FEVER AND SKIN RASH
Dr m.barak
Associated professor in pediatrics infectious disease
INTRODUCTION
 The differential diagnosis for febrile patients with a
rash is extensive.
 Diseases that present with fever and rash are usually
classified according to the morphology of the
primary lesion.
MORPHOLOGIC CLASSIFICATION of
RASH
 Maculopapular .
 Petechial.
 Diffusely erythematous with desquamation.
 Vesiculobullouspustular .
 Nodular.
AETIOLOGICAL CLASSIFICATION
 Viruses.
 Bacteria.
 Spirochetes.
 Rickettsiae.
 Medications
 IMMUNOLOGIC-MEDIATED DISORDERS
HISTORY
 A detailed history can be quite helpful in identifying the
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cause of fever and a rash.
A history of recent travel.
Animal exposure and inscet bites.
Drug ingestion
Contact with ill persons should be noted.
The time of year can be a clue to certain diagnoses
 Any rash that is sudden in onset and covers a large
part of the body
 Any rash that starts either shortly after a flu-like
illness begins, or a rash that starts after a flu-like
illness goes away
Some disorders among travellers
 Lyme disease.
 Strongyloides stercoralis.
 HIV/AIDS.
 Rocky Mountain spotted fever.
 Leishmaniasis.
 Leprosy
 STDs
Animal & Insect Contact Disorders
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Animal contact Q fever.Anthrax.Viral hemorrhagic fevers.Cat
scratch disease
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Insect exposure:
Mosquitoes:Malaria.Dengue.
FilariasisYellow fever.
Ticks :Tick typhus . Rocky Mountain spotted fever
Lyme disease .
Sand flies :Leishmaniasis&Sandfly fever
Black flies :Onchocerciasis
Speacial care to the following
 Conditions associated with valvular heart
disease,
 Sexually transmitted diseases or
 Immunosuppression from chemotherapy.
 Immune status is particularly important because
many of the diseases that result in fever and a
rash present differently in
immunocompromised patients.
Details about the rash :
 Site of onset,
 Rate .
 Direction of spread,
 Presence or absence of pruritus.
 Temporal relationship of rash and fever.
 It is also important to know whether any topical
or oral therapies have been attempted.
Identification of Primary Skin
Lesions
MACULE
 Circumscribed area of
change in normal
skin color, with no
skin elevation or
depression; may be
any size
PAPULE
 Solid, raised lesion up
to 0.5 cm in greatest
diameter
NODULE
 Similar to papule but
located deeper in the
dermis or
subcutaneous tissue;
differentiated from
papule by palpability
and depth, rather
than size
PLAQUE
 Elevation of skin
occupying a relatively
large area in relation
to height; often
formed by confluence
of papules
VESICLE
 Circumscribed,
elevated, fluidcontaining lesion less
than 0.5 cm in
greatest diameter;
may be
intraepidermal or
subepidermal in
origin
BULLA
 Same as vesicle,
except lesion is more
than 0.5 cm in
greatest diameter
LOOK FOR
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The patient's vital signs and general appearance.
Signs of toxicity.
Adenopathy.
Oral, genital or conjunctival lesions.
Hepatosplenomegaly.
]Evidence of excoriations or tenderness.
Signs of neck rigidity or neurologic
dysfunction.
LABORATORY DATA
 The complete blood count with differential, an
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erythrocyte sedimentation rate,
A chemistry panel, liver function tests.
Blood and urine cultures
Aspirates, scrapings and pustular fluid may be obtained
for Gram staining and culture.
Tzanck test may : unroofing a lesion and taking a
scraping of the lesion base.
Biopsy samples : from nonhealing or persistent purpuric
lesions.
Biopsy of inflammatory dermal nodules and ulcers
Specific diagnoses that may be
confirmed histologically
 Rocky Mountain spotted fever, herpetic infections,
systemic lupus erythematosus, erythema
multiforme, allergic vasculitis, secondary syphilis
and deep fungal infections
Serologic tests
 Systemic lupus erythematosus.
 Other collagen vascular disorders
 Syphilis.
 Rheumatoid arthritis .
 Human immunodeficiency virus infection.
Maculopapular Rash.
 Viral illnesses :rubeola, rubella, erythema
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infectiosum and roseola
Immune-mediated syndromes:Erythema Multiforme
Drug reactions: penicillins or cephalosporins
Bacterial infections :Lyme Disease &Secondary
Syphilis
- Others : early stages of meningococcemia, Rocky
Mountain spotted fever and Dengue fever
The exanthem of rubeola
 begins around the fourth
febrile day, with discrete
lesions spreading from the
hairline downward, sparing
the palms and soles.
 The exanthema: lasting four
to six days, fading gradually
in order of appearance,
leaving a residual faint
desquamation.
 Rubeola : Koplik's spots in
the oral mucosa.
The exanthem of rubeola
Erythema infectiosum fifth disease:
 Caused by human parvovirus B19.
 In children between three and 12 years of age,
although it can present as a rheumatic syndrome
in adults.
The prodrome : fever, anorexia, sore throat and
abdominal pain.
 Once the fever resolves, the classic bright-red
facial rash (“slapped cheek”) appears.
 Exanthem progresses to a diffuse, lacy, reticular
rash that may wax and wane for six to eight weeks
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Erythema infectiosum
Lyme Disease&Erythema Migrans
 Borrelia burgdorferi, which is transmitted by the
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bite of a tick (Ixodes species).
Erythema migrans, the pathognomonic rash,
develops in about 80 percent of patients with Lyme
disease.
Systemic symptoms: fever, chills, myalgias,
headaches and arthralgias.
The rash : on the proximal extremities, in body
creases and on the chest. It enlarges over a period
of days to weeks.
Complications:carditis,, arthritis and
acrodermatitis chronica atrophicans
Lyme disease
Lyme disease
Erythema Multiforme
 The dull-red lesions advance
from macules to papules, with
prominence of characteristic
target-shaped lesions.
 Vesicles and bullae develop in
the center of the papule .
 The systemic symptoms: fever
and prostration.
Secondary Syphilis
 The rash of secondary syphilis can be diffuse, with
localized eruptions often occurring on the head, neck,
palms and soles.
 The lesions : brownish-red or pink macules and
papules, papulosquamous, pustular or acneiform.
 Macules & papules (mucous patches )
Secondary Syphilis
Adult-onset Still's disease (AOSD)
 Major Criteria
Fever > 39°C
Arthritis/arthralgias > 2
weeks
Still's maculopapular red rash
and blanching eruption of the
proximal upper and lower
extremities Neutrophilic
leukocytosis
 Minor Criteria
Sore throat
Lymphadenopathy or
splenomegaly
Liver dysfunction
Negative Rheumatoid factor
and ANA testing
Rash in Adult-onset Still's disease
(AOSD)
Maculopapular rash in collagen
vascular disorders
Petechial& Purpric Eruptions
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MENINGOCOCCEMIA
ROCKY MOUNTAIN SPOTTED FEVER
Viral illnesses causing petechial rashes :
coxsackievirus A9, echovirus 9, Epstein-Barr
virus and cytomegalovirus infections, atypical
measles and viral hemorrhagic fevers caused
by arboviruses and arenaviruses.
Differential diagnosis of petechial rash
 Disseminated gonococcal infections.
 Bacteremia.
 Staphylococcemia
 Thromboticthrombocytopenic
MENINGOCOCCEMIA
 Seeding of Neisseria meningitidis from the nasopharynx
: acute meningococcal septicemia, meningococcal
meningitis or chronic meningococcemia.
 Petechial rash a high, spiking fever, tachypnea,
tachycardia and mild hypotension
ROCKY MOUNTAIN SPOTTED FEVER
 Caused by Rickettsia rickettsii.
 The prodrome : malaise, chills, a feverish feeling,
anorexia and irritability, photophobia, prostration and
nausea.
 Rash: on fourth day of illness,.starting as pink macules, ,
located on the wrists, forearms, ankles, palms and soles.
 Within 6 - 18 hours, the rash spreads centrally to involve
the arms, thighs, trunk and face, evolving into deep-red
papules,then into petechiae
Diffuse Erythema with Desquamation
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SCARLET FEVER
TOXIC SHOCK SYNDROME &SCALDED SKIN
SYNDROME
KAWASAKI'S DISEASE
Other causes : a)Enteroviral infections .b) Toxic
epidermal necrolysis&Graft-versus-host reaction. C)
Erythroderma & generalized pustular psoriasis
SCARLET FEVER
 An acute infection by group A beta-hemolytic streptococci
that produce an erythrogenic exotoxin.
 The rash : finely punctate erythema on the superior trunk and
face two to three days after the onset of illness spreading to
the extremities.
 : White, with red, swollen papillae (white strawberry tongue).
By the fourth or fifth day, it becomes bright red (red
strawberry tongue).
KAWASAKI'S DISEASE
 An acute febrile illness that affects infants and young
children (mean age: 2.6 years). Fever : temperature is
typically higher than 40°C ,lasting five to 30 days and not
responding to antibiotics nor antipyretics.
 Rash(within three days of the onset of fever ):
scarlatiniform on the trunk , erythematous on the palms
and soles, with subsequent distal desquamation.
 Mucous membrane : hyperemic bulbar conjunctiva,
injected oropharynx, dry, cracked lips and a strawberry
tongue.
 Non-suppurative cervical lymphadenopathy . Coronary
artery abnormalities develop in 20 to 25 percent of patients
TOXIC SHOCK SYNDROME AND SCALDED
SKIN SYNDROME
 Staphylococcus aureus exotoxins responsible for classic
toxic shock syndrome and scalded skin syndrome.
 Presention : hypotension, erythema, fever and
multisystem dysfunction.
 The rash : diffuse and can present as bullous impetigo,
scarlatiniform lesions or diffuse erythema.
 The mucous membranes :spared
Vesiculobullous-Pustular Eruptions
 VARICELLA-ZOSTERVIRUS INFECTIONS
 Coxsackie viruses and other entero viruses
 Noninfectious neutrophilic dermatoses :pustular
psoriasis,Reiter disease& “Pustular vasculitis”
Bowel-associated dermatosis-arthritis syndrome Rheumatoid
neutrophilic dermatosis Pyostomatitis vegetans
Familial
Mediterranean fever
Varicella.
 Primary infection with varicella-zoster virus
results in chickenpoxA mild prodrome lasting one
to two days before appearance of the rash is not
uncommon. The rash typically begins on the face,
scalp or trunk and then spreads to the extremities.
 The lesions : erythematous macules and progress to
papules with an edematous base , evolving into
vesicles, into pustules, which become umbilicated
and subsequently crust over in eight to 12 hours.
Zoster
 itHerpes
affects a single
dermatome and
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rarely crosses the midline .
The common locations :the chest
and the face
A prodrome : unusual skin
sensations may evolve into pain,
burning and paresthesias, which
precede the rash by two to three
days.
The rash : erythematous
maculopapular eruption
evolveing to a vesicular rash.
Drying of the lesions with crust
formation : in seven to 10 days,
Resolve in 14 to 21 days.
Coxsackie viruses and other enteroviruses
 Hand-foot-and-mouth disease: the children develop fever and
rash. The rash includes blisters to the mouth and tongue, to the
hands and the feet.
 Herpangina causes a fever, sore throat, and painful blisters or
ulcers to the back of the mouth.
Nodular Eruptions
 Erythema nodosum: acute intlammatory &immunologic
process involving the panniculus adiposus.
 Presenting features : fever, malaise and arthralgias.
 The nodules : painful and tender.
 The lesions : on the lower legs, knees and arms
Aetiology
 Idiopathic.
 Infectious causes
Beta-hemolytic streptococci .
Nocardia,
Pseudomonas,Hepatitis C virus
Mycobacterium species
 Noninfectious causes
Medications :sulphonamides
Systemic lupus erythematosus
Sarcoidosis , Ulcerative colitis ,
Behcet's syndrome &Pregnancy
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