Case 4: Two Black Eschars in a 6-year-old Girl

Zachary Graff; Geronimo Mendoza; Apurv Barche; Curtis Turner

doi:10.1542/pir.2016-0034

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Zachary Graff, MD*
Geronimo Mendoza, MD*
Apurv Barche, MD*
Curtis Turner, MD*

^*Texas Tech University Health Sciences Center School of Medicine, Amarillo, TX.

AUTHOR DISCLOSURE
Drs Graff, Mendoza, Barche, and Turner have disclosed no financial relationships relevant to this article. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.

Presentation

A previously healthy 6-year-old Hispanic girl presents with a 4-week history of a left lower back skin lesion and a 1-week history of a left forearm lesion. Both lesions progressed from an initial red bump to ulceration with overlying black crust. The lesions are mildly itchy and not painful. She denies fever, weight loss, night sweats, lymphadenopathy, and cough. She has no history of trauma, international travel, tuberculosis exposure, pet bites or scratches, or exposure to animal hides. There is no family history of cancer. Social history is notable for her father working at a dairy farm.

Physical examination reveals a temperature of 36.2°C (97.2°F), with other vital signs within normal limits. The girl is smiling and cooperative. Examination of the skin reveals a nontender 2.5 × 2-cm sharply defined ulcer with overlying black eschar on the left lower back with edematous and erythematous borders (Fig 1) and a similar 1-cm lesion on the left forearm (Fig 2). There is no clinically significant lymphadenopathy or hepatosplenomegaly. The remainder of the examination yields normal results.

Figure 1.

A 2.5 × 2.0-cm sharply defined ulcer with overlying black eschar on the left lower back with edematous and erythematous borders.

Figure 2.

A …