PMC9234608_01
Two painful and pruritic ulcerated papules with peripheral erythema on the right forearm in an immunosuppressed patient.
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Tacrolimus, and 5 mg/day Prednisone. Two years after solid organ transplantation, the patient felt a sudden onset of sharp pain on the right forearm that had developed into two small ulcerations the following day (Fig. 1).
Erythematous papules and plaques with overlying necrotic eschar and peripheral rim of erythema distributed across the patient's body without dermatomal pattern: A, Right eyebrow; B, Right forearm.
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Physical examination revealed erythematous papules and plaques with overlying necrotic eschar and peripheral rim of erythema on the right eyebrow (1 cm; Fig. 2A), right forearm (3 x2 cm; Fig. 2B), right posterior upper arm, right temple, and right lower quadrant of abdomen (<1 cm) that were nondraining.
Punch biopsy obtained from the periphery of the forearm lesion shows epithelial hyperplasia, ulceration, eosinophilic intranuclear inclusions, and multinucleated keratinocytes surrounded by a dense inflammatory infiltrate, typical of varicella or herpesvirus infection. (H&E); Original magnifications: A, x10; B, x40.
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Histology showed epithelial hyperplasia, ulceration, eosinophilic intranuclear inclusions and focal multinucleated keratinocytes surrounded by a dense inflammatory infiltrate (Fig. 3), consistent with varicella or herpesvirus infection.