Abstract

Opportunistic infections can be a difficult to manage complication of immunosuppressive therapy. Presented here is a 66 year old female with a history significant for diabetes metellus and kidney transplant on chronic immunosuppression. She initially presented to the emergency department for fatigue, weakness, and altered mental status. Quickly decompensating, her hospital stay was complicated by diabetic ketoacidosis, acute hypoxic respiratory failure requiring intubation, septic shock in the setting of klebsiella cystitis, pulmonary aspergillosis, disseminated cytomegalovirus (CMV), and blood cultures positive for methicillin resistant staphylococcus epidermidis. Dermatology was consulted for a rash of unspecified duration with hyperpigmented nodules, thin scaly plaques, and healing erosions scattered over the scalp, trunk and extremities. Initial histologic review noted scattered large atypical cells with viral cytopathic changes in addition to dense superficial and deep dermal neutrophilic abscess extending into the subcutis with surrounding granulomatous inflammation, giant cells, and vacuoles. Additional work up with AFB, Fite and GMS stains revealed numerous mycobacteria. PCR studies were positive for Mycobacterium Chelonae. The large atypical cells with viral cytopathic changes were positive for cytomegalovirus by immunohistochemistry. At time of consultation it was known this patient was critically ill with multiple infections prompting high suspicion for an infectious cause of the patient's skin manifestations. This case underscores the importance of careful examination of specimens in severely immunocompromised hosts, as multiple infectious processes can be present in one biopsy specimen. CMV viral infection in the skin is most commonly a secondary finding and should prompt close examination for a primary process. Early identification allows for prompt initiation of appropriate therapy which is of critical importance in this vulnerable population.

Financial Disclosure:
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