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A previously healthy, 10-year-old girl presented with 10 days of low-grade fever and bilateral, multiple cervical lymphadenitis. The enlarged lymph nodes were discrete, mildly tender, and with normal overlying skin. Her fever and cervical lesions persisted despite treatment with ampicillin-sulbactam. A chest radiograph was normal. Bacillus Calmette-Guérin (BCG) vaccine had been administered during the neonatal period. A tuberculin skin test with 2 U of tuberculin partial purified derivative (PPD) RT 23 SSI, 2 T.U./0.1 mL (Statens Serum Institut, Copenhagen, Denmark), was injected intradermally over the middle third of the right volar forearm. Erythematous induration over the tuberculin injection site appeared 24 hours postinoculation of tuberculin and peaked in size (25 × 22 mm) at 48 hours postinoculation. The induration became tender, and the erythema worsened. The evolution of the lesions is shown in the Figure. Results of a lymph node biopsy supported the diagnosis.
Skin ulceration over right volar forearm in a 10-year-old girl with cervical Mycobacterium tuberculosis lymphadenitis. Pictures were taken serially at days 4 (A and B), 7 (C), 30 (D), and 90 (E) after the tuberculin injection.
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Lu C, Lee P, Chang L, Chen C, Huang L. Picture of the Month—Quiz Case. Arch Pediatr Adolesc Med. 2007;161(3):303. doi:10.1001/archpedi.161.3.303