An immunosuppressed man with an isolated necrotic plaque on the chest

A 54-year-old man on systemic immunosuppressive therapy for 1 month after a liver transplant for hepatitis C virus presented with a 5-day history of a solitary plaque on the chest. Physical examination found an indurated, violaceous 53 3-cm tender plaque studded with pustules. Over the following days, the plaque became more purulent and developed a central erosion with necrosis (Fig 1). Punch biopsy found a nodular and diffuse dermal mixed cell infiltrate with multinucleated histiocytes and neutrophils (Fig 2, A). Fungal organisms with nonseptated hyphae and right angle branching were identified by Gomori methenamine silver stain (Fig 2, B).