A 13-year-old girl presents to our mission hospital in rural Kenya with a 2-week history of a rapidly progressing painless ulcer on her jaw and inside the oral cavity. There has been no fever or weight loss, but she reports some intermittent night sweats. She denies any oral trauma or recent dental procedures. She and her mother deny previous admissions to the hospital. No other members of her family have had a similar lesion. She and her family live 4 hours away, in an arid region of the country. Before presentation, they tried no treatments for this illness.

Physical examination is significant for a thin, pleasant girl. Vital signs on admission are temperature of 97.7°F (36.5°C), respiratory rate of 16 breaths/min, and heart rate of 94 beats/min. There is a 2 × 2.5–cm necrotic eschar overlying her mandible just below her lip with surrounding swelling (Fig 1). Internal...

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