Verrucous Skin Lesions in a Case of Acute Lymphoblastic Leukemia: A Rare Manifestation of Cytomegalovirus Infection

Excerpt

A 15 year-old-girl, known case of Pro T cell acute lymphoblastic leukemia on maintenance chemotherapy (vincristine, methotrexate and 6-mercaptopurine) presented with multiple skin lesions for 3 weeks duration. She had applied antibiotic cream (mupirocin) and taken oral cloxacillin with no relief. She was afebrile and had well-defined proliferating, necrotic, warty lesion with overlying ‘whorled’ crusts on ventral aspect of left forearm measuring 5 × 5 cm with infiltrated and erythematous surrounding skin (Fig. 1a). Similar lesions were also noted on right infra scapular area (4 × 4 cm) (Fig. 1b) and columella of nose (1 × 1 cm) (Fig. 1c). A few satellite lesions were noted (Fig. 1b). She had hemoglobin of 120 g/L, WBC 2.2 × 10⁹/L, platelet 370 × 10⁹/L with normal peripheral blood smear. Possibility of atypical mycobacterial, fungal or viral skin infection was considered. Biopsy from the margin of the left forearm ulcer showed cytoplasmic inclusion bodies with typical ‘owl eye’ appearance suggestive of CMV infection (Fig. 2a), which was confirmed by CMV immunostain (Fig. 2b). CMV DNA PCR was planned but couldn’t be done due to financial constraints. Her chemotherapy was withheld and she received oral valganciclovir 900 mg twice daily. After 3 weeks, she had significantly improved skin lesion.

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