Rounds Royale: Lesions

Let the games begin!

“A 5-year-old boy from rural east-central Ontario was referred to the urgent dermatology service with tender papulopustular and nodular lesions on the trunk, limbs, and face, which had developed over 9 days. The 7 lesions began as small papules that gradually enlarged and developed purulent discharge. At the time of presentation, the largest lesion was a nodule (around 2 cm) with a central depression (Figure 1A), while other lesions were smaller (0.5–1.5 cm), and some were actively draining pus (Figure 1B).

The patient had a 1-month history of a nonresolving cough, 2 brief febrile episodes, and mild lethargy. Three weeks before the skin lesions appeared, he had received 2 doses of oral dexamethasone for suspected croup, without improvement. Two days after the skin lesions appeared, he was started on azithromycin for clinical suspicion of pneumonia. Two days later, his treatment was changed to oral amoxicillin–clavulanic acid, given the pustular nature of the skin lesions. Six days after onset of the skin lesions, a chest radiograph showed left lower lobe infiltrate and a small pleural effusion. A complete blood count obtained at the same time revealed a leukocyte count of 10.1 (normal 5–13.2) × 10⁹/L with normal differential, a platelet count of 457 (normal 197–382) × 10⁹/L, and a hemoglobin of 125 (normal 96–128) g/L. His C-reactive protein was mildly elevated at 14.4 (normal < 5) mg/L. He completed a 7-day course of amoxicillin–clavulanic acid, which had no effect on the skin lesions.

The patient’s medical history was notable for reactive airway disease managed with fluticasone (250 μg, 2 puffs twice daily). There was no history of recurrent or severe infections, and he was immunized according to the standard schedule. He had no recent travel, ill contacts, or symptomatic family members. Aside from the family owning 2 healthy dogs, he had no other contact with animals. The family had regraded the front yard of their home around 3 months before the onset of the skin lesions.”

Don’t forget, people: phrasing matters. I need it in the form of a question — just like your existential crises during CaRMS. While we await your answer, a little Vivaldi — because drama belongs in diagnostics, too. Answer here via CMAJ!