Vesiculobullous lesions caused by cytomegalovirus infection in an immunocompromised adult

Recognition of Dual or Multiple Pathology in Skin Biopsies from Patients with HIV/AIDS

A large percentage of patients with HIV/AIDS will develop dermatological complications. Consequently, all practising clinicians and pathologists in regions with a high prevalence of HIV/AIDS must be familiar with the diverse cutaneous manifestations of the disease. This paper highlights the fact that biopsy material in this clinical context may occasionally reveal more than one pathological process. The potential spectrum includes two or more infections in a single skin biopsy (e.g., herpes simplex and cytomegalovirus infection), neoplastic lesions containing infective organisms (Kaposi sarcoma (KS) and cryptococcosis), dermatoses in association with neoplastic lesions (e.g., KS and interface dermatitis), or more than one dermatosis in a given specimen (e.g., papulopruritic eruption and nodular prurigo). Rare biopsies may even demonstrate triple pathology. The importance of careful examination of skin biopsies in this clinical context is emphasised. Failure to recognise an undiagnosed concomitant opportunistic infective pathogen could have potentially disastrous consequences for the patient.

Recognition of immune reconstitution syndrome necessary for better management of patients with severe drug eruptions and those under immunosuppressive therapy

The immune reconstitution syndrome (IRS) is an increasingly recognized disease concept and is observed with a broad-spectrum of immunosuppressive therapy-related opportunistic infectious diseases and severe drug eruptions complicated by viral reactivations. Clinical illness consistent with IRS includes tuberculosis, herpes zoster, herpes simples, cytomegalovirus infections and sarcoidosis: thus, the manifestations of this syndrome and diverse and depend on the tissue burden of the preexisting infectious agents during the immunosuppressive state, the nature of the immune system being restored, and underlying diseases of the hosts. Although IRS has originally been reported to occur in the setting of HIV infection, it has become clear that the development of IRS can also be in HIV-negative hosts receiving immunosuppressive agents, such as prednisolone and tumor necrosis factor α inhibitors, upon their reduction and withdrawal. Drug-induced hypersensitivity syndrome, a life-threatening multiorgan system reaction, is another manifestation of the newly observed IRS. Clinical recognition of the IRS is especially important in improving the outcome for diseases with an otherwise life-threatening progenosis. Clinicians should be aware of the implications of IRS and recognize that relieving the symptoms and signs of immune recovery by anti-inflammatory therapies needs to be balanced with anti-microbial therapies aiming at reducing the amplitude and duration of tissue burden of preexisting microbes.

Perineal ulcers in an infant: An unusual presentation of postnatal cytomegalovirus infection

Cytomegalovirus (CMV) disease can cause significant morbidity and mortality in neonates and immunosuppressed patients. Cutaneous disease is rare, even in at-risk patients. We report a case of CMV with perineal papules, erosions, and ulcers in a preterm but presumably immunocompetent patient, whose diagnosis was first suggested by skin biopsy and confirmed with serologic testing. The mode of transmission of CMV was unclear. The lesions resolved without CMV-specific therapy, and the child had no apparent systemic sequelae of infection. CMV disease should be considered in the differential diagnosis of perineal erosions and ulcers in infancy. In addition to the case, we briefly review the literature on cutaneous manifestations of CMV disease.

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.

Viral skin infections in the elderly: diagnosis and management

Over the past several years, there have been advances in the diagnosis and treatment of cutaneous viral diseases in elderly patients. Herpes zoster is caused by reactivation in adults of the varicella-zoster virus (VZV) that causes chickenpox in children. For many years, aciclovir was the gold standard of antiviral therapy for the treatment of herpes zoster. Famciclovir and valaciclovir are newer antivirals, which offer less frequent administration. Postherpetic neuralgia (PHN) refers to pain lasting 2 months or more after an acute attack of herpes zoster. The pain may be constant or intermittent. The treatment of established PHN may include topical anaesthetics, analgesics, tricyclic antidepressants and anticonvulsants, and nonpharmacological therapy may be used to complement such treatment. Therapeutic strategies to prevent PHN include the use of oral corticosteroids, nerve blocks, and treatment with standard antiviral therapy. The three most recently discovered human herpes viruses (HHV-6, HHV-7 and HHV-8), in common with the other members of the family, may cause a primary infection, establish latent infection in a specific set of cells in their host, and then reactivate if conditions of altered immunity develop. These viruses have been associated with an array of disorders, which are important for the clinician to recognise. Cytomegalovirus (CMV) is a member of the herpesvirus family that is very prevalent worldwide. More than 80% of primary infections and 20% of reactivation-producing symptoms occur in transplant populations. Treatment options include intravenous administration of ganciclovir, foscarnet or cidofovir. Herpes simplex virus (HSV) most commonly affects the genital and perioral regions. In the elderly, HSV infection is typically manifest at the vermilion border of the lip. The main concern of recurrent herpes labialis in the elderly is related to potential autoinoculation of the eye or genital area. Treatment with aciclovir, famciclovir or valaciclovir is indicated for these infections. Molluscum contagiosum is caused by a poxvirus, which produces cutaneous lesions that appear as small, firm, umbilicated papules. Immunocompromised patients often do not respond to the usual destructive therapies, and intravenous or topical cidofovir may be useful in these patients.

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.

Histopathologic findings in cutaneous cytomegalovirus infection

When cytomegalovirus (CMV) involves the skin, viral inclusions are typically present within mesenchymal cells, e.g., endothelial cells, fibrocytes, and sometimes within inflammatory cells, e.g., macrophages, in contrast to infection in other organs in which inclusions are usually present within ductal epithelial cells. Two cases of cutaneous CMV are presented, one showing prominent findings within eccrine ductal epithelium and the other revealing mostly endothelial cells affected by CMV. Due to the range of cytologic changes induced by CMV observed in these cases, there seem to be early, fully developed, and late cellular changes brought about by CMV analogous to how herpesvirus (varicella, zoster, simplex) induces different changes depending on its stage of infection.

The immune compromised host in the twenty-first century: management of mucocutaneous infections

Infectious diseases encountered in dermatology have changed tremendously during the past few decades with the emergence of the immunocompromised host. This change is a result of the human immunodeficiency virus epidemic, use of immunomodulating drugs, bone marrow transplantation, increasing prevalence of diabetes mellitus, and an aging population. New pathogens have been discovered and new disorders have occurred. In the compromised host, infection can be more aggressive and widespread locally, be caused by opportunistic pathogens, and be disseminated hematogenously from or to the skin. The prevalence of nonmelanoma skin cancer has increased, and squamous cell carcinomas can be more aggressive with more rapid local growth as well as frequency of metastasis.

Perianal cytomegalovirus ulcer in an HIV infected patient: case report and review of literature

We report the case of a 25-year-old man with acquired immunodeficiency syndrome, presenting with perianal ulcer and diarrhea. He had positive immunocytochemical tests for Cytomegalovirus (CMV) in circulating polymorphonuclear cells (PMN). The biopsy specimen was suggestive of CMV infection, and specific immunoperoxidase for CMV antigens positively stained endothelial cells and fibroblasts. In this report we review cutaneous CMV infection in immunocompromised patients.

Detection of varicella-zoster virus and herpes simplex virus by the polymerase chain reaction with degenerate primers

Varicella-zoster virus (VZV) and herpes simplex virus (HSV) are human pathogens of significance involved in multiple diseases with either typical or atypical clinical features. In neonates and immunocompromised patients these alphaherpesviruses may cause life-threatening diseases such as encephalitis. Detection of VZV by virus culture is difficult. Polymerase chain reaction (PCR) is quicker and more sensitive and applicable in most clinical microbiological laboratories. Using degenerate primers, glycoprotein B (gB) DNA was amplified from all alphaherpesvirus field strains present in clinical samples. The amplification of gB allowed virus typing of VZV, HSV-1 and HSV-2 using restriction enzyme digestion of the PCR products. Degenerate primers can replace conventional primers in diagnostic PCR without loss of sensitivity and specificity.

Diagnosis and treatment of a case of cutaneous cytomegalovirus infection with a dramatic clinical presentation

A patient receiving long-term immunosuppressive treatment of systemic lupus erythematosus developed multiple large painful ulcers on her upper body. Histologic analysis showed cytopathic changes typical of cytomegalovirus infection that was confirmed by immunoperoxidase staining and polymerase chain reaction analyses. Treatment with ganciclovir and foscarnet resulted in clinical resolution. No recurrence was evident 6 months later.

Cytomegaloviral virus infection in bone marrow transplantation recipients: strategies for prevention and treatment

Cytomegalovirus is major infectious pathogen following allogeneic bone marrow transplantation. In infected recipients, the virus is generally detected between 4 and 10 weeks after transplantation. Historically, CMV disease developed in 30-40% of seropositive recipients, the predominante manifestation being interstitial pneumonitis, which was generally lethal. Therapeutic interventions are discussed with special reference to the use of antiviral therapy for both treatment and prevention of CMV disease. The strategies developed in the bone marrow transplantation population to treat or prevent the development of CMV disease can be extrapolated to other patients groups who are immunosuppressed and at risk for developing clinical manifestations of CMV infection.

Improved detection of HSV by electron microscopy in clinical specimens using ultracentrifugation and colloidal gold immunoelectron microscopy: comparison with viral culture and cytodiagnosis

Three tests were compared to diagnose herpes virus infection: electron microscopy (EM), viral culture (VC) and cytodiagnosis (Tzanck smear). The study comprised 67 patients with skin or mucous membrane lesions suggestive of herpes simplex virus (HSV) infection. The sensitivity of EM increased 25% after virus concentration by ultracentrifugation. Herpes virus infection was confirmed in 55 of the 67 cases by EM or VC or both. EM detected 53 herpes virus-positive lesion samples of which 14 were not detected by VC; only two lesion samples that were herpes virus-positive in VC were not detected by EM. The sensitivities of EM, VC, and Tzanck smear for the group of 55 herpes virus-positive cases were 96%, 75% and 76%, respectively. The specificity of the Tzanck smear was 83% (prevalence 82%). Colloidal gold immuno-EM was used to rapidly type HSV-1, HSV-2 and varicella zoster virus (VZV) present in skin and mucous membrane lesions in less than 4 h. Immuno-EM was able to detect antiviral antibodies on viral envelopes and viral cores in lesion samples with negative VC. Antiviral antibodies do not interfere with typing of herpes viruses by immuno-EM. It is suggested that formation of viral immune complexes and inactivation of virus particles by antibodies may have caused a negative VC. Improved EM is discussed for its applicability to special cases that cannot rely on VC and cytodiagnosis or when rapid diagnosis is required.

Concurrent epidermal involvement of cytomegalovirus and herpes simplex virus in two HIV-infected patients. Military Medical Consortium for Applied Retroviral Research (MMCARR)

Although cytomegalovirus has previously been reported in cutaneous lesions of patients infected with the human immunodeficiency virus, these reports are not common despite the prevalence of this infection and the significant pathologic characteristics that it induces in HIV disease. Rare reports of possible epidermal involvement by cytomegalovirus have never been fully documented and have been believed by some to represent epidermal involvement by varicella-zoster and/or herpes simplex infections, with dermal involvement of cytomegalovirus. We present two cases of concurrent epidermal involvement by cytomegalovirus and herpes simplex virus documented by immunohistochemical studies and DNA hybridization studies and correlate this with the distinctive morphologic features seen in these two viral infections on routine staining.

Diagnosis of cutaneous cytomegalovirus infection: a review and report of a case

Cytomegalovirus infections are a major source of morbidity and mortality in immunocompromised patients. We report a case of cutaneous cytomegalovirus in a patient with the acquired immunodeficiency syndrome, in which routine light microscopy was suggestive but not diagnostic of cytomegalovirus. Immunohistochemical studies of the specimen for cytomegalovirus antigens revealed numerous intracytoplasmic and intranuclear viral inclusions. This case illustrates the utility of immunoperoxidase techniques to diagnose cytomegalovirus infection of the skin rapidly. Immunohistochemistry, DNA in situ hybridization, and polymerase chain reaction have been added to the more routine methods of viral culture and light microscopy to diagnose cytomegalovirus. In this report we review the cases of cutaneous cytomegalovirus in the literature and the laboratory detection methods available to establish this diagnosis.

Successful treatment of disseminated cutaneous cytomegalic inclusion disease associated with Hodgkin's disease

A case of disseminated cutaneous cytomegalic inclusion disease associated with Hodgkin's disease is described. The patient had a diffuse eruption of pruritic, erosive erythematous nodules. Histologically, many inclusion bodies were observed in perivascular areas of the skin lesions. Immunohistologically, the inclusion bodies positively stained with both anticytomegalovirus antibody and anti-factor VIII-related antibody. On electron microscopy many virus particles and dense bodies were found in the area where inclusion bodies were observed. Treatment with high-dose intravenous acyclovir and a large amount of immunoglobulin resulted in prompt healing of the skin lesions. Subsequently, the patient's Hodgkin's disease was well controlled on chemotherapy. The patient steadily improved without relapse of skin lesions 1 year after antiviral therapy was administered.

Clinically occult cytomegalovirus present in skin biopsy specimens in immunosuppressed hosts

Three patients with acquired immunosuppression in whom skin biopsy specimens were obtained to aid in the diagnosis of varying cutaneous eruptions are described. Amphophilic, granular, intranuclear inclusions within endothelial cells compatible with the presence of cytomegalovirus were found unexpectedly. Clinically, occult cytomegalovirus in the skin may be more common than generally appreciated and may not be the sole cause of the eruption for which biopsy specimens are obtained. Also, the need to remain alert for polymicrobial cutaneous infections in the immunocompromised host is emphasized.

Rapid diagnosis in varicella and herpes zoster: re-evaluation of direct smear (Tzanck test) and electron microscopy including colloidal gold immuno-electron microscopy in comparison with virus isolation

The Tzanck test and electron microscopy with the technique of colloidal gold labelling in varicella-zoster virus (VZV) infections were compared with virus isolation in 54 patients with clinically suspected varicella or herpes zoster infection. The Tzanck test and direct electron microscopy can determine whether or not an eruption is herpetic but cannot distinguish between herpes simplex virus (HSV) and VZV infection. However, colloidal gold immuno-electron microscopy, using monoclonal antibodies against HSV and anti-VZV IgG, can distinguish between these two herpes viruses. This achieves the same specificity as virus isolation followed by virus neutralization or virus typing using immunofluorescence techniques. The Tzanck test was positive in 91%, virus isolation, under optimal conditions of sampling and transportation, in 80%, direct electron microscopy (negative staining) in 80%, and colloidal gold immuno-electron microscopy after a virus concentration procedure in 95% of the cases. The colloidal gold technique offers a rapid diagnosis in patients with suspected VZV infection.

Cytomegalovirus infections and the skin

Cytomegalovirus has received renewed recognition as a pathogen in recent years. This article emphasizes the cutaneous manifestations of cytomegalovirus infection.

Dermal abscesses with Staphylococcus aureus, cytomegalovirus and acid-fast bacilli in a patient with acquired immunodeficiency syndrome (AIDS)

A 34-year-old man with acquired immunodeficiency syndrome presented with multiple skin lesions clinically suggestive of molluscum contagiosum. Three skin biopsy specimens were obtained which showed dermal abscesses containing multiple gram-positive cocci admixed with granular necrotic dermal material. In 2, there were cytomegalic inclusions present in macrophages and endothelial cells within the granulation tissue; immunohistochemistry was positive for cytomegalovirus (CMV) antigens. One biopsy specimen also contained a few acid-fast bacilli associated with mononuclear inflammatory cells. Cultures from the lesions grew Staphylococcus aureus and the lesions resolved when the patient was administered a course of systemic cephalosporin. Although lesions with multiple infectious agents have been reported in immunosuppressed patients, this is the first case describing the association of 3 organisms in a single skin biopsy specimen.

Cytomegaloviral epididymitis in a patient with the acquired immune deficiency syndrome

We report on a patient with cytomegaloviral epididymitis and the acquired immune deficiency syndrome. The diagnosis was suggested by epididymitis that was refractory to antibiotics, and by isolation of cytomegalovirus from the urine and semen. The definitive diagnosis was made with immunohistochemical staining for cytomegaloviral antigens in the epididymal ductal cells. Because of the ineffectiveness of antimicrobial agents in this disorder, epididymectomy is the current treatment of choice.