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FEVER AND SKIN RASH

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									FEVER AND SKIN RASH
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 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
• Animal contact      Q fever.Anthrax.Viral
  hemorrhagic fevers.Cat scratch disease
• 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, fluid-
  containing
  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
• 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 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 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 .
Erythema infectiosum
Lyme Disease&Erythema
Migrans
• Borrelia burgdorferi, which is
  transmitted by the 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          • Minor Criteria
  Fever > 39°C              Sore throat
  Arthritis/arthralgias     Lymphadenopathy
  > 2 weeks                 or splenomegaly
  Still's                   Liver dysfunction
  maculopapular red         Negative
  rash                      Rheumatoid factor
  and blanching             and ANA testing
  eruption of the
  proximal upper and
  lower extremities
  Neutrophilic
  leukocytosis
Rash in Adult-onset
Still's disease (AOSD)
Maculopapular rash in
collagen vascular
disorders
    Petechial& Purpric
    Eruptions
1. MENINGOCOCCEMIA
2. ROCKY MOUNTAIN SPOTTED
   FEVER
3. 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
1. SCARLET FEVER
2. TOXIC SHOCK SYNDROME
   &SCALDED SKIN SYNDROME
3. KAWASAKI'S DISEASE
4. 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-ZOSTER VIRUS 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.
  Herpes Zoster
• it affects a single
  dermatome and 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
THANK YOU

								
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