Abstract

Cytomegalovirus (CMV) is a common, often self-limited, viral infection that may reactivate to cause a variety of disease presentations, especially in the setting of immunocompromise. While cutaneous manifestations of systemic CMV infection are rare, recognition of dermatologic presentations of CMV are becoming increasingly reported in a variety of morphologies ranging from ulcers to vasculitis and morbilliform rashes. Three male patients aged 47, 79 and 85 years with untreated human immunodeficiency virus, penile erosive lichen planus and metastatic Merkel cell carcinoma on immune checkpoint inhibitor therapy, respectively, presented with isolated cutaneous ulcers. The ulcers were located on the perianal skin, glans of the penis and distal thumb and showed rolled margins with relatively clean bases. In each case, non-specific and overlapping histopathologic features were seen including surface epidermal erosion, spongiosis and reactive squamous changes. Dermal findings included a mixed inflammatory infiltrate with neutrophils, dermal fibrosis and a reactive myofibroblastic and vascular proliferation, to varying degrees. In each case, very rare dermal cytomegalic cells with nuclear and cytoplasmic inclusions were noted on high magnification. These isolated cells showed strong nuclear staining with an immunostain for CMV. Isolated ulcers or cutaneous pseudotumors due to CMV infection may occur in the setting of systemic or localized immunosuppression. It is important to recognize these lesions as infectious for proper clinical management. A high index of suspicion is needed, given the fact that scanning microscopy reveals non-specific findings consistent with ulcer bed, and only few diagnostic cells with viral cytopathic effect.

Financial Disclosure:
No current or relevant financial relationships exist.