Dermatology: Practical and Conceptual


Image Letter | Dermatol Pract Concept. 2023;13(2):e2023104 1

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

A 66-year-old man with a known case of myasthenia  gravis 

presented with multiple painful ulcers over the buttock, 

lower abdomen, and trunk for one month. Cutaneous exam-

ination showed multiple ecthymatous to ulcerative lesions 

with slough over the buttocks, perianal area, and over the 

lower abdomen and upper back, largest measuring 3 x 3 cm 

to smallest measuring 1x1 cm (Figure 1). Wedge biopsy from 

the perianal ulcer showed ulceration of the epidermis with 

lymphocytic infiltrate with epithelioid histiocytes and for-

eign body type of giant cells in the superficial dermis. The 

endothelial cells exhibited nucleomegaly with basophilic 

smudgy chromatin with occasional basophilic prominent 

intra-nuclear inclusions. Immunohistochemistry showed nu-

clear positivity of the endothelial cells for cytomegalovirus.

Teaching Point

Human cytomegalovirus (CMV) infection usually occurs 

in immunocompetent individuals causing the infectious 

mononucleosis-like syndrome. Although systemic symp-

toms are more common in immunosuppressed individu-

als with CMV infection, some can present with cutaneous 

manifestations that are difficult to diagnose based on 

their clinical appearance. The cutaneous manifestations 

of the CMV virus are maculopapular rash, blisters, bulla, 

erosions, plaques, and nodules. The most common pre-

sentation is cutaneous ulcers, which may be tender or 

non-tender and usually located over the genitalia, perianal, 

gluteal regions, and oral mucosa [1]. Since the virus re-

mains latent in the gastrointestinal tract and sheds during 

reactivation, leading to the preferential location of the 



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

ulcers over the perianal and gluteal area [2]. CMV-induced 

skin ulcers should be considered in immunosuppressed pa-

tients who are not responding to antibiotic therapy, simi-

lar to our case. The diagnosis of CMV ulcers can be made 

by  histology with immunohistochemistry and by serum 

polymerase chain reaction. Histopathological examina-

tion shows owl eye inclusions with cytopathic changes 

predominantly over the vascular endothelial cells and 

 macrophages [2].

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.

References

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 Cutaneous cytomegalovirus manifestations, diagnosis, and 

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2. Lei DK, Saul KD, Jackson JD, Ishaq NY, Brodell RT. Perianal 

 Ulceration in a Young Woman. Am J Dermatopathol. 2016; 38(9): 

683-684. DOI: 10.1097/DAD.0000000000000294. PMID: 

27541168.