APPROACH TO A PATIENT

OF FEVER WITH RASH

BY- DR. SUNDAR BANERJEE

 MORPHOLOGY OF RASH
 Macules are flat lesions defined by an area of changed color (i.e., a
blanchable erythema)
 Papules are raised, solid lesions <5 mm in diameter; plaques are
lesions >5 mm in diameter with a flat, plateau-like surface; and
nodules are lesions >5 mm in diameter with a more rounded
configuration.
 Vesicles (<5 mm) and bullae (>5 mm) are circumscribed, elevated
lesions containing fluid.
 Pustules are raised lesions containing purulent exudate.
 MORPHOLOGY OF RASH
 Nonpalpable purpura is a flat lesion that is due to bleeding into the
skin. If <3 mm in diameter, the purpuric lesions are termed petechiae;
if >3 mm, they are termed ecchymoses.
 Palpable purpura is a raised lesion that is due to inflammation of the
vessel wall (vasculitis) with subsequent hemorrhage.
 An eschar (tâche noire) is a necrotic lesion covered with a black crust.
 An ulcer is a defect in the skin extending at least into the upper layer of
the dermis.
 CASE 1
 An elderly female presented with sudden onset rash all over the body
with history of basal rise of temperature (one episode, undocumented),
which was itchy and was of generalized distribution.
 There was no history of any new food or drug intake or usage of any
new skin products .
 Following admission, there was no measurable rise in temperature.

 On examination, the rashes were found to be macular plaques.

 On taking thorough history, it was revealed that she was taking

Allopurinol for more than 3 months, to which there was no initial skin
rashes.

 She responded well to anti-allergics and IV Hydrocortisone following

stoppage of Allopurinol.
 DISTRIBUTION OF RASH ASSOCIATED
WITH FEVER
 LOCALIZED SKIN ERUPTIONS (i.e. Cellulitis, impetigo).

 GENERALISED SKIN ERUPTIONS

• CENTRALLY DISTRIBUTED MACULOPAPULAR ERUPTIONS

• PERIPHERAL ERUPTIONS
• CONFLUENT DESQUAMATIVE ERYTHEMAS
• VESICULOBULLOUS OR PUSTULAR ERUPTIONS
• URTICARIA-LIKE ERUPTIONS
• NODULAR ERUPTIONS
• ERUPTIONS WITH ULCERS OR ESCHARS
 CENTRALLY DISTRIBUTED MACULOPAPULAR
ERUPTIONS

 Although a drug reaction has many manifestations, including urticaria,

exanthematous drug-induced eruptions are most common and are often
difficult to distinguish from viral exanthems.
 Eruptions elicited by drugs are usually more intensely erythematous and
pruritic than viral exanthems, but this distinction is not reliable. A history of
new medications and an absence of prostration may help to distinguish a
drug-related rash from an eruption of another etiology. Rashes may persist
for up to 2 weeks after administration of the offending agent is discontinued.
 Certain populations are more prone than others to drug rashes. Of HIV-
infected patients, 50–60% develop a rash in response to sulfa drugs; 30–90%
of patients with mononucleosis due to Epstein-Barr virus develop a rash when
given ampicillin.
 CENTRALLY DISTRIBUTED MACULOPAPULAR
ERUPTIONS

 The rash of rubeola (measles) starts at the hairline 2–3 days into the illness
and moves down the body, typically sparing the palms and soles. Koplik’s spots
(1 to 2 mm white or bluish lesions with an erythematous halo on the buccal
mucosa)are pathognomonic for measles and are generally seen during the first 2
days of symptoms.
 CENTRALLY DISTRIBUTED MACULOPAPULAR
ERUPTIONS

 Rubella (German measles) also spreads from the hairline downward; unlike
that of measles, however, the rash of rubella tends to clear from originally
affected areas as it migrates, and it may be pruritic. Forchheimer spots (palatal
petechiae) may develop but are nonspecific because they also develop in
infectious mononucleosis, scarlet fever, and Zika virus infection. Postauricular
and suboccipital adenopathy and arthritis are common among adults with
rubella.
 The rash of erythema infectiosum (fifth disease), which is caused by human
parvovirus B19, primarily affects children 3–12 years old; it develops after fever
has resolved as a bright blanchable erythema on the cheeks (“slapped
cheeks”)with perioral pallor. A more diffuse rash (often pruritic) appears the next
day on the trunk and extremities and then rapidly develops into a lacy reticular
eruption that may wax and wane (especially with temperature change) over 3
weeks. Adults with fifth disease often have arthritis, and fetal hydrops can
develop in association with this condition in pregnant women.
 CENTRALLY DISTRIBUTED MACULOPAPULAR
ERUPTIONS

 Exanthem subitum (roseola) is caused by human herpesvirus 6, or less

commonly by the closely related human herpesvirus 7, and is most common
among children <3 years of age. As in erythema infectiosum, the rash usually
appears after fever has subsided. It consists of 2- to 3-mm rose-pink macules
and papules that coalesce only rarely, occur initially on the trunk and
sometimes on the extremities (sparing the face), and fade within 2 days.
 Typhoid fever, is caused by Salmonella typhi often presents with generalized
rashes (Rose spots) commonly seen on trunk associated with step-ladder
pattern fever and Faget’s sign.
CENTRALLY DISTRIBUTED MACULOPAPULAR
ERUPTIONS

 Other diseases with generalized maculopapular eruptions

• Rickettsial illnesses

• Dengue fever (petechial rashes)

• Lyme disease (Erythema Migrans)

• Southern tick associated rash illness (STARI) (Erythema Migrans)

• Acute rheumatic fever (Erythema Marginatum).

• Zika virus infection

 PERIPHERAL ERUPTIONS
 These rashes are most prominent peripherally or begin in peripheral (acral)
areas before spreading centripetally.

 Rocky Mountain spotted fever: Early diagnosis and therapy are critical
because of its grave prognosis if untreated. Lesions evolve from macular to
petechial, start on the wrists and ankles, spread centripetally, and appear on
the palms and soles only later in the disease.
 Secondary syphilis: which may be generalized but is prominent on the palms
and soles, should be considered in the differential diagnosis of pityriasis rosea,
especially in sexually active patients.
 Chikungunya fever: transmitted through aedes mosquito,associated with a
maculopapular eruption and severe polyarticular small-joint arthralgias.
 PERIPHERAL ERUPTIONS
 Hand-foot-and-mouth disease, most commonly caused by coxsackievirus A16
or enterovirus 71, is distinguished by tender vesicles distributed on the hands
and feet and in the mouth; coxsackievirus A6 causes an atypical syndrome with
more extensive lesions.
 The classic target lesions of erythema multiforme appear symmetrically on
the elbows, knees, palms, soles, and face. In severe cases, these lesions spread
diffusely and involve mucosal surfaces, associated with Herpes simplex virus,
mycoplasma and drugs like Chloroquine.
 Bacterial Endocarditis also present with peripheral lesions like Janeway lesions
and Osler’s node.
 CONFLUENT DESQUAMATIVE ERYTHEMAS

 These eruptions consist of diffuse erythema frequently followed by desquamation.

 Scarlet fever (second disease) usually follows pharyngitis; patients have

sandpaper rashes, a facial flush, a “strawberry” tongue, and accentuated petechiae
in body folds (Pastia’s lines).
 Staphylococcal scalded-skin syndrome is seen primarily in children and in
immunocompromised adults. Generalized erythema is often evident during the
prodrome of fever and malaise; profound tenderness of the skin is distinctive. In
the exfoliative stage, the skin can be induced to form bullae with light lateral
pressure (Nikolsky’s sign). In a mild form, a scarlatiniform eruption mimics scarlet
fever, but the patient does not exhibit a strawberry tongue or circumoral pallor.
 CONFLUENT DESQUAMATIVE ERYTHEMAS
 Kawasaki disease presents in the pediatric population as fissuring of the lips, a
strawberry tongue, conjunctivitis, adenopathy, and sometimes cardiac
abnormalities.
 VESICULOBULLOUS OR PUSTULAR ERUPTIONS
 Varicella is highly contagious, often occurring in winter or spring, and is
characterized by pruritic lesions that, within a given region of the body, are in
different stages of development at any point in time. In immunocompromised
hosts, varicella vesicles may lack the characteristic erythematous base or may
appear hemorrhagic.
 Pseudomonas “hot-tub” folliculitis are also pruritic and may appear similar to
those of varicella. However, hot-tub folliculitis generally occurs in outbreaks
after bathing in hot tubs or swimming pools, and lesions occur in regions
occluded by bathing suits. Pseudomonas aeruginosa should be considered in
immunosuppressed individuals with sepsis and hemorrhagic bullae.
 VESICULOBULLOUS OR PUSTULAR ERUPTIONS
 Lesions of variola (smallpox) also appear similar to those of varicella but are all
at the same stage of development in a given region of the body. Variola lesions
are most prominent on the face and extremities, while varicella lesions are most
prominent on the trunk.
 Herpes simplex virus infection is characterized by hallmark grouped vesicles on
an erythematous base. Primary herpes infection is accompanied by fever and
toxicity, while recurrent disease is milder
 Rickettsial-pox is often documented in urban settings and is characterized by
vesicles followed by pustules. It can be distinguished from varicella by an eschar
at the site of the mouse-mite bite and the papule/plaque base of each vesicle.
 NODULAR ERUPTIONS
 In immunocompromised hosts, nodular lesions often represent disseminated
infection.

 Disseminated candidiasis (often due to Candida tropicalis) may have a triad

of fever, myalgias, and eruptive nodules.
 Disseminated cryptococcosis lesions may resemble molluscum
contagiosum.
 Erythema nodosum and Sweet syndrome should be considered in
individuals with multiple nodules and plaques, often so edematous that they
give the appearance of vesicles or bullae which may occur in individuals with
infection, inflammatory bowel disease, or malignancy and can also be induced
by drugs.
 PURPURIC ERUPTIONS
 Acute meningococcemia classically presents in children as a petechial
eruption, but initial lesions may appear as blanchable macules or urticaria which
later becomes non-blanchable. Its differentials include Echovirus 9 and RMSF.
 Chronic meningococcemia and disseminated gonococcemia may have a
variety of morphologies, including petechial. Purpuric nodules may develop on
the legs and resemble erythema nodosum but lack its exquisite tenderness.
 Large ecchymotic areas of purpura fulminans reflect severe underlying
disseminated intravascular coagulation, which may be due to infectious or
noninfectious causes.
ERUPTIONS WITH ULCERS OR
ESCHARS
 The presence of an ulcer or eschar in the setting of a more widespread
eruption can provide an important diagnostic clue.
 For example, an eschar may suggest the diagnosis of scrub typhus or
rickettsial-pox.
 In illness like anthrax an ulcer or eschar may be the only skin
manifestation.
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