Cytomegalovirus in an AIDS patient

A 41-year-old woman with advanced HIV infection (CD4 cell count of 4 cells per μL) was admitted at our hospital with an ulcer on the central area of the tongue’s dorsal surface that started 1 week before (fi gure, A). She had fever, weight loss, and a recent diagnosis of histoplasmosis of the lymph nodes that was being treated with oral itraconazole. At the examination, the tongue was tender and the ulceration was involved by atrophy and elongated fi liform papillae that are typical of a hairy tongue, with a dark colour secondary to porphyrin pigment deposition by bacterial metabolism. A biopsy of the ulcer showed minimal epidermal changes and an “owl’s eye” appearance of the endothelial cells, which is pathognomonic for cytomegalovirus infection. The biopsy was negative for Histoplasma capsulatum organisms. No other site was aff ected by cytomegalovirus. Intravenous ganciclovir for 14 days was started with complete regression of the tongue ulcer (fi gure, B). The patient was started on antiretroviral treatment (stavudine, lamivudine, and efavirenz) and, as of February, 2006, she was asymptomatic, with a CD4 cell count of 208 cells per μL and a viral load of less than 50 copies per mL. She has had no further cytomegalovirusrelated complications. In patients with advanced AIDS, cytomegalovirus is a frequent cause of chorioretinitis, oesophagitis, pneumonitis, and chronic perineal ulcerations. It has also been involved in endocrine, bone marrow, central nervous system, and kidney abnormalities. Cutaneous manifestations are often atypical and range from vesicles to nodules and chronic ulcerations, but rarely aff ect the tongue. However, tongue involvement in advanced AIDS is common. The tongue is aff ected by local rather than systemic pathologies and a large number of concomitant lesions are often present. The most common lesions are candidosis, hairy leucoplakia, non-specifi c chronic glossitis, melanotic pigmentation, and herpes simplex infection. Fortunately, mucocutaneous lesions associated with cytomegalovirus or other herpesvirus infection respond well to systemic antiviral therapy but are diffi cult to diff erentiate from other ulcerogenic diseases—eg, aphthous major, necrotising stomatitis, and other unspecifi ed ulcerations—without biopsy and histopathological examination. Cytomegalovirus in an AIDS patient