Cytomegalovirus-Induced Perineal Ulcerations in a Woman: Case Report and Review of the Literature

A 48-year-old woman with a history of rheumatoid arthritis and insulin-dependent diabetes mellitus was admitted to the hospital with respiratory depression and somnolence following an accidental narcotic overdose. Two weeks prior to admission, she developed painful perineal ulcerations requiring opiate analgesics. She was hospitalized and treated for pneumonia four months prior with a full course of ceftazidime, doxycycline, and bactrim. The patient had a long history of rheumatoid arthritis treated with prednisone, azathioprine, and methotrexate. Physical examination revealed several small, shallow ulcerations in the suprapubic area and on the labia. A Tzank preparation of the perineal ulcers was negative. A 4 £ 4 mm punch biopsy of the labia demonstrated epidermal ulceration and a dermal perivascular inflammatory infiltrate with enlarged endothelial cells and eccrine glands (Figs. 1 and 2). Intracytoplasmic and intranuclear inclusions (Fig. 3) consistent with human cytomegalovirus (CMV) were demonstrated using an anti-CMV immunoperoxidase detection kit (DAKO Corp, Carpinteria, CA). Serum IgM and IgG anti-CMV antibodies were also elevated. Immunohistochemical staining for herpes simplex virus I/II, respiratory syncitial virus, and influenza A virus were negative. HIV testing was negative. During her hospitalization, the patient’s respiratory status declined and she was transferred to the medical intensive care unit. Chest radiographs demonstrated bilateral, diffuse, interstitial infiltrates. An open lung biopsy was performed and was positive for cytomegalovirus infection. Fungal, bacterial, and mycobacterial stains