Molluscum contagiosum has been classified as an AIDS-defining illness; it usually causes a self-limiting skin lesion, but can become widely disseminated. It has a predilection for the head and neck area of individuals with AIDS.¹ Lesions range in size from 0.2 cm to 0.6 cm, although giant forms have been reported. They classically have an umbilication. On the other hand, Kaposi sarcoma has a more generalised distribution, affecting more organs and systems. The lesions of Kaposi sarcoma are usually purple in colour, flattened or raised and they are more difficult to manage and contribute more to mortality.^1,2

Coexistence of Kaposi sarcoma and Molluscum contagiosum in the same patient is rare and more difficult to diagnose and manage. We present a case report of a patient living with HIV, with multiple skin lesions, for which both diseases were diagnosed.

Ethical approval to conduct the study was sought and obtained from the Health, Research and Ethics Committee (HREC) of Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria, with approval number UDUTH/HREC/2018/No. 658. Consent and permission were obtained from the patient to use his picture and details for the study.

A 37-year-old man who had been HIV-positive for 2 years later became poorly adherent to first-line antiretrovirals (defaulted for more than 6 months). He re-presented at our facility again with low CD4 count (98 cells per µL) and high viral load (> 10 000.00 copies/mL) and had developed progressive, generalized, asymmetrical, non-scaly, maculo-papular, hyperpigmented focally nodular cutaneous lesions involving the head, neck, trunk (anteriorly and posteriorly), and the proximal upper and lower limbs, especially on the medial surfaces with the largest nodule reaching 2.5 cm in diameter, over a period of 3 months (Figure 1 and Figure 2). He was on a first-line highly active antiretroviral therapy regimen (zidovudine/lamivudine/nevirapine) before defaulting. We conducted a skin biopsy for histopathology.

The patient was counselled and re-initiated on a second-line highly active antiretroviral therapy regimen (tenofovir/lamivudine/lopinavir). He was re-evaluated three months after re-initiation. He has since been compliant (current CD4 count of 450 cells per µL and an undetectable viral load of < 20 copies/mL). The patient’s lesions resolved, even though no dermatological procedures or creams were used.

Kaposi sarcoma and Molluscum contagiosum both have viral infectious aetiologies, and commonly occur when the CD4 cell count is less than 150 cells per µL.² The former is caused by a herpes virus, and the latter by a pox virus.² Our patient most likely had the infection either as reactivation or new infection during his period of non-adherence when his CD4 count and viral load deteriorated. We initially had a clinical suspicion of lepromatous leprosy due to the widespread nature of the lesions but the absence of nerve involvement and loss of sensation ruled it out.

The hallmark of AIDS is increased susceptibility to opportunistic infections.³ Kaposi sarcoma and Molluscum contagiosum are categorized as AIDS-defining illnesses. Even though their coexistence⁴ in HIV/AIDS patients has been widely described, the occurrence of the two diseases side by side within the same lesion is a rare occurrence.⁵

This case highlights why it is necessary to have a high index of suspicion when dealing with immunocompromised patients from clinical examination to sampling, during biopsy and ultimately in interpretation for the coexistence of skin diseases.