Caught in a Web of Necrosis

A previously healthy 15-month-old boy from West Texas presented with a rapidly progressive buttock lesion. Caregivers noted a dusky patch 2 days earlier that enlarged with blistering and a black center (Fig 1). A fall onto a ride-on toy the prior week raised concern for contusion; no injury or bite was witnessed. He appeared well and afebrile (temperature, 99.9°F) with a heart rate 155 bpm, blood pressure 118/59 mm Hg, Spo2 97%, and a 5 × 6 cm dusky plaque with central eschar and surrounding erythema/maceration in the left superior gluteal region (Figs 1-4).