History: A 65 year old male with history of emphysema secondary to pulmonary arterial hypertension status post bilateral lung transplant in 2010 on tacrolimus, mycophenolate mofetil, and prednisone presented with a 3 week history of a rash that erupted on the right dorsal forearm. The rash was mildly itchy, but was otherwise relatively asymptomatic. Pt. denies any known inciting factors or triggers for the rash and has never had it before. Review of systems was positive for chronic dyspnea on exertion that had not acutely changed. Review of systems was negative for fevers, chills, coughs, night sweats, fatigue.
PMH: Atrial Fibrillation, Diabetes Mellitus Type 2, Chronic Kidney Disease - stage 2, Cutaneous Squamous Cell Carcinoma of the scalp s/p Moh’s resection 2014, h/o of CMV viremia and pneumonia in 2010, H/o of aspergillus bronchitis, H/o of Bronchiolitis Obliterans Syndrome in 2012
Social Hx: Extensive Outdoor Exposure (Works in a garden and yard), former smoker, denies illicit drugs
Family Hx: Diabetes Mellitus (mother)
Medications: Alendronate, Amiodarone, Azithromycin, Bactrim, Calcium, Cholecalciferol, Diltiazem, Furosemide, Insulin Lispro, Insulin NPH, Metoprolol Tartrate, Mycophenolate Mofetil, Prednisone, Roprinole, Tacrolimus, Warfarin
Allergies: No Known Drug Allergies
Physical Exam: General: No Acute Distress, Alert and oriented x 3, Afebrile.
Upper Extremities: occupying ~50% of the right dorsal forearm there were multiple erythematous papules coalescing into indurated plaques with few overlying white papules; non tender, no spontaneous drainage, no edema (Figure 1 and Figure 2)
Left upper arm = solitary indurated erythematous discrete papule (not pictured)
Laboratory Results: CBC = WBC 8.8 (83% Neutrophils), HgB 10.9, Hct 33.0, Plt 192; CMP = WNL; UA = Negative; INR = 2.12; Tacrolimus trough = 7.5
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