A 10-year-old African-American boy had been removed from his home by the police when a neighbour noted that the boy was home alone over the weekend without parental supervision. The mother reportedly left this child with developmental disability and mental retardation at home with food and water and thought he could take care of himself. The police were concerned that he had skin lesions from abuse (Image 124a).
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What are these lesions?
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Are these lesions from abuse?
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What treatment does the boy need for these lesions?
How would neglect contribute to these lesions?
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The round lesions over the arms and legs with surrounding hyperpigmentation, eschar or central granulation tissue appear to be untreated furuncles or boils (closed), some of which have progressed to carbuncles (open). Boils are localized suppurative staphylococcal skin infections originating in a gland or hair follicle and characterized by pain, redness and swelling. Necrosis deep in the centre of the inflamed area forms a core of dead tissue that is spontaneously extruded, eventually resorbed or surgically removed. These may progress to carbuncles, which are deep-seated pyogenic infections, often preceded or accompanied by fever, malaise and prostration. In milder form, these can appear to be large, deep skin abscesses formed by a group or cluster of boils. There can be a large site of staphylococcal infection containing purulent matter in deep, interconnecting subcutaneous pockets. Pus eventually discharges to the skin surface through openings. Common sites for carbuncles are the back of the neck and the buttocks. 1
While these infections are not caused by abuse, it is easy to confuse them with a cigarette burn. A closer view of a lesion (Image 124b) reveals it is 9-10 mm diameter across, close to the size of a cigarette. The ‘punched out’ middle may suggest a deep burn caused by pressing the cigarette directly into the skin near a 90° angle. However, the number and distribution of the lesions and how they are healing suggests these are not thermal burns. Unfortunately, the child’s delayed development precluded obtaining meaningful information by interview.
Treatment may include antibiotics, local moist heat and when there is definite fluctuation and the hard white core is evident, incision and drainage. It is important to avoid irritating or squeezing the lesion to prevent spread of the infection. Many of the lesions would have to be covered. Given the number, oral as well as topical antibiotics will be needed and consideration should be given to the incidence of methicillin resistance in the community.
There are additional hypertrophic linear scars (Image 124c) which could suggest inflicted lesions. However, the total pattern of festering carbuncles with hypertrophic scarring is most likely due to poor nutrition and inadequate medical care, both caused by neglect. In addition, the act of leaving this child alone in a house over the weekend constitutes neglect.
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