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Dermatologists have the advantage of visualising the skin lesions and making the diagnosis. In immunocompetent patients most of the skin conditions have the characteristic clinical presentation and hence the diagnosis is made clinically by good visual impression. But the human immunodeficiency virus (HIV) has taken away this advantage. Owing to its profound effect on the immune system, the natural course and clinical features of most of the dermatological diseases have been altered. In this report we describe the unusual presentation of molluscum contagiosum as penile horn, in an HIV positive patient.
A 34 year old man presented with asymptomatic rapidly enlarging papular lesions on the penis and scrotum present for the past 6 months. He also had a significant weight loss and loss of appetite for the past month. On examination he was emaciated and had yellowish greasy scaling on the scalp, eyebrows, nasolabial folds, and chest. Examination of the lymphoreticular system did not reveal any abnormality. Genital examination revealed three well defined flesh coloured papules, two on the mucosal aspect on prepucial skin (one each at the 10 o’clock and 2 o’clock position) and the other one on scrotal skin near the root of the penis (fig 1). The size varied from 3 mm to 7 mm. All the lesions were non-tender and had keratotic projection in the centre, the height of which was more than its diameter. The scrotal lesion was fleshy and had a verrucous surface, and on pressing the lesion cheesy material could be expressed. Routine haemogram, liver, and renal function tests were within normal limits. Stool examination showed occasional Cryptosporidium. ELISA for HIV was positive. The CD4 count was just 38×106/l and lipid profile was within normal limits. Histopathological examination showed an acanthotic epidermis with craters filled with eosinophilic hyaline intracytoplasmic inclusion bodies, which are the hallmarks of molluscum contagiosum. After doing other baseline investigations the patient was started on HAART (stavudine + lamivudine + nevirapine) and was also started on prophylactic drugs for Pneumocystis carinii pneumonia and Mycobacterium avium complex infection in the recommended dosages. The molluscum lesions were treated with electrocautery.
Cutaneous horn (cornu cutaneum) is a clinical entity used for protruding dense, white or yellowish, short or curved hyperkeratotic structure resembling the horn of an animal. This term was proposed for lesions in which the height of the keratotic mass amounts to at least half of its diameter.1 It is an uncommon lesion which usually occurs over the exposed parts of the skin.2 It can develop over a wide array of benign, precancerous and malignant lesions.3 The occurrence of horn over the penis was first reported in 1827.2 Cutaneous horn of the penis is a rare condition with less than 100 cases reported in the world.3 The various predisposing factors for the development of penile horn are chronic prepucial inflammation, phimotic foreskin, trauma, poor hygiene, relapsing balanoposthitis, viral infection, and tumour, especially squamous cell carcinoma.3 Recently, verrucous carcinoma presenting as penile horn has been reported.2
Among the viral infections, human papillomavirus is commonly implicated. Molluscum contagiosum presenting as penile horn even in HIV infection is extremely rare. So far only one case has been reported in the literature.4 To the best of our knowledge our patient is the second report in the literature.
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