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JAMA Dermatology Clinicopathological Challenge
April 3, 2019

Violaceous Nodules in an Annular Configuration Encircling an Orthotopic Liver Transplant Scar

Author Affiliations
  • 1Division of Dermatology, David Geffen School of Medicine at UCLA, University of California, Los Angeles
  • 2Department of Dermatology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California
  • 3Department of Pathology, Southern California Permanente Medical Group, Los Angeles, California
JAMA Dermatol. 2019;155(5):619-620. doi:10.1001/jamadermatol.2018.5615

A man in his 50s presented with an abdominal skin eruption of 2 days’ duration. His medical history included hepatitis C, cirrhosis, and an orthotopic liver transplant (OLT) 3 years prior that was subsequently treated with tacrolimus, 5 mg, and mycophenolate, 750 mg, twice daily. Approximately 2½ years after the transplant, the patient developed gastric outlet obstruction secondary to an infiltrative gastric wall mass. The gastric wall mass was found to be associated with plasmablastic posttransplantation lymphoproliferative disorder (pPTLD). He was subsequently instructed to stop use of mycophenolate and decrease use of tacrolimus to 0.25 mg daily, then treated with 1 cycle of CHOP chemotherapy (cyclophosphamide, doxorubicin hydrochloride, vincristine sulfate, and prednisone) and lenalidomide, resulting in symptomatic and radiologic improvement. Five weeks after treatment with CHOP chemotherapy, the patient presented with an acute-onset abdominal skin eruption without fever or pain. A computed tomographic scan of the abdomen and pelvis showed possible abdominal wall cellulitis, so treatment with piperacillin-tazobactam and vancomycin was empirically started. Physical examination revealed confluent indurated violaceous papules and plaques coalescing into an annular pattern encircling the healed OLT incisional scar with central sparing (Figure 1A). A 4-mm punch biopsy specimen was obtained for histopathological evaluation (Figure 1B and C) and bacterial and fungal cultures.

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