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Crusty umbilical ulcer in a febrile child

A 12-year-old boy presented with complaints of fever, headache, myalgia, and vomiting for 8 days. On examination, he was febrile, had generalized lymphadenopathy (bilateral axillary and inguinal) and no obvious skin lesions. Systemic examination was normal except for mild, firm splenomegaly. The child was admitted. Clinical exam revealed a 5 × 5 mm ulcer with clear margins and a black crust without surrounding erythema, located on the lower side of the umbilicus (Figure 1). The patient's mother denied any trauma, insect bite or discharge from the lesion. Lab analyses showed normal hemoglobin levels (12 g/dL), leukopenia (4800/mm3), thrombocytopenia (106 000/ mm3), minimally raised liver enzymes (aspartate transaminase 121 U/L, alanine aminotransferase 94 U/L), normal bilirubin, and normal serum alkaline phosphatase. Blood and urine cultures and serologies for dengue and typhoid (enteric) fever were negative.