LAUSR

A 47-year-old man who had developed end-stage kidney failure from diabetic nephropathy and had received a live-donor kidney transplant 15 years earlier was admitted to the hospital with high fever. He has been immunosuppressed with cyclosporine, azathioprine, and prednisolone and had a serum creatinine level of 1.3 mg/dl. There was a tender swelling of the left lower limb, with ulceration of the left shin. His inflammatory markers were high. He was treated for cellulitis, with i.v. antibiotics. With resolution of inflammation, he was discharged. Over the next 2 weeks, he developed multiple violaceous nodules over his left shin, which later expanded into larger masses clumped together (Figure 1). Test results showed the following: Hb, 9.8 g/l; serum albumin, 3.8 g/dl; serum calcium, 10.8 mg/dl; and serum creatinine, 1.7 mg/dl. Test results were negative for HIV. Serum protein electrophoresis showed an M band in the gamma region, with a gamma-globulin level of 2.1 g/dl. X-rays showed lytic lesions in the left tibia underlying the cutaneous nodules (Figure 2). There were multiple lytic lesions in the skull (Supplementary Figure S1). Biopsy of the skin lesions confirmed the diagnosis of cutaneous plasmacytoma (Supplementary Figure S2). Polymerase chain reaction for Epstein-Barr virus was strongly positive in the aspirate from a skin nodule. Bone-marrow aspirate showed plasma cell myeloma with more than 60% plasma cells (Supplementary Figure S3). Immunosuppression was reduced, and he was referred for oncology care. The skin lesions shrank rapidly in response to chemotherapy, but the patient succumbed to sepsis 2 weeks later.