A previously healthy 2-year-old African American girl was referred by her pediatrician because of a 2-week history of annular erythematous papules and plaques on her forehead that spread to involve her right ear and upper extremities. She had a 3-week history of fever, decreased appetite, and bilateral tibial pain. The pain was evident on palpation and when the child attempted to bear weight on her lower extremities. Significant laboratory test results obtained by her pediatrician included the following: white blood cells, 11.1 × 109/L; hemoglobin, 99 g/L; hematocrit, 0.29; and Westergren erythrocyte sedimentation rate, 100 mm/h. Serologic tests were negative for antistreptolysin O; a throat culture was negative for organisms; and urinalysis revealed trace protein and red blood cells but no casts. A bone scan and x-ray films of the lower extremities revealed no abnormalities. On physical examination, there were several annular erythematous plaques and papules on the patient's forehead, right ear, and upper extremities. Some plaques had areas of central clearing (Figure 1). A 3-mm punch biopsy specimen was obtained (Figure 2 and Figure 3).
Gray LC, Abele DC. Annular Erythematous Plaques and Tibial Pain in a Child. Arch Dermatol. 1998;134(5):625-630. doi: