<![CDATA[Background: Molluscum contagiosum is ordinarily self-limiting, but in profound immunosuppression it becomes extensive, giant and atypical. Published reports almost uniformly describe such lesions as revealing previously undiagnosed HIV; lesions arising in a patient already established on antiretroviral therapy are far less often described and carry a more urgent meaning. Objective: To describe a fatal case of giant molluscum contagiosum arising on antiretroviral therapy, to show that the eruption marked unrecognized immunological failure, and to specify the measurements the dermatological consultation should have triggered. Case Presentation: A 39-year-old man presented with one year of enlarging papules and nodules on the eyelids, face, neck, hand and penis, the largest 3.5 × 2.5 × 1.5 cm, and 18 months of pruritic hyperpigmented limb papules, after 24 months of fixed-dose efavirenz, lamivudine and tenofovir disoproxil. Dermoscopy, Giemsa cytology and histopathology confirmed molluscum contagiosum; the limb eruption was pruritic papular eruption. CD4 was 31 cells/µL and CD8 1624 cells/µL, a CD4/CD8 ratio of 0.02; syphilis serology was non-reactive. Serial excision and enucleation, with weekly 90% trichloroacetic acid to the penile lesions, cleared the facial disease by month 3; he died at month 7. No viral load, resistance genotype, cryptococcal antigen or tuberculosis screen was performed. Conclusion: Giant molluscum contagiosum arising after two years of antiretroviral therapy marks therapy that is not working, not merely advanced HIV disease. An audit identified five indicated measurements never obtained. Dermatologists recognizing this eruption should treat the skin and, at the same visit, trigger a viral load and the advanced HIV disease package of care.]]>
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