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Acute ulceronecrotic rash in a child

A previously healthy 10yearold girl presented with a fiveday history of an acute ulceronecrotic purpuric rash. There was no antecedent history of drug intake or upper respiratory tract infection. The rash started as purpuric macules and papules involving the trunk and lower extremities. Shortly, her purpuric lesions became generalized and progressed to multiple necrotic lesions (Figure 1). There was no history of abdominal pain, arthralgia, or other systemic symptom. Physical exam revealed a body temperature of 37.2°C, pulse of 110, and otherwise normal vital signs. On examination, there were purpuric papules and plaques, some with hemorrhagic crusts, necrotic ulcers and hyperpigmented macules where previous lesions had resolved (Figure 2), distributed on the neck, trunk, lower limbs, and arms. Fewer lesions were present on the face, and her scalp, palms, soles, nails were spared. There was no palpable lymphadenopathy and abdominal and joint examination was normal. A 4mm punch biopsy was performed, the findings of which are shown in Figures 3 and 4.