ARTICLE
Cytomegalovirus (CMV) infections frequently occur in patients with acquired
immunodeficiency syndrome (AIDS). The most frequent involved sites are
the eye and the gastrointestinal tract. Cutaneous CMV lesions are very
rare. We report the case of a patient with a large penile ulcer due to
CMV. (Key words: penile ulceration, cytomegalovirus, AIDS.)
Cytomegalovirus (CMV) infections frequently occur in patients with acquired
immunodeficiency syndrome (AIDS). The most frequently involved sites are
the eye and gastrointestinal tract. Cutaneous CMV lesions are very rare.
We report the case of a patient with a large penile ulcer caused by CMV.
A 32-year-old man, with a history of intravenous
drug abuse, was diagnosed as having AIDS in November 1991. He also had
C hepatitis and oesophageal candidiasis. Treatment with zidoduvine and
cotrimoxazole was started in December 1991. He was admitted in September
1993 for a fever which had lasted for 2 months with a 4 kg weight loss.
Prior to his admission, he had been given benzathine-penicilline for a
very large, painless penile ulcer of 6 weeks duration. This treatment
had had no effect. He also complained of painful dysphagia.
Physical examination revealed a 3 cm, circumferential, superficial penile
ulceration, with a clean base and a well-defined, regular edge (Fig.
1). There was no inguinal lymphadenopathy.
Cultures for bacteria, cytodiagnosis, and syphilitic
serology were negative. The CD4 cell count was 13/mm3. The
patient was treated with intravenous (IV) acyclovir (30 mg/kg daily) for
8 days without clinical improvement.
Histopathological examination showed epidermal changes with hyperplasia,
hyperkeratosis, neoangiogenesis, and cytomegalic endothelial cells with
intranuclear inclusions. Immunohistochemical study (antiperoxidase method)
was positive with a CMV antibody, but negative with a Herpes simplex
virus (HSV) antibody. In situ hybridization studies for HSV were
also negative.
The oesophageal endoscopy showed two ulcerations
of the oesophagus. Histopathological and immunohistochemical studies pointed
towards CMV oesophagitis. No evidence of any other CMV localization was
found (ophthalmic examination, rectosigmoidoscopy), and CMV viremia was
negative.
Specific treatment with intravenous gancyclovir (5 mg/kg twice daily)
induced complete healing of both the penile ulcer and oesophageal ulcerations.
The treatment was continued for one month ; the maintenance dose was 5
mg/kg/day. In November 1993, phimosis developed which was treated by circumcision.
The patient died two months later of a cerebral vascular accident (in
an infectious, not classic, context).
Our patient had a penile CMV ulceration, demonstrated
by histopathological and immunohistochemical studies, with no other infectious
agent detected. He also had oesophageal CMV involvement. Complete healing
of both sites was achieved with gancyclovir treatment.
The non-response to acyclovir treatment precluded a herpes infection.
Differential diagnoses of penile ulceration can include foscarnet toxicity
[1], and a bullous drug reaction, which were both ruled out by the patient's
history.
This observation is very unusual: only one similar case of penile CMV
ulcer, with no other pathogenic agent involved has previously been reported
in the literature [2]. The clinical features are similar and remarkable.
The most frequent cutaneous manifestations of CMV infection in AIDS
[3-5] are torpid skin ulcerations, preferentially perianal, during CMV
septicemia, with diffuse visceral involvement. Other reported presentations
are morbilliform and maculopapular eruptions, vesicles and vesiculobullous
lesions, nodules, purpura, indurated and sometimes hyperpigmented plaques.
More recently, verrucous lesions with or without central ulceration have
been described [3]. Finally, oral manifestations have been reported with
ulcerated and necrotic lesions of the tongue, buccal mucosa and pharynx
[5].
REFERENCES
1. Fegueux S., Salmon D, Picard-Dahan C, et al. Penile ulcerations
with Foscarnet. Lancet 1990; 1: 547 (lettre).
2. Fong IW. Association of cytomegalovirus infection and penile ulcer.
Ann Intern Med 1993; 119: 1149.
3. Bournerias I, Boisnic S, Patey O, et al. Unusual cutaneous
cytomegalovirus involvement in patients with acquired immunodeficiency
syndrome. Arch Dermatol 1989; 12: 1243-6.
4. Toome BK, Bowers KE, Scott GA. Diagnosis of cutaneous cytomegalovirus
infection: a review and report of a case. J Am Acad Dermatol 1991;
24: 857-63.
5. Lesher JL, Augusta MD. Cytomegalovirus infections and the skin. J
Am Acad Dermatol 1998; 18: 1333-8.
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