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Special Feature
February 2013

Picture of the Month—Quiz Case

Author Affiliations


Author Affiliations: University of Medicine and Dentistry of New Jersey, New Brunswick (Ms Ahluwalia); Division of Dermatology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio (Dr Shah); and Section of Dermatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania (Dr Castelo-Soccio).

JAMA Pediatr. 2013;167(2):185. doi:10.1001/jamapediatrics.2013.938a

A 15-year-old girl presented to the office with a 3-day history of dark-purple and tender plaques on her lateral thighs and buttocks that were increasing in number (Figure 1 and Figure 2). Many appeared to be necrotic. This patient had a history of protein S deficiency diagnosed after a pulmonary embolism 1 year before presentation and was undergoing long-term anticoagulation therapy with warfarin. She stopped taking the warfarin as prescribed 2 to 3 weeks prior to presentation and when it was noted that she had a subtherapeutic international normalized ratio, the patient restarted warfarin. A punch biopsy of a representative plaque on the lateral thigh was performed and confirmed the diagnosis.

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Figure 1. Photograph of 1 necrotic plaque on the left lateral thigh.

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Figure 2. Photograph depicting numerous necrotic plaques on the lateral thigh.

What is your diagnosis?