An 8-year-old boy presented to the emergency department after he was found unconscious outside his church on a rainy day. He had been seen by his mother 1 hour earlier and was previously fit and well and up to date with immunizations.
An ambulance was called and paramedics noted a reduced Glasgow Coma Scale score of 3, trismus with normal respiratory effort, and a scalp hematoma on the left forehead. On arrival in the emergency department he was afebrile, normotensive with a heart rate of 120 beats/min, and had a respiratory rate of 20 breaths/min. His Glasgow Coma Scale score had improved to 14, but he had no recollection of events. His left leg was flexed, and he cried whenever this limb was examined. On closer inspection, his left foot was warm, with generalized mild erythema and swelling. There were bullae on the dorsum of the first and second toes and a cluster of painless, dry, black punctate lesions laterally (Figure, left). Similar, paler lesions were clustered symmetrically on the left (Figure, right) and right forearms.
Lillie J, Coulter F, Ganeshalingham A. Severe Lactic Acidosis in an Amnesic Child. JAMA. 2014;311(19):2015-2016. doi:10.1001/jama.2014.783