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Australasian Journal of Dermatology (2015) 56, e35–e38
doi: 10.1111/ajd.12127
BRIEF REPORTS
Neonatal Molluscum contagiosum: five new cases and a literature review Laura Berbegal-DeGracia,1 Isabel Betlloch-Mas,1 Francisco-José DeLeon-Marrero,1 Mª Teresa Martinez-Miravete2 and Julia Miralles-Botella3 1
Dermatology and 2Paediatric Services, General Hospital University of Alicante, and 3Dermatology Service, Clinical Hospital University of San Juan. Alicante, Spain
Congenital or neonatal Molluscum contagiosum (MC) is an unusual infection, barely reported in the literature. In these patients a mechanism of transmission that is neither via contact or sexual transmission should be considered. We describe five cases of neonatal MC and review the cases already published to discuss the possible aetiopathogenic mechanism.
infection may be produced through sexual contact. The appearance of MC congenitally or during the neonatal period is exceptional and only a few cases have been previously reported.4–9 In these cases, a different mechanism of transmission should be considered, such as vertical transmission. We here present a series of cases of MC that appeared during the neonatal period. In addition, we review the literature for previous cases and discuss a possible aetiopathogenic mechanism.
Key words: congenital, Molluscum contagiosum, neonatal, scalp, suction cup, vertical.
PATIENTS AND METHODS
ABSTRACT
INTRODUCTION Infection with Molluscum contagiosum (MC) is caused by a double-stranded DNA virus of the pox virus family1 that affects the skin and, less commonly, the mucous membranes. This infection is very common in young children. It typically presents as a variable number of skin-coloured umbilicated papules 2–8 mm in diameter.2 The papules are usually situated on the trunk and limbs in children and on the genitals in adults. Histologically, they show epidermal hyperplasia with a central crater and eosinophilic inclusion bodies within the keratinocytes.3 The transmission mechanism of MC is thought to be through the direct personto-person contact of infected skin, via fomites or by self-inoculation. During adolescence and in adulthood, especially when the lesions are in the genital area, the
Correpondence: Miss Laura Berbegal-DeGracia, Servicio de Dermatología, Hospital General Universitario de Alicante, Avenida Pintor Baeza 12, 03010 Alicante, Spain. Email: lauraberbegal @gmail.com Laura Berbegal-DeGracia, MD. Isabel Betlloch-Mas, MD. Francisco-José DeLeon-Marrero, MD. Mª Teresa MartinezMiravete, MD. Julia Miralles-Botella, MD. Conflict of interest: none Submitted 30 September 2013; accepted 11 November 2013. © 2013 The Australasian College of Dermatologists
First, we present a clinical description of the cases of neonatal MC seen and confirmed by a pathological study. We then review the cases previously published and analyse the clinical and epidemiological characteristics in conjunction with those of our series.
RESULTS Clinical cases Case 1 A 12-month old boy delivered via a vaginal birth had presented since birth with a 4–5 mm pink nodule that had continued to grow on the left temporal region. Assuming a diagnosis of MC we examined the mother, noting on her genitalia umbilicated papular lesions that had been present during her pregnancy. We performed a curettage of the lesions on both the mother and the child. The pathological study in both cases confirmed the diagnosis of MC. Case 2 A 4-month-old boy delivered via a vacuum-assisted vaginal birth was referred to the service with lesions on the scalp that had been present since his birth (Fig. 1). The mother had no history of cutaneous lesions. MC was suspected and a curettage was performed on one of the baby’s lesions. The histological study was consistent with this disorder. Abbreviation: MC
Molluscum contagiosum
e36
L Berbegal-DeGracia et al.
Case 3 A 14-month-old boy delivered via a vacuumassisted vaginal birth presented with various lesions on his scalp. The lesions, which had been present since his birth, were arranged in a circular pattern in the shape of a suction cap and had been gradually remitting, with just a pink papule persisting. The mother had no history of MC. A curettage of the lesion was performed and the pathological study confirmed MC. Case 4 A 3-month-old boy was born at term via vaginal delivery. Two weeks after birth he presented with a lesion on his scalp that had gradually become enlarged (Fig. 2). The mother had similar lesions on her thighs. A curettage of the lesions was performed on both the boy and the mother, with a pathological diagnosis of MC. Case 5 A 4-month-old boy presented multiple lesions on his scalp that had appeared shortly after birth (Fig. 3a). The
Figure 1 Papulo-vesicular lesions forming a circle on the scalp vertex (Case 2).
mother had no similar lesions. The boy had been delivered via a vacuum-assisted vaginal birth. A curettage of one of the lesions was performed and the histological study confirmed MC (Fig. 3b).
Review of the literature We have found 10 cases reported over 87 years (1926–2013). Information about the first cases, reported as isolated cases in 1926,4 19605 and 1971,6 is limited. Most of the remaining cases are recent, with a series of four cases in 2008,7 one in 20108 and another two recent cases in 2012.9 Table 1 shows the main characteristics of our patients and those that were also reviewed.
CONCLUSION MC during the neonatal period is exceptional;4–9 thus the interest in reporting the five new cases seen over a relatively short time. The appearance of MC in a newborn baby suggests the possible vertical transmission from mother to
Figure 2 Soft, pink, shiny 15-mm papule with central umbilication (Case 4).
Figure 3 (a) Multiple pink microvesicles arranged in a circle on the scalp (Case 5). (b) Histological study of Case 5 showing epidermal hyperplasia with a central crater and eosinophil inclusion bodies within the keratinocytes (Henderson–Paterson bodies) typical of Molluscum contagiosum. © 2013 The Australasian College of Dermatologists
term term term
vacuum
vacuum vacuum
Vaginal Vaginal Vaginal Vaginal Vaginal – – – – – – – Vaginal Vaginal Vaginal Post term Term Term Term Term – – – – – – – – – – 4010 4350 3340 3450 – – – – – – – – – – – –, not recorded; BW, birth weight; CC, cranial circumference at birth; F, female; M, male; m, months; w, weeks.
34.5 38.5 35 34.5 – – – – – – – – – – – – – Primigravida – – – – – Primigravida Primigravida – Primigravida Primigravida – – Genitals No No Thighs No – – – No – No No Thighs and genitals Groin and genitals No Focal Circular Circular Focal Circular Annular Cluster Focal Annular Focal Cluster Annular Generalised Annular Focal Scalp Scalp Scalp Scalp Scalp Scalp Scalp Thigh Scalp Foot Scalp Scalp Scalp Scalp Shoulder M M M M M – F – M M M M F F M Case 1 Case 2 Case 3 Case 4 Case 5 Young4 Merklen et al.5 Mandel and Lewis6 O’Connell et al.7 (1) O’Connell et al.7 (2) O’Connell et al.7 (3) O’Connell et al.7 (4) Luke and Silverberg8 Méndez et al.9 (1) Méndez et al.9 (2)
12 m 4m 14 m 3m 4m 10 w 5m 1w 11 m 10 m Few w 4m 9m 12 m 24 m
Single 4–5 mm Multiple Multiple Single 15 mm Multiple Multiple Multiple Single Multiple Single Multiple Multiple Multiple Multiple Single
BW (g) CC (cm) Pregnancy Maternal lesions Lesion arrangement Sex
Site
Lesion characteristics and size Age at diagnosis Reference
Table 1
Neonatal Molluscum contagiosum. Clinical and epidemiological characteristics of our five patients and those reported elsewhere
Gestational age
Delivery
Neonatal Molluscum contagiosum
e37
child during delivery via lesions in the genital area of the mother. However, we were able to determine this in only two of our five patients and in two of the 10 cases reviewed. The location of the lesions was on the scalp in most cases and the fact that delivery was vaginal (and not Caesarean) in all cases where it was documented also suggests this route of contagion. Notably, in three of our five patients delivery was vacuum assisted and the lesions were distributed annularly at the site where the device exerts pressure. Although this suggests that the suction cup may act as the tool to transmit the infection, this is unlikely due both to the absence of epidemiologically related cases and the fact that these devices are usually well sterilised. However, to exclude fomite transmission we need evidence of the mode of sterilisation of the vacuum ring and we also need details of whether parents shared a bath, as a mode of contact. It is more probable that the suction cap may alter the cutaneous barrier and favour infection through misdiagnosed lesions on the skin or genital mucous membrane of the mother. Furthermore, in the other reported cases that document a non-instrument aided vaginal delivery and in those where no maternal lesions were mentioned there may have been a misdiagnosed infection and the pressure exerted on the head during delivery could have triggered the transmission, as we hypothesised for vacuum-assisted delivery. This theory has been suggested as the cause of other neonatal lesions, like halo scalp ring,10 in which the pressure is able to produce local injury and initiate a characteristic circular alopecia. Other factors that may play a role in the greater pressure experienced in the birth canal include a prolonged delivery in a primigravida, the baby’s birth weight or its cranial perimeter. Though it is unusual, neonatal MC should be considered as a diagnostic possibility in the presence of solitary or multiple papules on the scalp, particularly if they have a circular pattern after a vacuum-assisted delivery, and it should not be confused with iatrogenic lesions. The most important point arising from this new case series is the open hypothesis that neonatal MC may be transmitted by a misdiagnosed infection favoured by factors that alter the skin barrier, such as the vacuum, in addition to the possibility of vertical transmission already mentioned in the literature.
REFERENCES 1.
2.
3.
4.
Bolognia JL, Jorizzo JL, Schaffer JV. Other viral diseases. In: Bolognia JL, Jorizzo JL, Schaffer JV (eds). Dermatology, 3th edn. Madrid: Elsevier, 2012; 1354–57. Paller AS, Mancini AJ. Viral diseases of the skin. In: Paller S, Mancini AJ (eds). Hurwitz Clinical Pediatric Dermatology, 4th edn. Madrid: Elsevier, 2011; 362–65. Requena L, Requena C. Histopatología de las infecciones víricas cutáneas más frecuentes. Actas Dermosifiliogr 2010; 101: 201–16. Young W. Molluscum contagiosum with unusual distribution. Kentucky Med. J. 1926; 24: 467. © 2013 The Australasian College of Dermatologists
e38 5.
6. 7.
L Berbegal-DeGracia et al. Merklen P, Ducourtioux M, D’Anglejan G. Molluscum contagiosum cliniquement atypique du cuir chevelu apparu a trios mois chez un nourrisson. Bull. Soc. Fr. Dermatol. Syphiligr. 1960; 67: 449–50. Mandel M, Lewis R. Molluscum contagiosum of the newborn. Br. J. Dermatol. 1971; 84: 370–72. O’Connell C, Oranje A, Van Gysel D et al. Congenital Molluscum contagiosum: report of four cases and review of the literature. Pediatr. Dermatol. 2008; 125: 553–56.
© 2013 The Australasian College of Dermatologists
8. 9. 10.
Luke D, Silverberg NB. Transmitted Molluscum contagiosum infection. Pediatrics 2010; 125: e423–25. Méndez C, Vicente A, Suñol M et al. Molluscum contagiosum congénito. Actas Dermosifiliogr 2012; 104: 836–7. Patrizi A, Savoia F, Neri I et al. An incomplete circle of alopecia: a new case of halo scalp ring? Pediatr. Dermatol. 2009; 26: 706–08.
This document is a scanned copy of a printed document. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material.
Australasian Journal of Dermatology (2015) 56, e35–e38
doi: 10.1111/ajd.12127
BRIEF REPORTS
Neonatal Molluscum contagiosum: five new cases and a literature review Laura Berbegal-DeGracia,1 Isabel Betlloch-Mas,1 Francisco-José DeLeon-Marrero,1 Mª Teresa Martinez-Miravete2 and Julia Miralles-Botella3 1
Dermatology and 2Paediatric Services, General Hospital University of Alicante, and 3Dermatology Service, Clinical Hospital University of San Juan. Alicante, Spain
Congenital or neonatal Molluscum contagiosum (MC) is an unusual infection, barely reported in the literature. In these patients a mechanism of transmission that is neither via contact or sexual transmission should be considered. We describe five cases of neonatal MC and review the cases already published to discuss the possible aetiopathogenic mechanism.
infection may be produced through sexual contact. The appearance of MC congenitally or during the neonatal period is exceptional and only a few cases have been previously reported.4–9 In these cases, a different mechanism of transmission should be considered, such as vertical transmission. We here present a series of cases of MC that appeared during the neonatal period. In addition, we review the literature for previous cases and discuss a possible aetiopathogenic mechanism.
Key words: congenital, Molluscum contagiosum, neonatal, scalp, suction cup, vertical.
PATIENTS AND METHODS
ABSTRACT
INTRODUCTION Infection with Molluscum contagiosum (MC) is caused by a double-stranded DNA virus of the pox virus family1 that affects the skin and, less commonly, the mucous membranes. This infection is very common in young children. It typically presents as a variable number of skin-coloured umbilicated papules 2–8 mm in diameter.2 The papules are usually situated on the trunk and limbs in children and on the genitals in adults. Histologically, they show epidermal hyperplasia with a central crater and eosinophilic inclusion bodies within the keratinocytes.3 The transmission mechanism of MC is thought to be through the direct personto-person contact of infected skin, via fomites or by self-inoculation. During adolescence and in adulthood, especially when the lesions are in the genital area, the
Correpondence: Miss Laura Berbegal-DeGracia, Servicio de Dermatología, Hospital General Universitario de Alicante, Avenida Pintor Baeza 12, 03010 Alicante, Spain. Email: lauraberbegal @gmail.com Laura Berbegal-DeGracia, MD. Isabel Betlloch-Mas, MD. Francisco-José DeLeon-Marrero, MD. Mª Teresa MartinezMiravete, MD. Julia Miralles-Botella, MD. Conflict of interest: none Submitted 30 September 2013; accepted 11 November 2013. © 2013 The Australasian College of Dermatologists
First, we present a clinical description of the cases of neonatal MC seen and confirmed by a pathological study. We then review the cases previously published and analyse the clinical and epidemiological characteristics in conjunction with those of our series.
RESULTS Clinical cases Case 1 A 12-month old boy delivered via a vaginal birth had presented since birth with a 4–5 mm pink nodule that had continued to grow on the left temporal region. Assuming a diagnosis of MC we examined the mother, noting on her genitalia umbilicated papular lesions that had been present during her pregnancy. We performed a curettage of the lesions on both the mother and the child. The pathological study in both cases confirmed the diagnosis of MC. Case 2 A 4-month-old boy delivered via a vacuum-assisted vaginal birth was referred to the service with lesions on the scalp that had been present since his birth (Fig. 1). The mother had no history of cutaneous lesions. MC was suspected and a curettage was performed on one of the baby’s lesions. The histological study was consistent with this disorder. Abbreviation: MC
Molluscum contagiosum
e36
L Berbegal-DeGracia et al.
Case 3 A 14-month-old boy delivered via a vacuumassisted vaginal birth presented with various lesions on his scalp. The lesions, which had been present since his birth, were arranged in a circular pattern in the shape of a suction cap and had been gradually remitting, with just a pink papule persisting. The mother had no history of MC. A curettage of the lesion was performed and the pathological study confirmed MC. Case 4 A 3-month-old boy was born at term via vaginal delivery. Two weeks after birth he presented with a lesion on his scalp that had gradually become enlarged (Fig. 2). The mother had similar lesions on her thighs. A curettage of the lesions was performed on both the boy and the mother, with a pathological diagnosis of MC. Case 5 A 4-month-old boy presented multiple lesions on his scalp that had appeared shortly after birth (Fig. 3a). The
Figure 1 Papulo-vesicular lesions forming a circle on the scalp vertex (Case 2).
mother had no similar lesions. The boy had been delivered via a vacuum-assisted vaginal birth. A curettage of one of the lesions was performed and the histological study confirmed MC (Fig. 3b).
Review of the literature We have found 10 cases reported over 87 years (1926–2013). Information about the first cases, reported as isolated cases in 1926,4 19605 and 1971,6 is limited. Most of the remaining cases are recent, with a series of four cases in 2008,7 one in 20108 and another two recent cases in 2012.9 Table 1 shows the main characteristics of our patients and those that were also reviewed.
CONCLUSION MC during the neonatal period is exceptional;4–9 thus the interest in reporting the five new cases seen over a relatively short time. The appearance of MC in a newborn baby suggests the possible vertical transmission from mother to
Figure 2 Soft, pink, shiny 15-mm papule with central umbilication (Case 4).
Figure 3 (a) Multiple pink microvesicles arranged in a circle on the scalp (Case 5). (b) Histological study of Case 5 showing epidermal hyperplasia with a central crater and eosinophil inclusion bodies within the keratinocytes (Henderson–Paterson bodies) typical of Molluscum contagiosum. © 2013 The Australasian College of Dermatologists
term term term
vacuum
vacuum vacuum
Vaginal Vaginal Vaginal Vaginal Vaginal – – – – – – – Vaginal Vaginal Vaginal Post term Term Term Term Term – – – – – – – – – – 4010 4350 3340 3450 – – – – – – – – – – – –, not recorded; BW, birth weight; CC, cranial circumference at birth; F, female; M, male; m, months; w, weeks.
34.5 38.5 35 34.5 – – – – – – – – – – – – – Primigravida – – – – – Primigravida Primigravida – Primigravida Primigravida – – Genitals No No Thighs No – – – No – No No Thighs and genitals Groin and genitals No Focal Circular Circular Focal Circular Annular Cluster Focal Annular Focal Cluster Annular Generalised Annular Focal Scalp Scalp Scalp Scalp Scalp Scalp Scalp Thigh Scalp Foot Scalp Scalp Scalp Scalp Shoulder M M M M M – F – M M M M F F M Case 1 Case 2 Case 3 Case 4 Case 5 Young4 Merklen et al.5 Mandel and Lewis6 O’Connell et al.7 (1) O’Connell et al.7 (2) O’Connell et al.7 (3) O’Connell et al.7 (4) Luke and Silverberg8 Méndez et al.9 (1) Méndez et al.9 (2)
12 m 4m 14 m 3m 4m 10 w 5m 1w 11 m 10 m Few w 4m 9m 12 m 24 m
Single 4–5 mm Multiple Multiple Single 15 mm Multiple Multiple Multiple Single Multiple Single Multiple Multiple Multiple Multiple Single
BW (g) CC (cm) Pregnancy Maternal lesions Lesion arrangement Sex
Site
Lesion characteristics and size Age at diagnosis Reference
Table 1
Neonatal Molluscum contagiosum. Clinical and epidemiological characteristics of our five patients and those reported elsewhere
Gestational age
Delivery
Neonatal Molluscum contagiosum
e37
child during delivery via lesions in the genital area of the mother. However, we were able to determine this in only two of our five patients and in two of the 10 cases reviewed. The location of the lesions was on the scalp in most cases and the fact that delivery was vaginal (and not Caesarean) in all cases where it was documented also suggests this route of contagion. Notably, in three of our five patients delivery was vacuum assisted and the lesions were distributed annularly at the site where the device exerts pressure. Although this suggests that the suction cup may act as the tool to transmit the infection, this is unlikely due both to the absence of epidemiologically related cases and the fact that these devices are usually well sterilised. However, to exclude fomite transmission we need evidence of the mode of sterilisation of the vacuum ring and we also need details of whether parents shared a bath, as a mode of contact. It is more probable that the suction cap may alter the cutaneous barrier and favour infection through misdiagnosed lesions on the skin or genital mucous membrane of the mother. Furthermore, in the other reported cases that document a non-instrument aided vaginal delivery and in those where no maternal lesions were mentioned there may have been a misdiagnosed infection and the pressure exerted on the head during delivery could have triggered the transmission, as we hypothesised for vacuum-assisted delivery. This theory has been suggested as the cause of other neonatal lesions, like halo scalp ring,10 in which the pressure is able to produce local injury and initiate a characteristic circular alopecia. Other factors that may play a role in the greater pressure experienced in the birth canal include a prolonged delivery in a primigravida, the baby’s birth weight or its cranial perimeter. Though it is unusual, neonatal MC should be considered as a diagnostic possibility in the presence of solitary or multiple papules on the scalp, particularly if they have a circular pattern after a vacuum-assisted delivery, and it should not be confused with iatrogenic lesions. The most important point arising from this new case series is the open hypothesis that neonatal MC may be transmitted by a misdiagnosed infection favoured by factors that alter the skin barrier, such as the vacuum, in addition to the possibility of vertical transmission already mentioned in the literature.
REFERENCES 1.
2.
3.
4.
Bolognia JL, Jorizzo JL, Schaffer JV. Other viral diseases. In: Bolognia JL, Jorizzo JL, Schaffer JV (eds). Dermatology, 3th edn. Madrid: Elsevier, 2012; 1354–57. Paller AS, Mancini AJ. Viral diseases of the skin. In: Paller S, Mancini AJ (eds). Hurwitz Clinical Pediatric Dermatology, 4th edn. Madrid: Elsevier, 2011; 362–65. Requena L, Requena C. Histopatología de las infecciones víricas cutáneas más frecuentes. Actas Dermosifiliogr 2010; 101: 201–16. Young W. Molluscum contagiosum with unusual distribution. Kentucky Med. J. 1926; 24: 467. © 2013 The Australasian College of Dermatologists
e38 5.
6. 7.
L Berbegal-DeGracia et al. Merklen P, Ducourtioux M, D’Anglejan G. Molluscum contagiosum cliniquement atypique du cuir chevelu apparu a trios mois chez un nourrisson. Bull. Soc. Fr. Dermatol. Syphiligr. 1960; 67: 449–50. Mandel M, Lewis R. Molluscum contagiosum of the newborn. Br. J. Dermatol. 1971; 84: 370–72. O’Connell C, Oranje A, Van Gysel D et al. Congenital Molluscum contagiosum: report of four cases and review of the literature. Pediatr. Dermatol. 2008; 125: 553–56.
© 2013 The Australasian College of Dermatologists
8. 9. 10.
Luke D, Silverberg NB. Transmitted Molluscum contagiosum infection. Pediatrics 2010; 125: e423–25. Méndez C, Vicente A, Suñol M et al. Molluscum contagiosum congénito. Actas Dermosifiliogr 2012; 104: 836–7. Patrizi A, Savoia F, Neri I et al. An incomplete circle of alopecia: a new case of halo scalp ring? Pediatr. Dermatol. 2009; 26: 706–08.
This document is a scanned copy of a printed document. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material.
