THE MOLLUSCUM CONUNDRUM: PEDIATRIC UNILATERAL CHRONIC CONJUNCTIVITIS

We present a case of unilateral chronic conjunctivitis in a child, refractory to antibiotic and steroid treatment. A complete response to surgical excision pinpointed an eyelid papule as the culprit. We aim to raise awareness for molluscum contagiosum as a potential cause of viral conjunctivitis in children.

Case report of a patient followed at the ophthalmology department of Hospital de Egas Moniz (Lisbon, Portugal). 

The anterior segment was imaged with Haag-Streit BQ 900® LED + IM 900® slit-lamp. Following surgery, histopathologic confirmation of the diagnosis was established.

A 9-year-old girl presented to our clinic complaining of left eye (OS) redness and itching in the last week. Her best corrected visual acuity was 20/20 and intraocular pressure (IOP) measured 14mmHg, in both eyes. On anterior segment examination, there was a solitary dome-shaped multilobulated papule at the superior eyelid margin of the OS, measuring 2x2mm. Mild conjunctival hyperemia and papillary reaction were noted bilaterally, leading to the assumption of allergic conjunctivitis. Treatment was initiated with dexamethasone/neomycin and ketotifen drops. The patient returned to the clinic a month later after symptom recurrence following treatment discontinuation. Slit-lamp examination showed a crusted eyelid margin with follicular swelling. The ocular surface was optimized with lid hygiene and artificial tears, and a prednisolone/chloramphenicol ointment was prescribed. The patient showed improvement under steroid treatment, but after stopping the medication, blepharoconjunctivitis returned. IOP had increased to 22mmHg in the left eye. A dexamethasone taper and timolol drops were added to the treatment regimen. At this time, disease persistence two months after presentation led to the expansion of our differential diagnosis and surgical removal (excisional biopsy) of the eyelid papule. Histopathologic diagnosis was positive for molluscum contagiosum. At the post-operative visit 15 days later both symptoms and signs had subsided. 

Eyelid papules from molluscum contagiosum may shed viral particles into the tear film, resulting in ocular surface involvement. Molluscum contagiosum can be easily overlooked in the differential of pediatric conjunctivitis, particularly in the presence of solitary or atypical lesions, as in our case. The delay in diagnosis resulted in steroid-dependent ocular hypertension, fortunately, reversible with treatment discontinuation and hypotensive drops. Treatment modalities include excision, cauterization and/or cryotherapy, requiring sedation in children, an additional setback. Suspicion should increase when the conjunctivitis assumes a chronic course, refractory to routine treatment, especially if unilateral and located on the same side as the periocular lesion.