title: Oral ulceration associated with concurrent herpes simplex virus, cytomegalovirus, and Epstein-Barr virus infection in an immunocompromised patient.
abstract: In immunocompromised patients, oral ulcerations are common and have a wide spectrum of causes, including herpesvirus infection. We report on a case in which an oral ulcer was simultaneously infected by herpes simplex (HSV), cytomegalovirus (CMV), and Epstein-Barr virus (EBV) in a kidney-pancreas transplant recipient. A 46-year-old woman presented with a clinically nonspecific dorsal tongue ulcer of 3 months duration. Histopathologic evaluation indicated keratinocytes exhibiting herpetic viral cytopathic effect. Nuclear and cytologic alterations suggestive of CMV infection were found in endothelial cells subjacent to the ulcer. Immunohistochemistry testing for HSV and CMV was positive in these cells. Large atypical mononuclear cells were also evident in the ulcer bed's inflammatory infiltrate, which had intense nuclear positivity for Epstein-Barr encoding region in situ hybridization. We believe this is the first well-documented report of the definitive concomitant presence of HSV, CMV, and EBV in an immunocompromised patient. Although the pathogenesis of coinfected ulcers remains unknown, a synergistic effect is possible.
authors.affiliation: Assistant Professor, Department of Stomatology, Faculté de Médicine Dentaire, Université de Montréal, Montreal, Quebec, Canada. Electronic address: Gisele.mainville.1@umontreal.ca.
authors.forename: Gisele N
authors.initials: GN
authors.lastname: Mainville
authors.affiliation: Professor, Department of Pathology and Laboratory Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA.
authors.forename: William L
authors.initials: WL
authors.lastname: Marsh
authors.affiliation: Emeritus Professor, Division of Oral and Maxillofacial Pathology and Radiology, The Ohio State University College of Dentistry, Columbus, Ohio, USA.
authors.forename: Carl M
authors.initials: CM
authors.lastname: Allen
mesh_terms: D000998:Antiviral Agents / Q000627:therapeutic use; D001706:Biopsy; D003586:Cytomegalovirus Infections / Q000150:complications* / Q000188:drug therapy; D020031:Epstein-Barr Virus Infections / Q000150:complications* / Q000188:drug therapy; D005260:Female; D006561:Herpes Simplex / Q000150:complications* / Q000188:drug therapy; D006801:Humans; D016867:Immunocompromised Host; D007150:Immunohistochemistry; D007166:Immunosuppressive Agents / Q000627:therapeutic use; D017403:In Situ Hybridization; D016030:Kidney Transplantation; D008875:Middle Aged; D019226:Oral Ulcer / Q000821:virology*; D016035:Pancreas Transplantation
chemical_list: D000998:Antiviral Agents; D007166:Immunosuppressive Agents