Abstract: SA-PO0996
Should You Surveil the Skin and the Serum? Invasive Cytomegalovirus Presenting with Cutaneous Lesions Following Heart-Kidney Transplant
Session Information
- Transplantation: Clinical - Case Reports
November 08, 2025 | Location: Exhibit Hall, Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Transplantation
- 2102 Transplantation: Clinical
Authors
- Panthappattu, Justin Joseph, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, United States
- Wilson, Clara, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, United States
- Hummel, Katie, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, United States
- Atlas, Olivia, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, United States
- Lim, Mary Ann C., Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, United States
- Ranganna, Karthik M., Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, United States
Introduction
Cytomegalovirus (CMV) can infrequently present with skin lesions. Early detection can prevent disease-related morbidity and mortality.
Case Description
A 34-year-old male patient with non-ischemic cardiomyopathy from giant cell myocarditis and stage IV chronic kidney disease from cardiorenal disease presented eight months after simultaneous heart-kidney transplant for evaluation of truncal ulcerative skin lesions in a non-dermatomal distribution associated with erythema, pain and discharge. He received CMV discordant transplant and completed prophylactic valganciclovir two months prior to presenting. His course was complicated by low level BK viremia and remains on tacrolimus, mycophenolate and prednisone. He denied fevers, confusion, vision changes, dyspnea, pleuritic chest pain, nausea and vomiting but reported non-bloody loose stools since transplant and recent gingival pain. Skin biopsy showed neutrophilic inflammation, intermixed lymphohistiocytic infiltrate and gram-positive bacterial aggregates without amastigotes. Viral staining revealed cells with large, atypical nucleoli and multiple nucleoli diagnostic of cutaneous CMV. CMV quantitative PCR was elevated at 227,000 IU/mL (log 5.4). Culture of the lesion grew methicillin-resistant Staph aureus. He was treated with IV ganciclovir, daptomycin and reduced immunosuppression leading to complete resolution.
Discussion
Cutaneous lesions are worrisome in the post-transplant phase. CMV discordance increases the risk of donor-derived infection which can lead to tissue-invasive disease necessitating longer periods of CMV-specific prophylaxis. Though not universally recommended, post-prophylaxis surveillance can be considered in high-risk patients and may lead to earlier detection. In the immunocompromised host, CMV infection presents on a spectrum from asymptomatic viremia and cytopenia to generalized symptoms of fevers or malaise to invasive diseases such as meningoencephalitis, retinitis, pneumonitis or enterocolitis. Less commonly, cutaneous lesions can indicate invasive CMV infection with the most common finding being ulcerative erythematous plaques in a peri-genital or peri-anal distribution. A high index of suspicion and early identification of invasive disease can prevent graft failure and death from untreated CMV.