Abstract

Cutaneous cytomegalovirus (CMV) infections are rare, easily missed, and associated with poor prognosis in immunosuppressed patients. A high degree of suspicion is necessary for diagnosis as cutaneous CMV manifestations are clinically non-specific, may mimic Herpesviridae or other cutaneous infections, and may show subtle histologic findings. Here we describe a 34-year-old man that underwent dual orthotopic heart and kidney transplantation (from a known CMV-seropositive donor) and eight months later developed vesiculopustular skin lesions over his mid-back and right lower abdomen. A punch biopsy of one of the abdominal lesions demonstrated ulceration with brisk lymphohistiocytic dermal infiltrate and atypical perivascular and stromal cells with viral cytopathic changes, including prominent nucleoli and multinucleation. These cells demonstrated positive nuclear immunostaining for CMV. Multiple prior CMV serologic tests had been negative in the patient. CMV was subsequently detected by PCR in serum, further supporting the diagnosis. The patient was treated with intravenous ganciclovir resulting in gradual improvement in the skin lesions. Here we highlight the importance of considering this uncommon skin infection in the differential for immunocompromised patients, review the available literature regarding cutaneous CMV infections, and discuss when immunostaining for CMV should be considered.