Image of the Week: Discoloration of the Nose, Fingers, and Toes

A 41-year-old man presents to the emergency department with dyspnea, headache, vomiting, and weakness. He had a kidney transplant 9 years ago and has been on a stable antirejection regimen. He has allergies to ciprofloxacin and trimethoprim-sulfamethoxazole. Physical examination reveals gray-blue discoloration of the nose, fingers, and toes. Chest radiograph and electrocardiogram are unremarkable. Arterial blood gas analysis demonstrates a pH of 7.5, Po₂ of 99 mm Hg, Pco₂ of 18 mm Hg, bicarbonate level of 20.8 mmol/L, and oxygen saturation of 99%.

Which of the following medications is associated with this patient’s presentation?

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