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A Lower-limb Skin Lesion in a 10-year-old Girl

Koirala, Archana, MBChB, MIPH*,†; McMullan, Brendan, BMed, DTMH, FRACP, FRCPA*,†; Wargon, Orli, MBBS, FACD, MClin Ed*,†; Yates, Kylie, MBBS, MClin Epi, FRACP†,‡; Goldberg, Hazel, MBBS, FRACP‡,§,¶; Palasanthiran, Pamela, MBBS, MD, FRACP*,†

The Pediatric Infectious Disease Journal: April 2019 - Volume 38 - Issue 4 - p e79
doi: 10.1097/INF.0000000000002127
Your Diagnosis, Please

From the *Sydney Children’s Hospital, Randwick, New South Wales, Australia

The University of New South Wales, New South Wales, Australia

St George Hospital, Kogarah, New South Wales, Australia

§Prince of Wales Hospital, Randwick, New South Wales, Australia

Sydney Eye Hospital, Sydney, Australia.

Accepted for publication April 26, 2018.

The authors have no funding or conflicts of interest to disclose.

Address for correspondence: Archana Koirala, MBChB, MIPH, 6216/6 Porter Street, Ryde, NSW 2112, Australia. E-mail:

A 10-year-old girl presented with a 7-cm circular plaque on her left leg (Fig. 1). The lesion was initially flat and itchy with three central areas of erythema and was thought to have started with an insect bite 4 weeks prior. Despite treatment with topical antibiotics and oral cephalexin, one of the areas of erythema became fluctuant. Incision and drainage revealed purulent discharge, but no organisms were identified by bacterial, fungal or mycobacterial microscopy and cultures. An ultrasound scan of the lesion showed subcutaneous edema deep to the region with no evidence of fluid collection. She was admitted to hospital and sequentially treated with flucloxacillin, oral clindamycin and topical corticosteroids intravenously.



The patient had no history of fever, weight loss or previous skin lesions. She had no known allergies and was fully immunized according to the Australian National Immunization Program. She was born in Australia to an Indonesian mother and Chinese father and lived in metropolitan Sydney, Australia, with her parents and younger sibling, who were all well. There was no recent water or animal exposure. She had travelled to Indonesia at the age of 18 months and again at 8 years of age.

Upon admission, the patient had a temperature of 37.1°C, heart rate of 100 beats/minute, respiratory rate of 20 breaths/minute, oxygen saturation of 100% in ambient air and blood pressure of 100/60 mm Hg. Physical examination revealed a 7-cm circular, red-brown, dry, flat lesion on her left leg. The lesion was surrounded by dry skin with evidence of scratch marks, suggesting mild atopic eczema. The patient was otherwise systemically well. She had no lymphadenopathy or hepatosplenomegaly, and although she had an intermittent mild cough, her chest was clear to auscultation. Complete blood count showed normal white cell count of 8.64 × 109/L (normal: 4.70–12.20), hemoglobin of 122 g/L (normal: 113–143) with a low mean corpuscular volume of 60.9 fL (normal: 75–86). Her C-reactive protein was mildly elevated at 7 mg/L (normal: <3), but serum electrolytes and liver transaminases were normal.

The patient proceeded to have a punch biopsy of the lesion, which showed a deep granulomatous and suppurative inflammatory process with perivascular inflammation involving the epidermis down to the subcutis. No organisms were identified by microscopy. Mycobacterial and fungal cultures had no growth.

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