A 52-year-old male with recent bilateral lung transplantation is hospitalized with three weeks fever, cough, and dyspnea. He received his transplant five months prior due to idiopathic pulmonary fibrosis. He is adherent to immunosuppression with tacrolimus, mycophenolate, and prednisone, as well as infectious prophylaxis with valganciclovir and atovaquone. He has no known drug allergies.
Physical exam reveals a tender, ulcerating lesion of the right forehead, where the patient denies preceding trauma. Computed tomography of the chest reveals a new, cavitating right upper lobe lesion shown below.
A biopsy of the skin lesion is performed, which is positive on both gram (pictured) and FITE staining.