Concurrent cytomegalovirus and herpes simplex virus infections in skin biopsy specimens from two AIDS patients with fatal CMV infection

Cytomegalovirus (CMV) infection involving the skin is rare. Only a few cases have been documented by skin biopsies, including three patients with acquired immunodeficiency syndrome (AIDS). We report concurrent CMV and herpes simplex virus (HSV) infections in skin biopsy specimens from nonanogenital sites in two adult AIDS patients with fatal CMV infection. In one case, a nonhealing ulcer on the lower lip provided the first clue to systemic CMV infection. In the other case, two necrotic papules developed on the legs during the course of systemic CMV infection. Microscopically diagnostic findings for both infections were present. Immunoperoxidase stains were positive for CMV in both cases and HSV in one case. In both cases, the infections were not appreciated in the original interpretations of the biopsy material. This may reflect either a low index of suspicion and/or unfamiliarity of the microscopic features of CMV and, to a lesser extent, of HSV infection in the skin. Familiarization with the diagnostic cytopathic changes of these viral infections and a high index of suspicion are essential for correct diagnosis in evaluation of skin lesions of immunocompromised hosts.