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Mucous Membrane Ulcers in an Immunocompromised Patient—Diagnosis

Mucous Membrane Ulcers in an Immunocompromised Patient—Diagnosis Diagnosis: Cutaneous cytomegalovirus infection (CMV). Microscopic findings The biopsy specimen showed an acute inflammatory infiltrate (Figure 3). Thorough examination of the endothelial cells demonstrated cytopathic changes and sparse cytoplasmic inclusions, suggesting infection by CMV, which was definitively confirmed by the results of immunoperoxidase staining (Figure 3). Figure 3. View LargeDownload Discussion Cytomegalovirus is an opportunistic virus that develops in the immunocompromised host. Viral dissemination leads to multiple organ system involvement, with the most important clinical manifestations consisting of pneumonitis, gastrointestinal disease, and retinitis. Cutaneous manifestations are variable and rare, and diagnosis is often delayed. The various clinical presentations that have been reported include ulcers, vesicles, purpuric macules, verrucous lesions, prurigo nodularis–like lesions, erythematous and crusted papules, and digital infarcts.1 However, most of the cases have involved ulcers that were localized mainly on the genital area. Although CMV usually represents a late manifestation of systemic infection, heralding a fatal course in HIV-positive patients, this is not always the case in other immunocompromised patients. In a case series involving cutaneous CMV infection in HIV-negative patients, all of the patients responded completely to ganciclovir therapy.2 In the present case, valganciclovir therapy (two 450-mg tablets twice a day for 1 month) resulted in progressive improvement of the mucosal lesions. One year later, our patient was still asymptomatic, without evidence of recurrence. Histopathologic analysis with specific CMV immunochemical techniques can make the accurate diagnosis. Polymerase chain reaction assay of the lesions is also useful. Combination therapy with antithymocyte globulin and cyclosporine can be used to treat low-risk nonsideroblastic myelodysplastic syndromes. Antithymocyte globulin is a polyclonal antibody against T lymphocytes that provokes a deep and prolonged immunosuppression due to a depletion of T lymphocytes. Among the profile of its secondary effects, a higher risk of CMV infections has been reported.3 The differential diagnosis also includes other opportunistic infections (eg, herpes,4 tuberculosis, mycobacteria, and deep mycoses), ulcers related to neutropenia, adverse drug reactions, inflammatory diseases (eg, pemphigus, Behçet disease, lichen planus, and neutrophilic dermatoses), and sexually transmitted diseases as well as primary skin tumors. The presence of persistent anogenital ulcers and, less frequently, oral ulcers should suggest the presence of CMV in these lesions in individuals whose immune system is immature or suppressed by drug treatment or coinfection with other pathogens, particularly HIV. Serologic testing should be performed in all cases to rule out HIV infection as well as because of the different prognostic implications. Return to Quiz Case. References 1. Daudén EFernández-Buezo GFraga JCardeñoso LGarcía-Díez A Mucocutaneous presence of cytomegalovirus associated with human immunodeficiency virus infection. Arch Dermatol 2001;137 (4) 443- 448PubMedGoogle Scholar 2. Choi Y-LKim J-AJang K-T et al. Characteristics of cutaneous cytomegalovirus infection in non-acquired immune deficiency syndrome, immunocompromised patients. Br J Dermatol 2006;155 (5) 977- 982PubMedGoogle ScholarCrossref 3. Rubin RHCosimi ABHirsch MSHerrin JTRussell PSTolkoff-Rubin NE Effects of antithymocyte globulin on cytomegalovirus infection in renal transplant recipients. Transplantation 1981;31 (2) 143- 145PubMedGoogle ScholarCrossref 4. León-Mateos ASánchez-Aguilar DToribio J Ulcers in a patient with a chronic lymphocytic leukemia [in Spanish]. Actas Dermosifiliogr 2007;98 (4) 279- 280PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Dermatology American Medical Association

Mucous Membrane Ulcers in an Immunocompromised Patient—Diagnosis

Archives of Dermatology , Volume 145 (8) – Aug 1, 2009
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Mucous Membrane Ulcers in an Immunocompromised Patient—Diagnosis

Abstract

Diagnosis: Cutaneous cytomegalovirus infection (CMV). Microscopic findings The biopsy specimen showed an acute inflammatory infiltrate (Figure 3). Thorough examination of the endothelial cells demonstrated cytopathic changes and sparse cytoplasmic inclusions, suggesting infection by CMV, which was definitively confirmed by the results of immunoperoxidase staining (Figure 3). Figure 3. View LargeDownload Discussion Cytomegalovirus is an opportunistic virus that develops in the...
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References (4)

Publisher
American Medical Association
Copyright
Copyright © 2009 American Medical Association. All Rights Reserved.
ISSN
0003-987X
eISSN
1538-3652
DOI
10.1001/archdermatol.2009.148-b
Publisher site
See Article on Publisher Site

Abstract

Diagnosis: Cutaneous cytomegalovirus infection (CMV). Microscopic findings The biopsy specimen showed an acute inflammatory infiltrate (Figure 3). Thorough examination of the endothelial cells demonstrated cytopathic changes and sparse cytoplasmic inclusions, suggesting infection by CMV, which was definitively confirmed by the results of immunoperoxidase staining (Figure 3). Figure 3. View LargeDownload Discussion Cytomegalovirus is an opportunistic virus that develops in the immunocompromised host. Viral dissemination leads to multiple organ system involvement, with the most important clinical manifestations consisting of pneumonitis, gastrointestinal disease, and retinitis. Cutaneous manifestations are variable and rare, and diagnosis is often delayed. The various clinical presentations that have been reported include ulcers, vesicles, purpuric macules, verrucous lesions, prurigo nodularis–like lesions, erythematous and crusted papules, and digital infarcts.1 However, most of the cases have involved ulcers that were localized mainly on the genital area. Although CMV usually represents a late manifestation of systemic infection, heralding a fatal course in HIV-positive patients, this is not always the case in other immunocompromised patients. In a case series involving cutaneous CMV infection in HIV-negative patients, all of the patients responded completely to ganciclovir therapy.2 In the present case, valganciclovir therapy (two 450-mg tablets twice a day for 1 month) resulted in progressive improvement of the mucosal lesions. One year later, our patient was still asymptomatic, without evidence of recurrence. Histopathologic analysis with specific CMV immunochemical techniques can make the accurate diagnosis. Polymerase chain reaction assay of the lesions is also useful. Combination therapy with antithymocyte globulin and cyclosporine can be used to treat low-risk nonsideroblastic myelodysplastic syndromes. Antithymocyte globulin is a polyclonal antibody against T lymphocytes that provokes a deep and prolonged immunosuppression due to a depletion of T lymphocytes. Among the profile of its secondary effects, a higher risk of CMV infections has been reported.3 The differential diagnosis also includes other opportunistic infections (eg, herpes,4 tuberculosis, mycobacteria, and deep mycoses), ulcers related to neutropenia, adverse drug reactions, inflammatory diseases (eg, pemphigus, Behçet disease, lichen planus, and neutrophilic dermatoses), and sexually transmitted diseases as well as primary skin tumors. The presence of persistent anogenital ulcers and, less frequently, oral ulcers should suggest the presence of CMV in these lesions in individuals whose immune system is immature or suppressed by drug treatment or coinfection with other pathogens, particularly HIV. Serologic testing should be performed in all cases to rule out HIV infection as well as because of the different prognostic implications. Return to Quiz Case. References 1. Daudén EFernández-Buezo GFraga JCardeñoso LGarcía-Díez A Mucocutaneous presence of cytomegalovirus associated with human immunodeficiency virus infection. Arch Dermatol 2001;137 (4) 443- 448PubMedGoogle Scholar 2. Choi Y-LKim J-AJang K-T et al. Characteristics of cutaneous cytomegalovirus infection in non-acquired immune deficiency syndrome, immunocompromised patients. Br J Dermatol 2006;155 (5) 977- 982PubMedGoogle ScholarCrossref 3. Rubin RHCosimi ABHirsch MSHerrin JTRussell PSTolkoff-Rubin NE Effects of antithymocyte globulin on cytomegalovirus infection in renal transplant recipients. Transplantation 1981;31 (2) 143- 145PubMedGoogle ScholarCrossref 4. León-Mateos ASánchez-Aguilar DToribio J Ulcers in a patient with a chronic lymphocytic leukemia [in Spanish]. Actas Dermosifiliogr 2007;98 (4) 279- 280PubMedGoogle ScholarCrossref

Journal

Archives of Dermatology – American Medical Association

Published: Aug 1, 2009

Keywords: ulcer,immunocompromised host,mucous membrane,cytomegalovirus

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