Cytomegalovirus-induced petechial rash in an immunocompetent patient with acute hepatitis

A 32-year-old woman presented with a 10-day history of rash and fatigue. Her medical history was significant for hypothyroidism treated with levothyroxine. Physical examination revealed erythematous punctate lesions on the lower extremities, discrete to confluent, without mucosal involvement, desquamation, lymphadenopathy, or other systemic signs. Laboratory evaluation showed a leukocyte count of 6.61×10³/?L with lymphocytic predominance (63.1%, absolute 4.17x10³/μL) and normal platelet count (193x10³/μL). Inflammatory markers (ESR, CRP) and coagulation profile were within normal limits. Liver tests demonstrated marked hepatocellular injury with ALT 886 U/L and AST 566 U/L without cholestasis. Peripheral blood smear revealed atypical lymphocytes. Abdominal ultrasonography showed mild hepatosplenomegaly. Serology confirmed acute primary cytomegalovirus (CMV) infection (IgM positive, low-avidity IgG). Differential diagnosis included Epstein-Barr virus infection, autoimmune hepatitis, and drug-induced hypersensitivity reactions including DRESS syndrome. Infectious diseases specialists recommended conservative management, whereas hepatologists favored antiviral therapy given the severity of hepatitis; ultimately, a conservative approach was adopted with close monitoring. During follow-up, aminotransferases peaked at ALT 1149 U/L and AST 663 U/L, accompanied by nausea, right upper quadrant pain, and profound fatigue. The cutaneous eruption resolved within three weeks, and liver enzymes normalized within five weeks. At the six-week follow-up, serology showed increasing IgG avidity and declining IgM titers. In immunocompetent individuals, CMV infection is typically asymptomatic, and clinically significant disease remains underrecognized. Cutaneous involvement is rarely reported, and transaminase elevations rarely exceed fivefold the normal limit, as in this case. This case highlights an uncommon presentation of CMV infection in an immunocompetent adult with exanthem and severe acute hepatitis.