Patients in the late stages of the acquired immunodeficiency syndrome (AIDS) often present with chorioretinitis, esophagitis, enterocolitis, hepatitis, adrenalitis, encephalitis, and occasionally pneumonitis due to cytomegalovirus (CMV) infection. I recently cared for a patient with human immunodeficiency virus (HIV) infection and a longstanding penile ulceration due to CMV infection, the first reported instance of this association.

A 25-year-old black man from Guyana presented with a painless penile ulcer of 6 months' duration, a 4.5-kg weight loss, and a 2-week history of fever, chills, and malaise. The patient is heterosexual with a history of previous intravenous drug abuse. Treatment with amoxicillin and local Polysporin ointment (Burroughs Wellcome, Research Triangle Park, North Carolina) for 2 weeks had no effect. Physical examination was significant for the presence of oral thrush and a large, nontender superficial ulceration of the glans penis and under-surface of the foreskin approximately 3 x 4 cm in size (Figure 1). Dark-field examinations of ulcer exudate and serum tests for venereal disease were negative; special cultures for herpes simplex virus, Haemophilus ducreyi, fungi, and mycobacteria were also negative. Biopsy of the ulcer showed chronic inflammatory infiltrate with the macrophages and endothelial cells showing enlarged nuclei with intranuclear inclusion. Results of immunostaining for CMV early antigen were positive. Serologic examinations for HIV (by enzyme-linked immunosorbent assay [ELISA] and Western blot) were positive, the CD4 cell count was 3/mm³ (1% of lymphocytes), and the CD4/CD8 ratio was 0.06.

View larger version (152K): [in this window] [in a new window]   Figure 1. Extensive superficial ulceration of the glans penis and under-surface of the foreskin in a patient with cytomegalovirus infection.

The patient was initially treated with acyclovir, 2000 mg/d for 7 days, with no improvement and some progression of the ulcer. After 1 week of therapy with intravenous ganciclovir, 5 mg/kg twice daily, marked improvement (>50% reduction) occurred, and the ulcer eventually healed.

Cytomegalovirus has not been previously reported to cause penile ulcers, but ulceration of the penis has been attributed to treatment with foscarnet in a patient with CMV infection [1]. Perineal ulcers in five immunosuppressed patients have been reported to show the presence of CMV [2]; however, herpes simplex virus was also identified in three of the five specimens, and CMV was not considered to be the cause of the ulcers. In our patient, CMV appeared to be etiologic because no other agent could be implicated, and a definite response was seen with ganciclovir but not with acyclovir.