June 2004

Fig.1

History: A 43 year-old white male with a history of stage IVB nodular sclerosing Hodgkin's Disease underwent neoadjuvant chemotherapy with cyclophosmamide and MENSA rescue followed by total body irradiation before receiving an allogenic stem cell transplant from his HLA-identical sister in August of 2003. His course was complicated by grade IV Graft vs. Host Disease (GVHD) of the gastrointestinal tract and grade II GVHD of the hands. His GVHD was treated with infliximab, prednisone, tacrolimus and mycophenolate. His course was further complicated in October of 2003 when he was found to have Cytomegalovirus (CMV) viremia and was placed on a course of ganciclovir 450 mg.

On December 19, 2003, he presented to dermatology with the chief complaint of a pruritic plaque on his left forearm. His oncologist confirmed that the lesion had been present for 2.5 months and was unresponsive to oral antibiotics. He denied having an intravenous catheter or tape placed at the site of the lesion. He recalled noticing an abrasion in the area of the lesion subsequent to rubbing his arm on a table. His medications included mycophenolate mofetil 1000 mg bid, prednisone 5 mg qd, tacrolimus 1 mg bid, fluconazole 100 mg bid, and amlodipine 6 mg qd. He denied fever or chills.

Physical Examination: : A 10 x 6 cm scaly, erythematous plaque with a central black eschar measuring 3.5 x 2.5 cm was noted on his left forearm (Figure 1). No other skin lesions were noted.

Laboratory Values: A complete blood count with differential revealed a white blood cell count of 6500/uL (nl = 4.5-11 x 103 /uL) and an absolute neutrophil count of 2800/uL, or 43% (nl = 57-67%).

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