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Ulcerating lesions on forearm, fingertips and tongue in a liver‐transplant recipient

A 39-year-old man presented with a 2-week history of an asymptomatic erythematous plaque on the right forearm. The centre of the lesion had superficial ulceration with a ring of peripheral microvesicles (Fig. 1a). Six weeks previously, a superficial irregular circinate ulcer had arisen on the tongue (Fig. 1b), and 4 weeks previously the patient had developed ulceration of the distal phalanges of the right index and middle finger, with loss of the involved nails (Fig. 1c). Treatment with flucloxacillin had been ineffective. The patient had successfully undergone liver transplantation 14 months previously, and liver function was normal. His medication included ciclosporin 150 mg daily, mycophenolate mofetil 360 mg daily and prednisolone 20 mg daily. He had developed pulmonary tuberculosis 4 months before presentation, and this was being treated with isoniazid, rifampicin, ethambutal and pyrazinamide.