10.5826/dpc.1302a104
text/xml
2160-9381
2745
en
Laxmisha  Chandrashekar 
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
Cutaneous Cytomegalovirus Infection in a Case of Myasthenia Gravis 
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Image Letter
2023-04-29
2022-08-03
2023-04-29
2023-06-05
e2023104
Dermatol Pract Concept
Laxmisha  Chandrashekar 
2023/04/29
10.5826/dpc.1302a104
e2023104
Department of Dermatology & STD, JIPMER, Puducherry, India
2160-9381
en
e2023104
Lei DK, Saul KD, Jackson JD, Ishaq NY, Brodell RT. Perianal Ulceration in a Young Woman. Am J Dermatopathol. 2016 Sep; 38(9):683-4.
Cutaneous Cytomegalovirus Infection in a Case of Myasthenia Gravis 
https://dpcj.org/index.php/dpc/article/download/2745/2090
      Cutaneous Cytomegalovirus Infection in a Case
                 of Myasthenia Gravis
     Sree Yazhini Ramar1, Logamoorthy Ramamoorthy1, Bheemanathi Hanuman Srinivas2,
                                Laxmisha Chandrashekar1


1 Department of Dermatology & STD, JIPMER, Puducherry, India
2 Department of Pathology, JIPMER, Puducherry, India



Citation: Ramar SY, Ramamoorthy L, Srinivas BH, Chandrashekar L. Cutaneous Cytomegalovirus Infection in a Case of Myasthenia
Gravis. Dermatol Pract Concept. 2023;13(2):e2023104. DOI: https://doi.org/10.5826/dpc.1302a104
Accepted: September 26, 2022; Published: April 2023
Copyright: ©2023 Ramar et al. This is an open-access article distributed under the terms of the Creative Commons
Attribution-NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted
noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding author: Laxmisha Chandrashekar, M.D, Professor, Department of Dermatology & STD, JIPMER, Puducherry, Pin-605006.
E-mail: laxmishac@gmail.com




Case Presentation                                                        Teaching Point
A 66-year-old man with a known case of myasthenia ­gravis                Human cytomegalovirus (CMV) infection usually occurs
presented with multiple painful ulcers over the buttock,                 in immunocompetent individuals causing the infectious
lower abdomen, and trunk for one month. Cutaneous exam-                  mononucleosis-like syndrome. Although systemic symp-
ination showed multiple ecthymatous to ulcerative lesions                toms are more common in immunosuppressed individu-
with slough over the buttocks, perianal area, and over the               als with CMV infection, some can present with cutaneous
lower abdomen and upper back, largest measuring 3 x 3 cm                 manifestations that are difficult to diagnose based on
to smallest measuring 1x1 cm (Figure 1). Wedge biopsy from               their clinical appearance. The cutaneous manifestations
the perianal ulcer showed ulceration of the epidermis with               of the CMV virus are maculopapular rash, blisters, bulla,
lymphocytic infiltrate with epithelioid histiocytes and for-             erosions, plaques, and nodules. The most common pre-
eign body type of giant cells in the superficial dermis. The             sentation is cutaneous ulcers, which may be tender or
endothelial cells exhibited nucleomegaly with basophilic                 non-tender and usually located over the genitalia, perianal,
smudgy chromatin with occasional basophilic prominent                    gluteal regions, and oral mucosa [1]. Since the virus re-
intra-nuclear inclusions. Immunohistochemistry showed nu-                mains latent in the gastrointestinal tract and sheds during
clear positivity of the endothelial cells for cytomegalovirus.           reactivation, leading to the preferential location of the




Image Letter | Dermatol Pract Concept. 2023;13(2):e2023104                                                                         1
                              Figure 1. Multiple ulcers over the perianal and gluteal region with
                              minimal slough size ranging from 3 x 3 cm to 1 x 1 cm.




ulcers over the perianal and gluteal area [2]. CMV-induced       References
skin ulcers should be considered in immunosuppressed pa-
tients who are not responding to antibiotic therapy, simi-        1. Drozd B, Andriescu E, Suárez A, De la Garza Bravo MM.
                                                                     Cutaneous cytomegalovirus manifestations, diagnosis, and
                                                                     ­
lar to our case. The diagnosis of CMV ulcers can be made
                                                                     treatment: a review. Dermatol Online J. 2019; 25(1):13030
by ­histology with immunohistochemistry and by serum
                                                                     /qt84f936cp. PMID: 30710895.
polymerase chain reaction. Histopathological examina-             2. Lei DK, Saul KD, Jackson JD, Ishaq NY, Brodell RT. Perianal
tion shows owl eye inclusions with cytopathic changes                ­Ulceration in a Young Woman. Am J Dermatopathol. 2016; 38(9):
predominantly over the vascular endothelial cells and                 683-684. DOI: 10.1097/DAD.0000000000000294. PMID:
­macrophages [2].                                                     27541168.




2                                                                       Image Letter | Dermatol Pract Concept. 2023;13(2):e2023104
