1. FEVER AND SKIN RASH Dr m.barak Associated professor in pediatrics infectious disease

2. 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.

3. MORPHOLOGIC CLASSIFICATION of RASH Maculopapular. Petechial. Diffusely erythematous with desquamation. Vesiculobullouspustular. Nodular.

4. AETIOLOGICAL CLASSIFICATION Viruses. Bacteria. Spirochetes. Rickettsiae. Medications IMMUNOLOGIC-MEDIATED DISORDERS

5. 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

6. Some disorders among travellers Lyme disease. Strongyloides stercoralis. HIV/AIDS. Rocky Mountain spotted fever. Leishmaniasis. Leprosy STDs

7. 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

8. 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.

9. 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.

10. Identification of Primary Skin Lesions

11. MACULE Circumscribed area of change in normal skin color, with no skin elevation or depression; may be any size

12. PAPULE Solid, raised lesion up to 0.5 cm in greatest diameter

13. NODULE Similar to papule but located deeper in the dermis or subcutaneous tissue; differentiated from papule by palpability and depth, rather than size

14. PLAQUE Elevation of skin occupying a relatively large area in relation to height; often formed by confluence of papules

15. VESICLE Circumscribed, elevated, fluid- containing lesion less than 0.5 cm in greatest diameter; may be intraepidermal or subepidermal in origin

16. BULLA Same as vesicle, except lesion is more than 0.5 cm in greatest diameter

17. 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.

18. 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

19. 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

20. Serologic tests Systemic lupus erythematosus. Other collagen vascular disorders Syphilis. Rheumatoid arthritis. Human immunodeficiency virus infection.

21. 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

22. 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.

23. The exanthem of rubeola

24. 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.

25. Erythema infectiosum

26. 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

27. Lyme disease

29. 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.

30. 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 )

31. Secondary Syphilis

32. 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

33. Rash in Adult-onset Still's disease (AOSD)

34. Maculopapular rash in collagen vascular disorders

35. 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.

36. Differential diagnosis of petechial rash Disseminated gonococcal infections. Bacteremia. Staphylococcemia Thromboticthrombocytopenic

37. 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

39. 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

41. 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

42. 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).

44. 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

47. 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

50. 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

51. 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.

53. 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.

55. 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.

57. 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

58. 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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