I have spoken many times on MS-Selfie about the risks associated with chronic immunosuppression. I was, therefore, not surprised to hear about a patient of a colleague of mine who developed molluscum contagiosum on fingolimod. I suggested they stop fingolimod and transition the patient onto teriflunomide, and if the patient was unable to tolerate teriflunomide, start interferon-beta. The logic behind these switch agents is that they are not immunosuppressive and have potential antiviral activity. I was then reminded of this issue when I noted a case report of a child with MS developing disseminated molluscum contagiosum on fingolimod (see Murali et al. Int J Dermatol. 2024 Mar 8. doi: 10.1111/ijd.17128.).
What is molluscum contagiosum?
Molluscum contagiosum is a common viral skin infection caused by the molluscum contagiosum virus (MCV). This condition primarily affects children, sexually active adults, and individuals with weakened immune systems. Molluscum contagiosum is characterised by the development of small, raised, and usually painless bumps on the skin. These bumps are often flesh-coloured, dome-shaped, and typically have a small indentation in the centre.
The virus spreads through direct skin-to-skin contact or sharing personal items, such as towels or clothing, with an infected person. Molluscum contagiosum is typically benign and self-limited and usually resolves independently without treatment. However, in some cases, medical intervention may be necessary to manage the symptoms and prevent the spread of the virus.
The diagnosis of molluscum contagiosum is usually based on the appearance of the characteristic lesions. Sometimes, a skin biopsy or PCR on an aspirate of the lesion is done to make the diagnosis. Treatment options for molluscum contagiosum may include cryotherapy (freezing the bumps), cantharidin topical ointment or minor surgical procedures to remove the lesions.
Avoid scratching or picking at the bumps, as this can spread the virus to other parts of the body and increase the risk of secondary bacterial infections. Practising good hygiene and avoiding direct skin contact with affected individuals can help prevent the transmission of molluscum contagiosum.
This case reminded me of a patient I had in the alemtuzumab CARE-MS 1 trial who caught molluscum contagious from her daughter. The infection spread all over her body, and when her immune system was reconstituted, she mounted an immune response to the virus, with all the lesions becoming inflamed and forming pustules. At the height of the antiviral response, she looked like she had smallpox.
Not only is MCV a problem with immunosuppression, but also HPV, which causes warts, cervical and other cancers, hepatitis B and C, HIV, TB, and the herpes viruses. This is why it is important to be carefully screened for these viruses and bacteria before starting immunosuppression. If you have an active viral or bacterial infection, you must clear the infection or start antiviral or antibacterial therapy before immunosuppression.
After starting an immunosuppressive DMT, I would like to know if you have developed any viral or bacterial infections.
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Please note that the opinions expressed here are those of Professor Giovannoni and do not necessarily reflect the positions of Queen Mary University of London or Barts Health NHS Trust. The advice is intended as general and should not be interpreted as personal clinical advice. If you have problems, please tell your healthcare professional, who will be able to help you.
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