Abstract

Cutaneous manifestations of cytomegalovirus (CMV) are rarely diagnosed as CMV infections are mostly subclinical in immunocompetent hosts. However, in immunosuppressed patients, cutaneous manifestations are polymorphous and include morbilliform, urticarial, petechial, and purpuric eruptions. We describe a 47-year-old female with ambiguous lineage acute leukemia (on dasatinib) who presented with myalgia and petechiae on the bilateral palms and fingers. The differential diagnosis included dasatinib-related cutaneous adverse event versus petechial eruption with acral distribution due to viruses such as parvovirus, coxsackie, SARS-CoV-2, and CMV. Histopathologic examination revealed an increased number of small caliber vessels in the dermis. Rare cytomegalic cells with enlarged nuclei containing eosinophilic intranuclear inclusion bodies were identified, along with red blood cell extravasation. An immunohistochemical stain for CMV antibody (CCH2 and DDG9 clones) highlighted these enlarged endothelial cells. Laboratory evaluation demonstrated positive CMV IgG and CMV viremia. Following treatment with intravenous ganciclovir, the petechial eruption resolved and the CMV DNA was undetectable by PCR. The patient was transitioned to oral valganciclovir for a total one-month course after CMV DNA clearance. This case reflects cytomegalovirus infection presenting as acral petechiae associated with myalgia in the setting of immunosuppression. In the context of this presentation, infections due to CMV, parvovirus, coxsackie, and COVID-19 should be considered in the differential diagnosis. Histopathologic exam can be helpful in this context, and anti-CMV antibody stain is useful in subtle cases.

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