FEVER AND SKIN RASH DR M. YOUSRY ABDEL-MAWLA,MD. Zagazig Faculty of Medicine
INTRODUCTION <ul><li>The differential diagnosis for febrile patients with a rash is extensive.  </li></ul><ul><li>Diseases...
MORPHOLOGIC CLASSIFICATION of RASH <ul><li>Maculopapular . </li></ul><ul><li>Petechial.  </li></ul><ul><li>Diffusely eryth...
AETIOLOGICAL CLASSIFICATION <ul><li>Viruses. </li></ul><ul><li>Bacteria.  </li></ul><ul><li>Spirochetes.  </li></ul><ul><l...
HISTORY <ul><li>A detailed history can be quite helpful in identifying the cause of fever and a rash.  </li></ul><ul><li>A...
Some disorders among travellers <ul><li>Lyme disease.  </li></ul><ul><li>Strongyloides stercoralis.  </li></ul><ul><li>HIV...
Animal & Insect Contact Disorders <ul><li>Animal contact   Q  fever. Anthrax.Viral hemorrhagic  fevers.Cat scratch disease...
Speacial care to  the following <ul><li>Conditions associated with valvular heart disease,  </li></ul><ul><li>Sexually tra...
Details about the rash  : <ul><li>Site of onset, </li></ul><ul><li>Rate . </li></ul><ul><li>Direction of spread,  </li></u...
Identification of Primary Skin Lesions
MACULE <ul><li>Circumscribed area of change in normal skin color, with no skin elevation or depression; may be any size   ...
PAPULE <ul><li>Solid, raised lesion up to 0.5 cm in greatest diameter   </li></ul>
NODULE <ul><li>Similar to papule but located deeper in the  dermis  or  subcutaneous  tissue; differentiated from papule b...
PLAQUE <ul><li>Elevation of skin occupying a relatively large area in relation to height; often formed by confluence of pa...
VESICLE <ul><li>Circumscribed, elevated, fluid-containing lesion less than 0.5 cm in greatest diameter; may be intraepider...
BULLA <ul><li>Same as vesicle, except lesion is more than 0.5 cm in greatest diameter   </li></ul>
LOOK FOR <ul><li>The patient's vital signs and general appearance. </li></ul><ul><li>Signs of toxicity.  </li></ul><ul><li...
LABORATORY DATA <ul><li>The complete blood count with differential, an erythrocyte sedimentation rate, </li></ul><ul><li>A...
Specific diagnoses that may be confirmed histologically   <ul><li>Rocky Mountain spotted fever, herpetic infections, syste...
Serologic tests   <ul><li>Systemic lupus erythematosus. </li></ul><ul><li>Other collagen vascular disorders </li></ul><ul>...
Maculopapular Rash. <ul><li>Viral illnesses :rubeola, rubella, erythema infectiosum and roseola   </li></ul><ul><li>Immune...
The exanthem of rubeola <ul><li>begins  around the fourth febrile day , with discrete lesions spreading from the hairline ...
The exanthem of rubeola
Erythema infectiosum fifth disease :   <ul><li>Caused by human  parvovirus B19 .  </li></ul><ul><li>In  children between t...
Erythema infectiosum
Lyme Disease&Erythema Migrans   <ul><li>Borrelia burgdorferi , which is transmitted by the bite of a tick (Ixodes species)...
Lyme disease
Lyme disease
Erythema Multiforme   <ul><li>The dull-red lesions advance from macules to papules, with prominence of characteristic targ...
Secondary Syphilis   <ul><li>The rash of secondary syphilis can be diffuse, with localized eruptions often occurring on th...
Secondary Syphilis
Adult-onset Still's disease (AOSD)   <ul><li>Major Criteria </li></ul><ul><li>Fever > 39°C Arthritis/arthralgias > 2 weeks...
Rash in  Adult-onset Still's disease (AOSD)
Maculopapular rash in collagen vascular disorders
Petechial& Purpric Eruptions <ul><li>MENINGOCOCCEMIA </li></ul><ul><li>ROCKY MOUNTAIN SPOTTED FEVER </li></ul><ul><li>Vira...
Differential diagnosis of petechial rash   <ul><li>Disseminated gonococcal infections.  </li></ul><ul><li>Bacteremia.  </l...
MENINGOCOCCEMIA <ul><li>Seeding of  Neisseria meningitidis  from the nasopharynx : acute meningococcal septicemia, meningo...
 
ROCKY MOUNTAIN SPOTTED FEVER <ul><li>Caused by  Rickettsia rickettsii. </li></ul><ul><li>The prodrome  : malaise, chills, ...
 
Diffuse Erythema with  Desquamation <ul><li>SCARLET FEVER </li></ul><ul><li>TOXIC SHOCK SYNDROME &SCALDED SKIN SYNDROME </...
SCARLET FEVER <ul><li>An acute infection by group A beta-hemolytic streptococci that produce an erythrogenic exotoxin.   <...
 
KAWASAKI'S DISEASE <ul><li>An acute febrile illness that affects infants and young children (mean age: 2.6 years).  Fever ...
 
 
TOXIC SHOCK SYNDROME AND SCALDED SKIN SYNDROME <ul><li>Staphylococcus aureus  exotoxins responsible for classic toxic shoc...
 
 
Vesiculobullous-Pustular Eruptions <ul><li>VARICELLA-ZOSTER VIRUS INFECTIONS </li></ul><ul><li>Coxsackie viruses and other...
Varicella.   <ul><li>Primary infection with varicella-zoster virus results in chickenpoxA mild prodrome lasting one to two...
 
Herpes Zoster   <ul><li>it affects a single dermatome and rarely crosses the midline  .   </li></ul><ul><li>The common loc...
 
Coxsackie  viruses and other enteroviruses   <ul><li>Hand-foot-and-mouth  disease: the children develop fever and rash. Th...
 
Nodular Eruptions <ul><li>Erythema nodosum: acute intlammatory &immunologic process involving the panniculus adiposus. </l...
Aetiology <ul><li>Idiopathic.  </li></ul><ul><li>Infectious causes   </li></ul><ul><li>Beta-hemolytic streptococci .  Noca...
 
 
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F E V E R A N D S K I N R A S H Final

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F E V E R A N D S K I N R A S H Final

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