Updated: 10/9/2017

Molluscum contagiosum

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Snapshot
  • A 3-year-old girl presents to her pediatrician’s office with several pink spots on her body. Her parents report that she seems mostly unbothered by these lesions but occasionally scratches at them. Several of her friends have similar lesions. On physical exam, there are several 2-3 mm flesh-colored papules with central umbilication. Her pediatrician counsels them that this viral infection is benign and self-resolves. However, if the lesions seem to bother the patient, then there are treatment options such as cryotherapy or topical cantharidin.
Introduction
  • Clinical definition
    • painless and umbilicated cutaneous lesions caused by the molluscum contagiosum virus
  • Epidemiology
    • incidence
      • up to 30% in patients with HIV
    • demographics
      • school-aged children
        • most common
        • the children are typically immunocompetent
      • adolescents and young adults
        • transmitted via sexual contact and can present as genital lesions
      • immunocompromised individuals
        • transmitted via physical or sexual contact
    • risk factors
      • atopic dermatitis
      • immunocompromised states
  • Etiology
    • molluscum contagiosum virus
      • an enveloped DNA poxvirus
  • Pathogenesis
    • the molluscum contagiousum virus is transmitted via
      • autoinoculation
      • physical and sexual contact from an infected person
    • after the virus invades epidermal cells, it proliferates and creates lobulated epidermal growths
  • Associated conditions
    • if patient has genital molluscum
      • other sexually transmitted infections may be found
    • in adults
      • may be an indicator of HIV
  • Prognosis
    • lesions resolve spontaneously within 9 months
    • no scarring
Presentation
  • Symptoms
    • primary symptoms
      • usually asymptomatic
      • may have pruritus and/or tenderness
  • Physical exam
    • immunocompetent patients
      • single or grouped lesions
      • .1-1 cm papules with central umbilication
        • pearly
        • flesh-colored
      • location
        • trunk
        • extremities
        • head
        • neck
        • genitals
    • immunocompromised patients
      • > 30 lesions
      • > 1 cm lesions
      • lesions on the eyelid
Studies
  • Dermatoscope exam
    • central umbilication
  • Biopsy
    • indication
      • confirms the diagnosis when it is clinically uncertain
  • Histology
    • molluscum bodies
      • Henderson-Patterson bodies
      • large cells with granular eosinophilic cytoplasm that contain accumulated virons
  • Making the diagnosis
    • a clinical diagnosis
Differential
  • Chicken pox
  • Verruca vulgaris
  • Milia
Treatment
  • Management approach
    • treatment is usually not necessary as lesions resolve within 6-9 months
    • multiple first-line therapies are available and chosen based on shared-decision making by the physician and the patient or the patient's family
  • Medical
    • cryotherapy
      • indications
        • well tolerated in adolescents and adults
        • can be too painful for young children, especially with multiple lesions
    • topical podophyllotoxin 0.5% cream    
      • indication
        • ideal for genital lesions
    • cantharidin
      • indication
        • treatment is applied topically in the office and blistering occurs hours later
        • ideal for children with multiple lesions
  • Operative
    • curretage
      • indication
        • well tolerated in adolescents and adults
        • can be too painful for young children, especially with multiple lesions
        • ideal for those who wish for more immediate resolution
Complications
  • Secondary bacterial infection
 

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Questions (1)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M1.MC.4723) A 7-year-old boy with no past medical history presents to his pediatrician after his mother notices several small bumps on his trunk. The boy does not remember when they appeared but he says that they are not painful or itchy. Vital signs are normal and physical exam shows 5 mm flesh-colored papules scattered across his abdomen. The papules are shown in Figure A. The remainder of the physical exam is unremarkable. The virus most likely responsible for this rash has what kind of genetic material? Review Topic

QID: 108550
FIGURES:
1

Single-stranded, linear RNA

11%

(11/103)

2

Double-stranded, linear RNA

5%

(5/103)

3

Single-stranded, linear DNA

14%

(14/103)

4

Double-stranded, linear DNA

55%

(57/103)

5

Double-stranded, circular DNA

15%

(15/103)

M1

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