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JAMA Dermatology Clinicopathological Challenge
January 2016

Ulcerative Pretibial Lesions in the Setting of Multifactorial Immunosuppression

Author Affiliations
  • 1Georgetown University School of Medicine, Washington, DC
  • 2Department of Dermatology, Georgetown University Hospital/Washington Hospital Center, Washington, DC
JAMA Dermatol. 2016;152(1):85-86. doi:10.1001/jamadermatol.2015.3811

A man in his 50s with a kidney transplant to treat adult polycystic kidney disease, common variable immunodeficiency, and type 2 diabetes mellitus was admitted for a 1-month history of an enlarging left lower extremity mass. He reported that the lesion spontaneously ulcerated, was occasionally painful, and intermittently drained small amounts of sanguinopurulent fluid. He pointed out a similar but smaller ulcerated nodule on the right lower extremity but denied any preceding trauma to the affected areas. His lesions were unresponsive to a course of oral sulfamethaxazole with trimethoprim, prompting surgical incision and drainage and initiation of intravenous vancomycin and piperacillin with tazobactam therapy. Physical examination revealed an edematous left leg with a 3.5-cm blue-gray tumor with overlying superficial ulceration surrounded by a collarette of delicate scale. Superior to this lesion, there was a firm 7-mm bluish papule. On the right anterior leg, there was a 1.5-cm violaceous nodule with small central ulceration and overlying crust (Figure, A). Deep wound culture of the larger left leg lesion and punch biopsy specimens taken from the larger left leg lesion for histopathological analysis (Figure, B-D) and tissue culture of the right leg lesion were obtained.

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