Netflix has a new series called “Diagnosis.” The star is Lisa Sanders, MD, a columnist for The New York Times Magazine which publishes her column, also called “Diagnosis,” in which she presents a puzzling medical case and people from around the world help her figure out what it is. In other words, she is crowdsourcing the diagnostic process.

I never cease to be amazed by the frequency with which a so-called rare condition is the underlying reason for the SYMPTOM of a chronic wound. After January 1, an advanced practitioner does not have to physically BE in the wound center. I wonder what will happen to these patients? They don’t need a dressing change clinic, they need a place they can go to get the underlying disease diagnosed that is causing the SYMPTOM of a chronic wound. Maybe telemedicine will be the answer, but I am not so sure.

Every wound management doctor has a short list of brilliant colleagues who are willing to read text messages at all hours, usually with an appended photo and the caption, “What the heck is this?” Ironically, within minutes of my reading the AMA story about Dr. Sanders, a colleague texted me photos of a patient and said, “Have you ever seen THIS?” I said, “Let’s crowdsource it.” So I am. We need a diagnosis for this patient.

I know these details are sketchy – this is from a midnight text message – but here it goes:

There are 3 patients status – post organ transplant with the same cutaneous lesions. One patient had a lung transplant due to idiopathic pulmonary fibrosis, and the two liver transplants were due to NASH (Nonalcoholic steatohepatitis- “fatty liver”).  They do not have mucosal lesions- only cutaneous skin lesions. The patients are not HIV positive. All are on Tacrolimus.  In two patients the lesions are on the legs and in one patient they are on the forearm. They have all been biopsied, sometimes more than once and the findings (read by dermatopathology) were non-specific (no neutrophilic infiltrate although of course all 3 are on immunosupressives).  Viral, acid-fast and fungal studies are negative. They appeared spontaneously and were not triggered by trauma. They don’t hurt unless you manipulate them. Topical steroids didn’t help, intralesional steroids did not help, nor did taking 40 mg of prednisone a day orally.

What’s the diagnosis?