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Multiple, Tender Perianal Ulcers in a Young Woman

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A woman in her late 30s was evaluated by the dermatology inpatient consult service for a 4-day history of perianal pain. Her medical history included systemic lupus erythematosus, antiphospholipid antibody syndrome, and external hemorrhoids. Six months before admission, she underwent a deceased donor kidney transplant. One month before presentation, she was hospitalized for acute cellular transplant rejection managed with systemic corticosteroids, belatacept, mycophenolate mofetil, and tacrolimus therapies. Her immunosuppressive regimen at the time of dermatologic evaluation consisted of prednisone, 5 mg daily, and mycophenolate mofetil, 500 mg twice daily.

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C. Cytomegalovirus infection

Examination of a punch biopsy specimen revealed epidermal ulceration with mixed dermal inflammation (Figure, B and C). There were large fibroblasts and endothelial cells with glassy cytoplasm and large intranuclear inclusions surrounded by a clear halo, giving the “owl’s eye” appearance (Figure, D). Inclusions were positive for cytomegalovirus (CMV) immunohistochemical stain. Quantitative PCR results demonstrated a CMV load of 172 000 copies/mL (5.24 log10 IU/mL) in the blood. A PCR swab from the ulcer base was positive for CMV. Based on these findings, a diagnosis of cutaneous ulceration secondary to CMV infection was made.

A common infectious complication after renal transplant, CMV increases the risk for allograft rejection.1 As with this patient, CMV-seronegative patients who receive renal transplants from seropositive donors are at highest risk of hospitalization from CMV disease.1 In patients who receive a transplant, CMV infection may lead to significant morbidity and mortality, most notably owing to CMV colitis. This patient had diarrhea; however, the diagnosis of CMV colitis was obscured by concurrent C difficile colitis.

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Article Information

Corresponding Author: Caroline A. Nelson, MD, Department of Dermatology, Yale University School of Medicine, 15 York St, New Haven, CT 06510 (caroline.nelson@yale.edu).

Published Online: February 17, 2021. doi:10.1001/jamadermatol.2020.5764

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank Emma Weiss, MD (Department of Dermatology, Yale University School of Medicine), for technical contributions and for her role in writing the manuscript. She was not compensated. We thank the patient for granting permission to publish this information.

References
1.
Reischig  T , Jindra  P , Svecová  M , Kormunda  S , Opatrný  K  Jr , Treska  V .  The impact of cytomegalovirus disease and asymptomatic infection on acute renal allograft rejection.   J Clin Virol. 2006;36(2):146-151. doi:10.1016/j.jcv.2006.01.015 PubMedGoogle ScholarCrossref
2.
Drozd  B , Andriescu  E , Suárez  A , De la Garza Bravo  MM .  Cutaneous cytomegalovirus manifestations, diagnosis, and treatment.   Dermatol Online J. 2019;25(1):13030/qt84f936cp.PubMedGoogle Scholar
3.
Resnik  KS , DiLeonardo  M , Maillet  M .  Histopathologic findings in cutaneous cytomegalovirus infection.   Am J Dermatopathol. 2000;22(5):397-407. doi:10.1097/00000372-200010000-00003 PubMedGoogle ScholarCrossref
4.
Kotton  CN .  CMV: prevention, diagnosis and therapy.   Am J Transplant. 2013;13(suppl 3):24-40. doi:10.1111/ajt.12006 PubMedGoogle ScholarCrossref
5.
Hughes  CM , Spring  S , Radalage  R , Graham  M , Dendle  C , Rogers  BA .  Incidental mucocutaneous cytomegalovirus detection and its predictive value for systemic disease.   Pathology. 2020;52(4):478-482. doi:10.1016/j.pathol.2020.02.009 PubMedGoogle ScholarCrossref
6.
Lin  M , Giusto  D , Jakate  S , Proia  L .  A man with a chronic painful perianal ulcer.   Clin Infect Dis. 2008;46(4):575-576; 637-579. doi:10.1086/526770PubMedGoogle ScholarCrossref
7.
Haidar  G , Boeckh  M , Singh  N .  Cytomegalovirus infection in solid organ and hematopoietic cell transplantation.   J Infect Dis. 2020;221(suppl 1):S23-S31. doi:10.1093/infdis/jiz454PubMedGoogle ScholarCrossref
8.
Lambert  EM , Strasswimmer  J , Lazova  R , Antaya  RJ .  Cytomegalovirus ulcer.   Arch Dermatol. 2004;140(10):1199-1201. doi:10.1001/archderm.140.10.1199 PubMedGoogle ScholarCrossref
9.
Plotkin  SA , Wang  D , Oualim  A ,  et al.  The status of vaccine development against the human cytomegalovirus.   J Infect Dis. 2020;221(suppl 1):S113-S122. doi:10.1093/infdis/jiz447PubMedGoogle ScholarCrossref
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