Red Book Online Presents: Diagnosis Detective | May 2025
Editor: Kristina A. Bryant, MD, FAAP
Case contributed by Anne Hutchinson, MD Candidate, Ban AL-Sayyed, MD, Loyola University Hospital and Medical Center, Pediatric Infectious Diseases
A 15-year-old previously healthy female from Illinois presents with a five-month history of an erythematous, verrucous, and exophytic nontender skin lesion. According to the patient, the lesion initially appeared as a red pustule that drained both pus and blood. The patient sought medical attention from her primary care provider, who prescribed a short course of cephalexin. Despite this treatment, the lesion continued to progress into an ulcer with pustules, crusts, and serosanguinous discharge.
The patient reports no use of topical emollients; she has been cleaning the lesion only with warm water. She denies recent fevers, myalgias, fatigue, or weight loss. On physical exam, no significant lymphadenopathy is noted, and there are no focal neurological deficits. The patient demonstrates full strength in both her upper and lower extremities.
The patient has not traveled outside Illinois. She owns a dog, cat, and fish, but denies any recent animal scratches or bites. There have been no tick and mosquito bites. Additionally, no close contacts have similar skin lesions.
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