Cutaneous Cytomegalovirus Infection in an Immunocompetent Patient: Innocent Bystander or Culprit?

Abstract

We present a rare case of cutaneous cytomegalovirus (CMV) infection in a nonimmunocompromised patient. A 74-year-old woman with a history of diabetes presented with an ulcer on the right lateral tibia that occurred at the site of a nerve core biopsy. Subsequent biopsy of the ulcer edge showed granulation tissue with neutrophilic inflammation. The patient underwent extensive antibiotic treatment for possible infection with weekly wound care. However, the ulceration persisted and enlarged. A repeat biopsy 1 year later showed superficial and deep mixed inflammation with an associated vasculitis. On close examination, endothelial and eccrine ducts cells showed characteristic CMV viral cytopathic changes with positivity on CMV immunohistochemical stain. Although the patient was started on valganciclovir, the ulceration did not resolve with treatment and slightly enlarged. Treatment modalities included dapsone, prednisone, weekly wound care, wound vacuum, and eventually a skin graft of the ulcer site. This case highlights the presence of CMV infection in a cutaneous ulceration in a relatively immunocompetent patient, and the lack of response to treatment raises the question whether CMV was causative, partially contributory, or simply an innocent bystander.

Unusual isolated cytomegalovirus cutaneous infections: A subtle histopathologic diagnosis with review of the literature

“…Most patients had systemic CMV infection and were immunosuppressed, commonly with HIV/AIDS infection, following organ transplant, or other iatrogenic causes. Interestingly, one of the cases reported here occurred in the setting of local immunosuppression as a result of long‐term corticosteroid use in an otherwise immunocompetent patient, which is exceedingly rare 9–15 . Co‐infection with HSV was noted in several previous reports, but it was not detected in our cases.…”

“…Interestingly, one of the cases reported here occurred in the setting of local immunosuppression as a result of long-term corticosteroid use in an otherwise immunocompetent patient, which is exceedingly rare. [9][10][11][12][13][14][15] Co-infection with HSV was noted in several previous reports, but it was not detected in our cases. Frequent histopathologic findings included ulceration, cytomegalic viral cytopathic changes, particularly involving vascular endothelial cells with vasculitis, and a neutrophilic or mixed inflammatory infiltrate.…”

“…Arguments favoring an etiopathogenic role for CMV emphasize improvement of patient symptoms only after initiation of CMV‐targeted therapy, 2,23,28–32 as observed here. Those authors favoring secondary involvement by CMV cite studies documenting CMV in otherwise unremarkable skin, 8,15,21,32 a lack of response to CMV‐directed therapy in some, 14 and spontaneous resolution without treatment 10 . Additionally, CMV is often accompanied by bacterial and/or other viral infections such as HSV, particularly in patients with HIV/AIDS 7,8 .…”

Refractory rheumatoid vasculitis complicated by cytomegalovirus reactivation as a manifestation of immune reconstitution inflammatory syndrome

“…Therapy-refractory RV and CMV vasculitis share many clinical symptoms, both leading to severe ulcers, making it difficult to distinguish them clinically. [5][6][7] Our patient showed exacerbation of RV immediately after reduction of immunosuppressive agents rather than during immunosuppressive therapy. Thus, the paradoxical induction of vasculitis by immunosuppressive therapy was indicative of IRIS.…”