Cytomegalovirus infection in normal and immunocompromised humans. A review

Unusual isolated cytomegalovirus cutaneous infections: A subtle histopathologic diagnosis with review of the literature

Cytomegalovirus (CMV) infection is common and often self-limited. Reactivation results in a variety of disease presentations, especially in the setting of immunocompromise. While cutaneous manifestations of systemic CMV infection are rare, dermatologic manifestations of CMV are increasingly reported with a wide morphologic spectrum clinically. Three male patients, with untreated human immunodeficiency virus (HIV), penile lichenoid dermatitis treated with long-term topical and intralesional corticosteroids, and metastatic Merkel cell carcinoma on immune checkpoint inhibitor therapy, each presented with isolated cutaneous ulcers. The ulcers were located on the perianal skin, glans of the penis, and distal thumb. In each case, nonspecific histopathologic features were seen. However, very rare dermal cytomegalic cells with nuclear and cytoplasmic inclusions were present and highlighted with an immunohistochemical stain for CMV. Isolated ulcers due to CMV infection may occur in the setting of systemic or localized immunosuppression. A high index of suspicion is needed upon histopathologic evaluation, as few cytomegalic cells may be present and accurate diagnosis is crucial for prompt and appropriate clinical management.

Hepatitis B virus and cytomegalovirus coinfection in an older patient: a case report

Cytomegalovirus (CMV) infection involving the skin is relatively rare. We herein report a case involving a man in his late 70s with positive hepatitis B surface antigen who presented with multiform skin lesions, including a papuloid rash, papular urticaria, and purpura. The patient had taken no antiviral drugs for nearly 13 years but had recently developed severe liver injury. Laboratory examination revealed positive CMV immunoglobulin M, CMV polymerase chain reaction result of 1.09 × 102 copies/mL, and a slightly decreased CD4+ cell count; however, the CD8+ T-cell count was within the normal range. A skin biopsy was performed in the region of the papular eruption on the left inner thigh, and the pathologic findings were consistent with CMV infection. After admission, the patient began a combination of antiviral therapy for hepatitis B virus and CMV. After 3 weeks of treatment, the patient was discharged with skin lesions, and his liver function recovered.

Late-onset cytomegalovirus cholangiopathy in a renal transplant patient: Case report and review of the literature

This case report highlights the investigation and treatment of a 70-year-old male with cytomegalovirus (CMV) cholangiopathy. The patient underwent a kidney transplant in 2016 and presented 3 years later with the atypical presentation of left shoulder pain associated with dilated biliary tree and mild transaminitis. Initial endoscopic retrograde cholangiopancreatography (ERCP) showed diffuse stricture of the common bile duct, requiring stenting, and over the course of a year multiple stent changes were required to prevent cholestasis. CMV polymerase chain reaction (PCR) tests were conducted on bile duct brushings and found to be positive. Oral valganciclovir was given for 6 weeks but the strictures did not resolve. He underwent a laparoscopic total choledochectomy and hepaticojejunostomy as definitive treatment. CMV involvement of the biliary tract has rarely been reported in kidney transplant patients. Antiviral therapy in the form of ganciclovir or valganciclovir is often sufficient to eradicate CMV infection and improve clinical disease. Surgical management should be considered only if the patient has failed medical therapy, or if there is suspicion of malignancy. This case shows that in renal transplant patients presenting with cholangiopathy, CMV disease should be considered as a possible differential even in patients without early CMV infection or with prior CMV prophylaxis.

Cytomegalovirus induced genital ulcer in human immunodeficiency virus positive patient

Cytomegalovirus (CMV) can cause life-threatening disease in immunocompromised patients, such as those with human immunodeficiency virus. It is a rare but important cause of ulceration in the female genital tract. Although cutaneous manifestations are rare, there are growing reports of CMV infections in genital and perigenital ulcers in immunocompromised individuals. CMV disease of the female genital tract may result in significant morbidity, with fever, pain, bleeding, and superinfection, and it may be associated with the development of pelvic inflammatory disease and cervical intraepithelial neoplasia. There are several options for diagnosis and for safe treatment.

Oral and cutaneous manifestations of viral and bacterial infections: Not only COVID-19 disease

Globalization entails several medical problems along with economic and social complications. Migrations from other continents, increasing numbers of tourists worldwide, and importation of foreign parasites (eg, Aedes albopictus) have made diseases previously unknown in Europe a reality. The rapid spread of the coronavirus disease 2019 pandemic throughout the world is a warning that other epidemics are still possible. Most, if not all of these diseases, transmitted by viruses or bacteria, present with cutaneous symptoms and signs that are highly important for a speedy diagnosis, a fundamental concept for arresting the diseases and saving lives. Dermatologists play a significant role in delineating cutaneous and mucosal lesions that are often lumped together as dermatitis. We provide a review of many of these cutaneous and mucosal lesions that sometimes are forgotten or even ignored.

CMV presenting as a skin growth in renal transplant patient

CMV infection is one of the most common opportunistic infection in kidney transplant patients. If not treated, it is associated with increased mortality and graft loss. It can present as viremia or CMV disease in the form of CMV syndrome or tissue invasive CMV disease. The cutaneous presentation of CMV disease is a rare finding. Its identification is vital as cutaneous CMV infection can signal systemic infection and poor prognosis. In our case, 46-year-old male who was a post renal allograft recipient (RAR) presented as a protuberant growth over the medial side of the left ankle. On skin biopsy, nucleomegaly and inclusion bodies were seen in the epithelial cells. Immunohistochemistry was positive for CMV infection. Patient was treated with Ganciclovir, however, he succumbed to death because of severe sepsis due to secondary bacterial infection. Thus, CMV disease should always be kept in mind in immunocompromised patients like post RAR patients who present with cutaneous features like ulcerative lesions or fungating growth.

Unusual Manifestations of Acute Cytomegalovirus Infection in Solid Organ Transplant Hosts: A Report of Two Cases

Cytomegalovirus (CMV) infection is a common cause of morbidity and mortality in immunocompromised hosts. Tissue-invasive CMV disease causing ulcerative skin disease or esophageal necrosis is rare. We herein describe two cases: a 47-year-old renal and pancreas transplant recipient who presented with skin ulcerations on his elbow and a 50-year-old renal transplant recipient who presented with acute esophageal necrosis. In both, tissue biopsy revealed CMV inclusion bodies by immunohistochemical staining of infected endothelial and mucosal cells. Ganciclovir was given to both cases and full remission occurred. Due to the varying presentations of acute CMV infection in immunosuppressed hosts, high suspicion and early tissue biopsy are vital for proper diagnosis and treatment when any suspicious cutaneous or mucosal manifestations are present.

Contemporary infectious exanthems: an update

An exanthem is a skin rash that may be associated with mucous membrane eruption, fever or other symptoms. It may develop as manifestation of an infectious disease or as adverse reaction to drugs. Beside the ‘classical exanthems’ commonly occurring in childhood, other exanthems, defined as ‘atypical’ for the different morphology and causal agents, may occur. Among the atypical exanthems with infectious etiology, viral, bacterial, parasitic and helminth infections are implicated. We describe herein etiology and epidemiology of the atypical exanthems caused by infectious agents. In case of exanthem, to make a correct etiological diagnosis is crucial for both the patient and community concerning issues such as time off school, immunizations and risk in pregnancy and immunocompromised individuals.

Cytomegalovirus Scrotal Ulcer in a Renal Transplant Patient

BACKGROUND

Cytomegalovirus (CMV) is a highly prevalent herpesvirus that can present with cutaneous disease in immunocompromised individuals. This may reflect systemic involvement, which is associated with significant morbidity and mortality.

OBJECTIVE

To report a case of cutaneous CMV in an immunocompromised patient and to discuss the differential diagnosis of genital ulcers.

METHODS

A medical chart review was conducted on a patient who presented with a scrotal ulcer after renal transplantation. A review of the literature on cutaneous CMV disease was also completed.

RESULTS

Biopsy of the scrotal ulcer revealed classic findings of CMV disease. The patient also developed CMV viremia. Treatment with valganciclovir resolved his scrotal ulcer and viremia.

CONCLUSION

The differential diagnosis for genital ulcers is broad, especially in the immunocompromised patient. Cutaneous CMV disease should be ruled out with biopsy and immunohistochemical examination in immunocompromised patients, as it may reflect systemic involvement and significantly affect patient care.

Cytomegalovirus Cutaneous Infection in an Immunocompromised Patient

Cytomegalovirus (CMV), a member of the Herpesviridae family, is an opportunistic infection with a typically benign course in the healthy host but has a more ominous course in the immunocompromised population. CMV infection commonly affects the visceral organs, particularly the respiratory and the gastrointestinal tract. CMV cutaneous lesions are rare and can be easily missed. We present a case of a 76-year-old woman presenting with a diffuse non-pruritic macular lesion with scattered vesicles and bullae, which was initially treated as a varicella zoster virus infection and herpes simplex viral infection, but was later found on biopsy to be due to cytomegalovirus. She has a history of Sjögren's syndrome, interstitial lung disease, and being on chronic immunosuppression therapy. This case highlights the importance of considering CMV infection in the differential diagnosis of vesicular skin lesions in immunocompromised patients. Based on a PubMed search for "cutaneous cytomegalovirus", "cutaneous CMV", "cytomegalovirus skin", and "skin CMV" in material published in the last 20 years (from 1996 to 2016) and reviewing any applicable referenced material outside of those dates, cases of cutaneous CMV are not well documented.

Cutaneous ulcer as leading symptom of systemic cytomegalovirus infection

Cytomegalovirus (CMV) infection rarely manifests with skin ulcerations. We describe a case report of a 64-year-old woman with chronic immunosuppression for treatment of mixed connective tissue disease, presenting with new onset leg ulcerations after a recent change in immunosuppressive regimen. She subsequently developed fulminant hepatitis, encephalopathy, and pancytopenia and was found to have severe systemic CMV viremia. Skin ulcer biopsy was positive by immunohistochemical staining for CMV infected endothelial cells. Both systemic disease and skin ulcer rapidly improved after stopping immunosuppression and administering intravenous ganciclovir. New onset skin ulcers in an immunosuppressed individual, especially with recent changes in immunosuppressive regimen, should raise the suspicion of reactivation of CMV.

Cutaneous cytomegalovirus infection on multi dermatomal herpes zoster scars: an isotopic immune response

As more patients with human immunodeficiency virus (HIV) are surviving, despite severe immune suppression, clinicians are faced with atypical manifestations of both common and uncommon dermatoses. A 30-year-old black South African woman presented with a 10-month history of multiple chronic ulcers appearing on a multidermatomal herpes zoster (HZ) scar. The woman was infected with HIV, and her CD4 count was 45 cells/μL. Histology and PCR revealed cytomegalovirus (CMV) infection. This case highlights an unusual presentation of cutaneous CMV occurring as an isotopic immune response on a pre-existing multidermatomal HZ scar.

Peripheral blood leukocytes and serum nested polymerase chain reaction are complementary methods for monitoring active cytomegalovirus infection in transplant patients

BACKGROUND

Human cytomegalovirus is an important cause of morbidity and mortality in immunocompromised patients. Qualitative polymerase chain reaction (PCR) has proven to be a sensitive and effective technique in defining active cytomegalovirus infection, in addition to having low cost and being a useful test for situations in which there is no need for quantification. Real-time PCR has the advantage of quantification; however, the high cost of this methodology makes it impractical for routine use.

OBJECTIVE

To apply a nested PCR assay to serum (sPCR) and to evaluate its efficiency to diagnose active cytomegalovirus infection compared with PCR of peripheral blood leukocytes (L-PCR).

METHODS

Samples of 37 patients were prospectively evaluated. An internal control was created and applied to sPCR to exclude false-negative results.

RESULTS

In total, 21 patients (57%) developed active cytomegalovirus infection. After analyzing the two methods for the diagnosis of active infection, higher sensitivity and negative predictive value of the L-PCR versus sPCR (100% versus 62%), and higher specificity and positive predictive value of sPCR versus L-PCR (81% versus 50% and 72%, respectively) were observed. Discordant results were observed in 11 patients who were L-PCR-positive but sPCR-negative for active cytomegalovirus infection, five of whom developed clinical symptoms of cytomegalovirus. Clinical symptoms were observed in 14 patients, 12 of whom were diagnosed with active infection by nested L-PCR (P=0.007) and seven by nested sPCR (P=0.02). Higher specificity and a positive predictive value for sPCR were observed.

CONCLUSION

Nested L-PCR and sPCR were considered to be complementary methods for the diagnosis and management of symptomatic cytomegalovirus infection.

Atypical presentation of exophytic herpes simplex virus type 2 with concurrent cytomegalovirus infection: a significant pitfall in diagnosis

We report 3 unusual cases of atypical exophytic cutaneous herpes simplex virus (HSV) type 2 with concurrent cytomegalovirus (CMV) infection in immunosuppressed patients and raise awareness to the significant clinical and pathologic challenges in establishing the correct diagnosis. In all the 3 cases, the lesions presented as fungating plaques and nodules with areas of superficial erosion. Initial clinical differential included genital warts, syphilis, versus cutaneous malignancy. All the 3 patients were referred to the dermatology clinic where a combination of cutaneous biopsies, viral cultures of the lesions, polymerase chain reaction, CMV antigenemia, and immunoperoxidase stains for CMV and HSV confirmed the diagnosis of HSV type 2 with concurrent CMV infection. All the 3 patients were treated with oral valganciclovir with significant improvement noted at the follow-up visit. In addition, we review the previously reported HSV/CMV cutaneous coinfection cases.

Perianal Plaques of Cytomegalovirus in a Patient with Central Nervous System Lymphoma

Cutaneous manifestations of cytomegalovirus (CMV) in patients without human immunodeficiency virus remain rare. Perianal CMV may be observed due to periodic fecal shedding but may be confused for other pathogens, and definitive diagnosis requires histopathologic examination. An instructive case is described, and the literature reviewed.

Stevens-Johnson syndrome associated with cytomegalovirus infection in a child with ependymoma

BACKGROUND

Stevens-Johnson syndrome is an uncommon, acute life-threatening disease characterized by extensive epidermal sloughing and mucositis. In childhood, as in adulthood, this condition is mostly related to drugs, in particular antibiotics. Only a few cases reported were firmly attributed to infectious agents, mainly Mycoplasma pneumonia but the causative role of infectious microorganisms seems particularly relevant in pediatric patients. The seriousness of this condition imposes a prompt recognition and the early withdrawal of the potential causative drugs or the institution of directed measures against infectious agents (depending on the suspected etiology), as well as a supportive and more specific therapy. Some treatments claim to halt the progression of skin detachment, but remain of unproven benefit due to the lack of prospective, well controlled, randomized clinical trials.

MAIN OBSERVATIONS

We report a case of a 2-year-old boy admitted in our hospital for the treatment of an ependymoma of the posterior fossa, who developed a Stevens-Johnson syndrome associated most probably with a cytomegalovirus infection. He was successfully treated with high dose intravenous immunoglobulin and gancyclovir.

CONCLUSION

To the best of our knowledge, this is the first case of SJS associated with CMV infection.

Can skin be the first site of CMV involvement preceding a systematic infection in a renal transplant recipient?

Cytomegalovirus (CMV) is an important and well-described opportunistic virus in renal transplant recipients (RTRs) with infection occurring mainly after the first month post-renal transplant. CMV can present as primary infection, reinfection or reactivation of latent disease. Skin manifestations are rare and variable, and diagnosis is often delayed. We present one case of skin CMV ulcer of perineal areas without systemic symptoms of CMV disease and a negative quantitative polymerase chain reaction. This case serves to illustrate the protean nature of CMV disease in RTR.

Cytomegalovirus infection in pediatric rheumatic diseases: a review

Human cytomegalovirus (HCMV) is familiar to pediatric rheumatologists mainly as a cause of opportunistic disease in pharmacologically immune suppressed patients. However, HCMV also has a variety of immuno-modulatory effects, through which it may influence the course of rheumatic conditions. In this article we discuss the interplay between HCMV and the immune system, and review the clinical manifestations, diagnosis, and treatment of HCMV infection in children with rheumatic disease.

Epithelial raft cultures for investigations of virus growth, pathogenesis and efficacy of antiviral agents

The organotypic epithelial raft cultures, originally developed to study keratinocytes differentiation, represent a novel approach to the study of viruses able to infect epithelial cells. Organotypic epithelial raft cultures accurately reproduce the process of epithelial differentiation in vitro and can be prepared from normal keratinocytes, explanted epithelial tissue, or established cell lines. This culture system permits cells to proliferate and fully differentiate at the air-liquid interface on a dermal-equivalent support. Normal primary human keratinocytes (PHKs) stratify and fully differentiate in a manner similar to the normal squamous epithelial tissues, while transformed cell lines exhibit dysplastic morphologies similar to the (pre)neoplastic lesions seen in vivo. This three-dimensional (3D) culture system provides an essential tool for investigations of virus growth, virus-host cell interactions, for the genetic analysis of viral proteins and regulatory sequences, and for the evaluation of antiviral agents. The 3D epithelial cultures have proven a breakthrough in the research on papillomaviruses, since their life cycle is strictly linked to the differentiation of the host epithelium. In the last years, several reports have shown the usefulness of the 3D epithelial cultures for the study of other viruses that target at least during a part of their life cycles epithelial cells. The 3D epithelial cultures allow the analysis of virus-host cell interactions in stratified epithelia that more closely resemble the in vivo situation. In this review we describe the advances on research on 3D epithelial cultures for the study of virus growth and pathogenesis of different families of viruses, including papilloma-, herpes-, pox-, adeno-, and parvoviruses.

Cutaneous manifestations of cytomegalovirus disease in renal transplant recipients: a case series

Cytomegalovirus (CMV) is an important and well-described opportunistic virus in the immunocompromised host, with infection occurring mainly after the first month in the new renal transplant recipient. CMV can present as primary infection, reinfection, or reactivation of latent disease. It is capable of protean manifestations. Cutaneous manifestations are variable, rare, and diagnosis often delayed. We present 3 cases of cutaneous CMV disease in renal transplant recipients. Manifestations in our patients included ulceration of the tongue and perianal areas, facial petechiae, and nodular lesion involving the ear. This case series serves to highlight the importance of early skin biopsy in the diagnosis and management of cutaneous CMV disease.

The chemokine receptor homologue encoded by US27 of human cytomegalovirus is heavily glycosylated and is present in infected human foreskin fibroblasts and enveloped virus particles

Human cytomegalovirus (HCMV), a member of the beta-herpesvirus family, encodes four homologues of cellular G protein-coupled receptors (GPCRs). One of these, the protein product of HCMV open reading frame (ORF) UL33, has been identified in HCMV-infected cells and virus particles and shown to be heat-aggregatable and N-glycosylated. Another, the product of ORF US28, has been functionally characterized as a beta-chemokine receptor. Here we report the use of RT-PCR, coupled in vitro transcription-translation, immunoprecipitation, and Western immunoassays to (i) show that RNA from the open reading frame US27 appears predominantly during the late phase of replication; (ii) identify the protein encoded by HCMV US27 in infected cells and enveloped virus particles; (iii) demonstrate that the US27-encoded protein is heterogeneously N-glycosylated and resolves as two species following treatment with peptide N-glycosidase F; and (iv) show that both the recombinant and deglycoylated infected cell US27 protein aggregate when heated in the presence of SDS prior to electrophoresis in polyacrylamide gels, a property which is abrogated with the addition of urea to sample buffer.

Immediate nasal prosthetic rehabilitation following cytomegalovirus erosion: a clinical report

The immediate prosthetic rehabilitation of a patient with erosive cutaneous cytomegalovirus (CMV) is presented. Although CMV is a major cause of morbidity and mortality in immunocompromised patients, skin lesions are rarely discussed in the literature. Recognition of the susceptibility of medically compromised patients to infections that can cause extraoral and intraoral deformity is essential to prevention, early diagnosis, and prompt intervention of a life-threatening destructive debilitation. A method for rapidly fabricating a nasal prosthesis is described, and the importance of prompt esthetic and psychological rehabilitation is reviewed.

Antigenemia for cytomegalovirus in renal transplantation: choosing a cutoff for the diagnosis criteria in cytomegalovirus disease

Cytomegalovirus (CMV) infection is a frequent complication in transplant recipients, causing a high level of morbidity and mortality. We studied 203 consecutive renal transplant recipients performed between January 2000 and December 2001. Patients underwent weekly measurements of CMV pp65 antigen to assess CMV activity from the 4th to the 12th week posttransplantation. The results were reported as number of cells positive for the pp65 antigen among 10(5) granulocytes. In order to define a best cutoff to diagnose CMV disease with desirable sensitivity and specificity, we used a receiver operator characteristics (ROC) curve. The cutoff of four positive cells corresponded to a sensitivity of 93% and specificity of 60% (AUC = 0.87) for the diagnosis of CMV disease. The chosen cutoff for starting antiviral treatment was 10 cells, since this was associated with a sensitivity of 92% and specificity of 70% (AUC = 0.90). In conclusion, the highly sensitive cutoff points for the diagnosis of antigenemia was four cells and 10 cells for initiation of antiviral therapy.

Cytomegalovirus cholangitis and pancreatitis in an immunocompetent patient

Cholangitis and pancreatitis associated with cytomegalovirus (CMV) infection in an immunocompetent patient is reported. Endoscopic retrograde cholangiography performed on a 55-year-old man for evaluation of the cause of jaundice and liver dysfunction revealed a distal focal irregular narrowing of the common bile duct. Microscopic findings of the resected specimen showed chronic cholangitis and CMV pancreatitis. Immunohistochemistry disclosed that epithelial cells in the inflamed bile duct were positive for CMV antigen, which was compatible with CMV cholangitis. Inflammation of the biliary tract or pancreas by CMV has been commonly reported as a complication in immunocompromised patients. Our report appears to be a rare case, but suggests that CMV cholangitis or pancreatitis should be considered in the differential diagnoses of common bile duct stenosis or pancreatitis even in immunocompetent individuals.

Cytomegalovirus disease latent and active infection rates during the first trimester after kidney transplantation

Cytomegalovirus (CMV) infection is the single most frequent infectious complication in renal transplant recipients. The aim of this study was to determine the incidence of latent and active infections with CMV during the first 3 months after kidney transplantation. From January 2000 to December 2001, 203 consecutive adult renal transplant recipients underwent weekly measurements of pp65 CMV antigen from the 4th to the 12th posttransplantation week. Latent infection (seropositivity) was found in 92% of the population. Primary infection occurred in 4.9% (10 of 203), among whom 66% were previously seronegative patients. Among the primary infection patients, 70% (7 of 10) developed severe disease. The overall incidence of viremia was 69.5%, being more frequent among cadaver recipients (79% vs 59%; P =.02). The overall incidence of CMV disease was 38.4% (78 of 203) with 24.6% classified as severe disease requiring antiviral therapy. In conclusion, our population showed a high prevalence of latent infection with viremia. Not all patients developed clinical disease. Most subjects experienced a mild spectrum of symptoms, probably due to the prospective search for active infection during the major risk period after kidney transplantation.

Human cytomegalovirus infection of the gastrointestinal tract in apparently immunocompetent patients

Human cytomegalovirus (HCMV) infection is usually reported in immunocompromised patients. This study reports 11 cases of HCMV infection of the gastrointestinal (GI) tract diagnosed in apparently immunocompetent hosts. The median age of the patients studied was 76 years, and the major presenting symptoms were diarrhea, epigastric pain, and abdominal discomfort. The large intestine was involved in 6 cases, the stomach in 4 cases, and the lower esophagus in 1 case. Endoscopy revealed ulcers or hypertrophic folds in the GI tract and single ulcers or erosions in the colon and rectum. Light microscopy showed chronic inflammatory infiltrate in the lamina propria in all cases. The diagnosis of HCMV infection was based on the histological and immunohistochemical identification of HCMV inclusion bodies in different cell types, including epithelial, endothelial, stromal, and smooth muscle cells. Both "classical" inclusions, characterized by an "owl's eye" appearance, and atypical inclusions were found. For all patients, no apparent causes of immunodeficiency were detected at the time of diagnosis of HCMV infection. At follow-up, however, 4 patients were found to harbor a malignant tumor (ie, pancreas, lung, Vater's papilla, and extrahepatic bile duct) at an interval of 2 to 5 months after the diagnosis of HCMV infection. Especially in elderly patients, HCMV infection of the GI tract might be an early clue to the presence of immunologic defects induced by an underlying neoplasia.

Vesicular and pustular eruption related to cytomegalovirus in an immunocompetent patient

Cytomegalovirus (CMV), a member of the herpesviridae family, can cause various dermatologic and systemic disorders especially in immunosuppressed subjects. However, immunocompetent individuals rarely present with cutaneous eruptions related to CMV. We describe an immunocompetent patient who developed a skin eruption and mild hepatitis related to CMV.

Lymphocyte subpopulations during cytomegalovirus disease in renal transplant recipients

We have determined the number of circulating T, B and natural killer cells in renal transplant recipients in order to detect changes during cytomegalovirus (CMV) infections. Serial blood samples were taken from 61 patients on standard triple immunosuppression therapy (cyclosporin A, azathioprine and prednisone). Using two-color flow cytometry analysis, the absolute number of CD3+, CD4+, CD8+, CD19+, CD3+HLA-DR+ and CD16+56+ cells was determined. Forty-eight patients (78.7%) developed active CMV infection, and all of them subsequently recovered. Twenty of the infected patients (32.8%) presented symptoms compatible with CMV disease during the infectious process. The number of lymphocytes and their main subpopulations were normal before the onset of CMV disease. During the disease there was a decrease followed by a significant increase (P<0.005) in the number of CD3+, CD4+, CD8+ and CD3+HLA-DR+ cells. No significant changes were observed in natural killer cells or B lymphocytes during the disease. We conclude, as observed in all viremic patients recovering from infection, that recovery is associated with an increase in the number of T cell subsets. The monitoring of different lymphocyte subsets along with antigenemia can be extremely useful in the detection of patients at high risk of developing CMV symptoms, allowing the early introduction of antiviral therapy or the reduction of immunosuppression therapy.

Nodular perianal herpes simplex with prominent plasma cell infiltration

BACKGROUND

Nodules are exceptional manifestations of herpes simplex virus (HSV) infection in immunocompromised patients. Only two cases of nodular HSV-2 infection of the perianal region have been reported previously.

GOAL

The case of a 46-year-old homosexual man with AIDS presenting with painful perianal nodules resembling squamous cell carcinoma is described.

STUDY DESIGN

This case report presents details of the histologic findings and treatment regimen.

RESULTS

Histologic examination showed the presence of rare multinucleated giant epithelial cells and a dense inflammatory infiltrate composed mostly of plasma cells. Polymerase chain reaction analysis was positive for HSV-2 and negative for HSV-1, cytomegalovirus, Epstein-Barr virus, and human herpesvirus types 6 and 7. After being treated ineffectively with oral acyclovir (4 g/d) for 15 days, the patient was treated with oral valacyclovir (6 g/d), resulting in marked improvement in 10 days and complete resolution after 2 months.

CONCLUSIONS

In immunocompromised patients, HSV-2 infection may present with atypical clinical and histopathological features.

Protein-losing cytomegalovirus gastritis in a patient with Stevens-Johnson syndrome

We present a case of protein-losing cytomegalovirus gastritis in a previously immunocompetent 14-year-old Japanese girl that occurred during treatment of drug (zonisamide)-induced Stevens-Johnson syndrome with hepatic failure. Her hepatic failure and symptoms of Stevens-Johnson syndrome were successfully treated with intravenous prednisolone and infusion of fresh-frozen plasma or albumin, as the occasion demanded. However, during the course of treatment, she complained of severe epigastralgia together with hypoproteinemia, and cytomegalovirus gastritis was found by endoscopic and histological examinations. The possible mechanism by which cytomegalovirus gastritis occurred in the present case and effective diagnostic procedures are discussed.

Cytomegalovirus neuritis in perineal ulcers

BACKGROUND

Although a range of cytomegalovirus (CMV)-induced cutaneous manifestations is described in AIDS patients, skin involvement in immunocompromised patients is rare, and intraneural CMV inclusions or CMV neuritis has not been documented in skin biopsies.

METHODS AND RESULTS

Cutaneous biopsies of CMV lesions were collected prospectively for 12 months. The morphology, sites and symptomatology of the individual lesions, associated systemic illnesses, treatment schedules and disease outcome were recorded. A total of nine biopsies were obtained from three females who presented with extensive painful perineal ulceration and disseminated cutaneous ulcers, nodules and plaques. Clinically, herpes simplex virus (HSV) ulceration was diagnosed and treatment with acyclovir was initiated after biopsies from the natal cleft, perineum and neck were obtained. All were superficial and demonstrated HSV infection. Only the natal cleft biopsy demonstrated coexistent CMV inclusions. Suboptimal healing necessitated two further biopsies from each patient, none of which demonstrated HSV inclusions. Three of four deep perineal biopsies demonstrated CMV inclusions within nerves attended by a lymphocytic infiltrate and architectural disturbances. Two deep cutaneous biopsies of the trunk and abdominal wall confirmed CMV in extraneural locations only. One superficial perineal biopsy did not demonstrate any viral inclusion.

CONCLUSIONS

In documenting CMV neuritis in painful perineal ulcers, the histopathological spectrum of perineal CMV ulcers is expanded, a cutaneous neurotropic characteristic of CMV is presented and a direct role for CMV in the pathogenesis of pain is suggested. CMV latency within perineal nerves is also revisited as another potential site of CMV reactivation in immunocompromised patients, and another potential site for possible venereal transmission of CMV infection. The exclusive presence of HSV in initial superficial biopsies highlights the need for optimally biopsied tissue to confirm the coexistence of CMV infection.

Cytomegalovirus infections

Over the past two decades, there has been an escalation in the number of patients undergoing immunosuppressive therapy following solid organ or bone marrow transplantation, as well as a dramatic increase in the incidence of AIDS. As a result, human cytomegalovirus (HCMV)--once considered a neonatal disease--has captured great interest and importance as a major pathogen in both immunocompromised and immunocompetent patients. Like other members of herpesviridae family, HCMV establishes latency in myeloid lineage cells with potential for reactivation. The natural history of HCMV infection can be divided into primary infection, latency, and reinfection. This review article briefly discusses the molecular pathogenesis of HCMV, then focuses on the clinical picture of this disease, with emphasis on the skin pathology. Diagnostic methods and treatments are also discussed.