesion, which revealed HPV DNA. fluent, molluscum contagiosum lesions on the Previous studies have shown that ocular con- skin of the four eyelids. On the limbus of the junctival squamous papilloma may be related left eye, two white multilobular lesions, 4 and to HPV types 6 and 11,4 and squamous dys- 1 mm in diameter, were noted at 6 and 7 plasia or carcinoma to HPV type 16.5 HPV o'clock respectively (Fig 1). Another similar antigens and DNA types 16, 18, 31, 33, and lesion, 2 mm in diameter, was present on the limbus in the right eye, at 3, 4, and 6 o'clock. 35 have been identified within squamous dys- http://bjo.bmj.com/ plastic changes or carcinomas affecting the The lobules of these lesions, encroaching on Figure 3 Micrograph of tumour cells. There is were dome-shaped with a slight mitotic activity and koilocytosis, especially near female reproductive tract.6 Such findings sug- to the cornea, the surface ofthe tumour. (Haematoxylin and gest an oncogenic potential of HPV infection. central umbilication. There was a mild peri- eosin staining X 86.) In the present case, HPV was, thus, probably lesional conjunctival injection around each responsible for squamous papilloma with dys- limbal lesion. Anterior chamber, vitreous, and plastic changes of the lacrimal sac. The mode fundus examinations were normal in both of transmission of HPV to the epithelium of eyes. An excisional biopsy of the largest sac is unknown, but it could lesion in the left eye was performed. the lacrimal on September 27, 2021 by guest. Protected copyright. occur during passage of a fetus through the Histopathological examination was consistent infected birth canal. with the diagnosis ofmolluscum contagiosum Ophthalmologists should be alert to the (Fig 2). It showed a hyperacanthosis and possibility of HPV infection, especially in a hyperkeratosis of the epithelium, an oedema young adult with lacrimal sac papilloma, as of the underlying intercellular space, and this disorder may have oncogenic potential. numerous swollen cells containing eosino- YU NAKAMURA philic intracytoplasmic inclusions ('mollus- YUKIHIKO MASHIMA cum bodies'). Three months after the biopsy, Department of Ophthalmology the excised lesion had not grown back, while Figure 4 Micrograph of tumour cells. Cells KAORI KAMEYAMA the other limbal lesions ofboth eyes remained Department ofPathology, no treatment. In both near the surface ofthe tumour are positivefor Keio University School ofMedicine unchanged despite anti-HPV antibody immunohistochemical eyes, no new conjunctival, limbal, or comeal staining (x86). Correspondence to: Yu Nakamura, MD, lesions were seen and the foreign body sensa- Department of Ophthalmology, Keio University tion was stable. School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160, Japan. Accepted for publication 16 November 1994 1 Ramon LF. Ophthalmic pathology: an atlas and textbook. 3rd ed. Philadelphia: WB Saunders, 1986: 2320-2. 2 Anderson KK, Lessner AM, Hood I, Mendenhall W, Stringer S, Warren R. Invasive transitional cell carcinoma of the lacrimal sac arising in an inverted papilloma. Arch Ophthalmol 1994; 112: 306-7. 3 MacDonell JM, MacDonell PJ, Mounts P, Wu TC, Green WR. Demonstration of papillo- mavirus capsid antigen in human conjunctival Figure 5 Micrograph of tumour cells (X45). neoplasia. Arch Ophthalmol 1986; 104: 1801-5. The nuclei ofthe tumour cells near the surface 4 MacDonell PJ, MacDonell JM, Kessis BS, Green are positivefor a wide spectrum HPV WR, Shah KV. Detection of human papillomas fluorescein-labelled DNA in situ hybridisation by in situ hybridization with radioactive probes. probe. Hum Pathol 1987; 18: 1115-9. 394 Letters

Ophthalmic involvement is usually con- MARIANNE TOUBLANC fined to Department ofPathology, the eyelids.2 Conjunctival and comeal Bichat-Claude Bernard Hospital, lesions are very rare. In immunocompetent Paris, France patients, conjunctival involvement occurs CATHERINE RUGGERI Br J Ophthalmol: first published as 10.1136/bjo.79.4.393 on 1 April 1995. Downloaded from mainly as a chronic follicular keratoconjunc- Department of Tropical and Infectious Diseases, tivitis, secondary to molluscum contagiosum Bichat-Claude Bernard Hospital, lesions of the eyelids.3 It was hypothesised to Paris, France be a hypersensitivity reaction to the pox virus Correspondence to: Isabelle Cochereau, MD, rather than a site of viral replication. Such a Department of Ophthalmology, Bichat-Claude chronic follicular keratoconjunctivitis has Bernard Hospital, 46, Rue Henri Huchard, 75018 already been reported in AIDS.2 Only one Paris, France. case of a single lesion of molluscum contagio- Accepted for publication 5 December 1994 Figure 2 Histological section ofthe lesion shows sum of the limbus has been reported in an swollen cells containing eosinophilic viral AIDS patient.4 Our case is, to our knowledge, inclusions in the hyperacanthosis epithelium the first documented report of multiple bilat- 1 Kohn SR. Molluscum contagiosum in patients (haematoxylin and eosin x 10). eral molluscum lesions of with the acquired immunodeficiency syndrome contagiosum the [Letter]. Arch Ophthalmol 1987; 105: 458. limbus in a patient infected with HIV. We did 2 Robinson MR, Udell U, Garber PF, Perry HD, not observe any sign of follicular conjunctivi- Streeten BW. Molluscum contagiosum of the COMMENT tis, although subepithelial infiltrates were eyelids in patients with acquired immune deficiency syndrome. Ophthalmology 1992; 99: Molluscum contagiosum is an infection ofthe noted in the right eye. 1745-7. skin caused by a pox virus. Whereas mollus- As the HIV epidemic extends, epibulbar 3 DenisJ, Chauvaud D, Savoldelli M, Pouliquen Y. cum contagiosum lesions are limited in molluscum contagiosum will tend to become Fine structure of palpebral molluscum conta- number in immunocompetent patients, they more common and should be giosum and its secondary conjunctival lesions. recognised. Graefes Arch Klin Exp Ophthalmol 1978; 208: tend to be prolific, disseminated, persistent, HEROLD MERISIER 207-16. and recurrent in AIDS patients.' As no drug ISABELLE COCHEREAU 4 Charles NC, Friedberg DN. Epibulbar mol- is effective against molluscum contagiosum, THANH HOANG-XUAN luscum contagiosum in acquired immune Department the treatment is limited to local of Ophthalmology, deficiency syndrome. Case report and review cryotherapy Bichat-Claude Bernard Hospital, of the literature. Ophthalmology 1992; 99: and/or curettage. Pans, France 1123-6. http://bjo.bmj.com/ on September 27, 2021 by guest. Protected copyright.