A 76-year-old man originally from Barbados was admitted to hospital after experiencing one month of progressive generalized weakness that culminated in his inability to carry out independent activities of daily living. The patient's medical history included hypertension, type 2 diabetes, previous smoking (20 pack-years) and diabetic nephropathy that resulted in a kidney transplant six years earlier. After transplantation surgery, the patient had experienced stage 5 chronic renal insufficiency as a result of progressive allograft dysfunction. The patient was taking an immune suppression regimen consisting of extended release tacrolimus (25 mg/d), mycophenolate mofetil (720 mg, twice daily) and prednisone (5 mg/d). Other medications taken by the patient included labetolol, amlodipine, calcitriol and darbapoietin α.The patient reported having a decreased appetite and undergoing a 6-kg weight loss during the previous month, without fever, chills or night sweats. Several small painless peripheral nodular skin lesions had also developed over a two-month period. The patient reported no other symptoms during the review of systems. He had not recently travelled outside of Quebec and had no sick contacts. However, he owned several pet fish, which he kept in a fresh water aquarium that he cleaned himself twice each month.On initial physical examination, the patient had no fever and had normal vital signs. He was alert and oriented, with no lateralizing signs. He had temporal muscle wasting and a body mass index of 19 kg/m 2 . We found six ulcerated lesions, the largest of which was 2 cm in diameter, on the dorsal hand, forearm and legs (Figure 1). We felt no lymphadenopathy or hepatosplenomegaly. The results of initial laboratory investigations are presented in Box 1.We biopsied a skin lesion on the patient's left forearm, and microbiological testing showed acid-fast bacilli. Radiography of the patient's chest showed bilateral nodular densities, and computed tomography confirmed the presence of multiple pulmonary nodules (Figure 2). Gastroscopy showed multiple millimetric black mucosal discolourations in the duodenum (Figure 3A and 3B). The lesions were thought to be evidence of disseminated mycobacterium to the gastrointestinal tract. The patient was PRACTICE | CASES