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In spite of lower viral loads and increasing T cell counts, AIDS patients receiving highly active antiretroviral therapy (HAART) are not always successful in mounting an immune response to some opportunistic pathogens. In fact, CMV retinitis, which was known to occur in HIV patients with CD4 counts below 50×106/l, has been described in immune reconstituted patients with CD4 counts above 200×106/l.1 It is therefore important to make observations about the clinical spectrum of infectious disease in immune reconstituted AIDS patients. Here we report an isolated lesion of molluscum contagiosum in an immune reconstituted AIDS patient.
A 46 year old Hispanic female presented with a history of burning, tearing, and itching of her left eye for 1 month. Three years earlier she had been diagnosed with AIDS during a hospital admission for Pneumocystis carinii pneumonia (PCP). At that time her CD4 count had been 27×106/l and her viral load 905 000. After 3 months of HAART with combivir, norvir, and fortovase her viral load dropped to 15 000 and her CD4 count rose to 184×106/l. Her viral load became undetectable 6 months after initiation of therapy and has remained so for 2½ years. Her recent CD4 count was 435×106/l.
Best corrected visual acuity was 20/25 in each eye. A 2 mm smooth, dome-shaped, translucent papule with central umbilication was present inferior to the medial aspect of the left lower lid margin (Fig 1). The lesion was excised and histopathology revealed invasive acanthosis with lobules of epithelial hyperplasia invaginating into the dermis. Intranuclear and intracytoplasmic inclusion bodies typical of molluscum contagiosum were noted (Fig 2). The lesion did not recur after biopsy.
Immunocompetent patients with molluscum contagiosum involving the eyelid typically suffer from an isolated lesion that is self limited. Larger, more numerous and widespread molluscum contagiosum lesions have been documented in patients with AIDS, individuals immunosuppressed from using prednisone and methotrexate, or patients with lymphoreticular malignant neoplasms or sarcoidosis.2–5 In HIV infected individuals the disease runs a more protracted course with persistent lesions and there appears to be an inverse relation of the CD4 count and the number of molluscum contagiosum lesions.6
The present case shows that the patient’s reconstituted immune system from HAART can limit molluscum contagiosum infection to a single lesion at the eyelid, clinically and histologically identical to molluscum contagiosum lesions found in immunocompetent hosts. Such limited expression of molluscum contagiosum could be from a competent T cell response as noted in individuals with normal immune function or those with reconstituted immune response from HAART.5,7 Thus, clinically the presence of a solitary molluscum contagiosum lesion in an HIV infected individual suggests appropriate response to HAART.