An 11-year-old boy presents to the emergency department with a chief complaint of rash. He noticed 2 dark areas of discoloration to the right side of his face this morning when looking in the mirror. The dark areas do not hurt but are slightly itchy. He lives in Tennessee and went swimming in a local lake with family one day before his emergency department visit but did not notice any bites, new exposures, or trauma to the area. He has never had a rash like this before. No other family members feel ill or have a rash. He has not had a fever or any recent illness. He has no known medical history, does not take any medications, and has never had surgery. He is up to date on immunizations.

Vital signs were within normal limits. On examination the patient has 2 nonpalpable, nontender, well-demarcated, black macules to the right...

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