Is There a Medical Explanation?

By ANN S. BOTASH, MD, ANNE R. SVEEN, MD, LORI D. FRASIER, MD-Series Editor | February 1, 2004

Dr Botash is associate professor of pediatrics and director of the Child Abuse Referral and Evaluation Program at SUNY Upstate Medical University in Syracuse, NY. Dr Sveen is assistant professor of pediatrics at SUNY Upstate Medical University. Dr Frasier is associate professor of pediatrics at the University of Utah School of Medicine in Salt Lake City; she is also medical director of the Medical Assessment Team at the Center for Safe and Healthy Families at the Primary Children's Medical Center.

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Case 1: & Case 2: CASE 1:

Figure 1

A 13-year-old girl of African American descent is brought to the pediatrician's office because of a lesion on her neck. The girl's mother had telephoned the office before the visit, stating that the lesion resembled a blister at first, but now looked like a burn. In the office, the girl is afebrile and not distressed. She explains that she awoke the morning prior to the visit with a blister on the right side of her neck. It gradually became bigger, and she used cold washcloths to wipe it. The central area became more painful and the skin layers peeled off, revealing a weepy, inflamed circular area (Figure 1). The burn is of second degree in the center and first degree in the surrounding tissue. There are no other skin findings, and the rest of the physical examination is normal. The mother is very upset by the finding but can offer no explanation. The girl repeatedly says she does not know how the lesion occurred. Case 2:

Figure 2

Figure 3

An 11-year-old boy is brought by his mother to the pediatrician's office with a 1-day history of a rash on his shoulders and arms. His mother relates that he woke up with the rash, and she was very concerned about how quickly it appeared. The patient is a healthy boy who denies any recent illness, associated pruritus, trauma to the skin, or use of any new products. Physical examination reveals macular, hyperpigmented lesions on the boy's shoulders and upper arms. They appear in a similar pattern on both shoulders without vesiculation, petechiae, or bruising. The rest of the physical examination is normal. Because child abuse is suspected, photographs are obtained (Figures 2 and 3). Note the linear hyperpigmented marks in Figure 3. Have the children in these 2 cases been intentionally harmed-or is there a medical explanation in both cases for the lesions?

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