January 2015






HPI: A 50-year-old Caucasian man with a past medical history of end-stage renal disease (status post failed renal transplant on hemodialysis), type I diabetes mellitus, hypertension, hyperlipidemia, atrial fibrillation, and gout presented with left forearm swelling concerning for a wound infection. The patient had received a living unrelated donor renal transplant in 1999 which subsequently developed chronic transplant glomerulopathy. One month after re-initiation of hemodialysis and cessation of anti-rejection medications, he noticed a rash around the left arm fistula site with intermittent elbow pain, redness, and swelling. He received five courses of oral antibiotics without resolution of the rash prior to hospital admission.


PMH:End-stage renal disease, Type I Diabetes Mellitus, Hypertension,

Hyperlipidemia, Atrial Fibrillation, Gout


Social Hx:Married,Disabled, former carpenter

Denies alcohol, tobacco, or IVDU


Penicillin (pruritus)

Medications:ASA, Cacitriol, Warfarin, Digoxin, Ergocalciferol

Tamsulosin, Insulin lispro pump,Furosemide, Atorvastatin

Gemfibrozil, Megestrol acetate, Midodrine, Nephro-Vite

Esomeprazole, Prednisone, Hydroxyzine,Montelukast sodium

Albuterol inhaler, Tramadol


Physical exam:

The left forearm was diffusely edematous and erythematous from hand to elbow. There was a 1 cm circumferential black ulcer on the dorsal left hand with tracking of similar ulcers up the arm in a sporotrichoid distribution (Fig. 1). There was a larger black necrotic eschar on the ulnar aspect of the left forearm (Fig 2). The entire extremity from the elbow distally was exquisitely tender to palpationor manipulation. Grip strength of the left hand was severely decreased.


Laboratory results:WBC count: 11,000, 83% neutrophils

Hemoglobin: 12.5, Creatinine: 5-6, ESR: 66



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