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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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Corresponding Author: Caroline A. Nelson, MD, Department of Dermatology, Yale University School of Medicine, 15 York St, New Haven, CT 06510 (firstname.lastname@example.org).
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.
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