A concise guide for DD of fever with rash. for residents in dermatology. made by me as a part of residency in dermatology.

1. DR. SABHA TALIB NEAZEE

2. • It is an elevation of body temperature above normal
circadian variation.
An AM temperature of >37.2* C (98.9 F)
An PM temperature of >37.7 *C(99.9 F)
Ref: Harrisson textbook of medicine

3. Types Character Examples
Continuous Temp remains above
normal through out the
day. Fluctuates less tha
1* C in 24 hrs
Typhoid fever,typhus,
malignant hyperthermia
Remittent Fluctuates more than
1*C in 24 hours
Sepsis, TB, rheumatic
fever
Intermittent Fever for some hours
and remits to normal for
rest of day
Pyogenic infections,
miliary TB
Recurrent fever High spikes with
intermittent low grade
fever
Malaria, cholecystytis

5. • Change of human skin which affects its color,
appearance or texture.
Types-
Macule
Papule
Nodule
Plaque
Pustule
Vesicle
Bulla

6. • Drug ingestion within past 30 days
• Drug or food allergies
• Travel history
• Insect bite
• Sun exposure
• Immunizations
• Sexual exposure
• Cardiac abnormalities
•

7. WITH FEVER

8. BACTERIAL VIRAL NONINFECTIOUS
Scarlet fever Measles Drug eruption
Secondary syphilis Rubella Toxic erythema
neonaturum
RMSF Exanthem subitum Erythema multiforme
Leptospiral infection Exanthem infectiosum Urticaria
Disseminated
gonococcal infection
Gianotti-crosti syndrome Rheumatic fever
PPGSS Lupus erythomatosus
Pityriasis rosea
Eruptive
pseudoangiomatosis
Dengue
Chikungunya
Ebola virus disease
Zica virus
ref:article”febrile illnesses with skin rashes” www.icjournol.com, evaluating febrile patient with febrile illness-
www.aafp.org

9. Infective agent- paramyxovirus
Incubation period-7-18 days
History- preceded by fever, cough and very red eyes
older children may have photophobia. 3Cs
Epidemiology- 5-9 years
Morphology- erythematous and maculopapular rash that may
become confluent , sparing palms and soles.
Koplik spots- pathognomic. Opposite to premolar, 24-48 hrs
before exanthem
Distribution- first face, then neck and shoulders, spreads
centrifugally and inferiorly, fades in 4-6 days
Infectivity- from prodromal symptoms to 4 days after onset of
rash
r

11. Infective agent: rubella virus
Incubation period:14-21 days
Epidemiology: young adults
History: prodrome of fever ,malaise, cough and sore
throat.
Morphology: light pink macules and papules. Individual
lesions are small often with peripheral blanching.
Forscheimer spots: small, red spots( petechiae) n soft
palate
Distribution: starts face or neck and then spreads
caudally
Infectivity: from1 week before to 4 days after the onset of
rash.

13. Infective agent: HHV 6 or 7
Incubation period:10-15 days
History: children below 3 years of age, high grade fever,
urti, diarrhea, seizures
Morphology: generalized erythematous macules with
some papules. Rash described as “RAINBOW
FOLLOWING THE STORM”
Distribution: face is usually spared, rash seen on trunk
and neck, extremities are involved later.
Infectivity : whole duration of disease

15. Infective agent: parvovirus B19
Incubation period:4-14 days
History: children 4-10 years. Common in winter and
spring. Prodrome of low grade fever, malaise, myalgia,
pharyngitis diarrhea or arthralgia.
Morphology and distribution: the rash is biphasic.
1. Confluent, erythematous plaques on cheeks, with
sparing of nasal bridge and periorbital regions. So
called SLAPPED CHEEK. Fades over 1-4 days.
2. The rash then spreads to the trunk and extensor
extremities which undergoes patchy clearing with lacy
reticular pattern
Infectivity: not infectious when rash appears

17. Infective agent: EBV, enterovirus, RSV, hep C.
Incubation period: unknown
Epidemiology: children 1-6 years of age
History: URTI, diarrhea, fever, malaise.
Morphology: monomorphous, flat topped, pink brown
papules, or papulovesicles 1-10 mm in diameter,
Distribution: over cheeks, buttocks, extensor surfaces of
forearms, extensor surfaces of legs. Symmetrical.
Infectivity: not infectious.

19. Infective agent: Parvovirus B19
Incubation period: 10 days
Epidemiology: young adults
 History: prodrome of fever and fatigue, apthous
ulceration like oral lesions.
Morphology: papular lesions, erythema and edema of
hands and feet which soon turns out to be purpuric.
Distribution: hands and feet with sharp demarcation at
wrists and ankles

21. Infective agent: HHV 6, HHV 7
History: prodrome of fever, headache, arthralgias
Epidemiology: young adults
Morphology: discrete, oval or round, erythematous scaly
plaques, with fine scales. Herald patch. Hanging curtain
sign.
Distribution: trunk and extremities. Christmas tree
pattern.
Infectivity: non infective

23. Infective agent: DEN virus 1,2,3 and 4
Incubation period: 8 to 10 days
History: biphasic fever, myalgia, arthralgia, headache,
retro bulbar pain and rash.
Morphology: transient facial erythema, maculopapular
eruption, generalized erythema with islands of normal
skin, purpura/ecchymoses,
Distribution: generalized

25. Infective agent: CHIKV
Incubation period: 2-3 days
History: biphasic or saddle back fever
Morphology: maculopapular eruption, hyper
pigmentation, transient erythema, generalized erythema
with islands of normal skin, palmo plantar desquamation,
Distribution: hyperpigmentation over centrofacial area,
generalized, chik sign. millian`s ear sign

27. • Ebola virus.
• Incubation period- 2 to 20 days.
• History- sharp chest pain, fever, headache, diarrhea,
vomiting.
• Morphology: day 4-6: maculopapular rash,centriprtal
distribution, ghost like features.
day7- desquamation, prominent on palms and soles
day8- generalized cutaneous erythema.
• Infectivity: spreads by direct contacts, body fluids,
contaminated needles or syringes
Ref: article-cutaneous manifestations of Ebola virus. Online dermatology journal.

29. • Incubation period: 3-14 days
• History: majority- no symptoms
fever, malaise, headache, conjuctuvutis
• Maculopapular rash
• Transmission: aedes mosquito bite,vertical transmission,
sexual contact, blood and blood products

30. OF MACULOPAPULAR RASH WITH FEVER

31. Infective agent: B hemolytic streptococcus pyogenes
Epidemiology: children
 History: fever with chills, URTI, headache, vomiting
Morphology: punctuate erythema, becoming confluent,
rash fading in 4-5 days followed by desquamation, linear
petechiae in antecubital and axillary folds( Pastia`s sign),
strawberry tongue,
Distribution: begins on face and spreads to extremity

33. • Infective agent: salmonella typhi
• History: bloody stools, fever with chills, nausea,
vomiting.
• Morphology: rose spots. Appears in 2nd week.grouped
blanching papules on anterior trunk. Lasts 3-5 days.
• Distribution: between the T4 and T10.
• Others : erythema typhosum, haemorrhagic bullae,
pustular dermatitis, erythema multiforme.

35. Infective agent:Treponema pallidum
Epidemiology: young adults, sexually active
History: H/o genital ulcers, fever may or may not be
present.
Morphology:macular syphilide- most comman, papular
syphilid- most characteristic, corona veneris, corymbose
syphilide, buschke olendroff sign, leukoderma colli
charateristically palm and soles involvement.

37. • Infective agent: rickettsia rickettsii
• Epidemiology: young adults with tick exposure. M>F
• History: abrupt fever, severe headache, myalgias
• Morphology: rash evolving from pink macules to red
papules and finally to patechiae
• Distribution: starts on wrists and ankles spreading
centripetally.

39. OF FEVER WITH MACULOPAPULAR RASH

40. • Morphology: erythematous maculopapular eruption,
symmetric, may get confluent, patechiae and macular
purpura.
• History: of intake of drug within a week up to 10 days.
• Distribution: rash first appears on trunk and upper
extremity and spreads caudally.
Ref-article-maculopapular drug reaction versus maculopapular viral exanthem www.iijd.in

42. • Morphology: blotchy macular erythema,
• Distribution: almost any site except palms and soles
• History: may or may not be associated with fever
• Ref- rook`s textbook of dermatology

44. • Morphology: macular, papular or urticarial lesions, classic
IRIS or TARGET lesions.
• Distribution: preferentially distal exremities, may involve
palms or trunk as well as oral and genital mucosa.
• Epidemiology: any age group.

46. • Erythema marginatum: non pruritic rash
• commonly affects the trunk and proximal extremities
• spares the face
• Serpiginous polycyclic annular lesions
• rash typically migrates from central area to periphery
• Well defined borders

48. • Localised form- malar or butterfly rash.
• Generalized form- maculopapular rash with palms and
soles
• The rash usually spares the DIP, PIP and MCP.

50. IN FEVER

51. Systemic erythema with dermal
caseation
Systemic erythema without dermal
caseation
Scarlet fever Bacteremia
Toxic shock syndrome GVHD
SSSS Generalized pustular psoriasis
Kawasaki disease

52. • Staphylococcus aureus
• Diffuse macular erythema that desquamates over 1 to 2
weeks
• All ages but common in menstruating women
• High fever, multi organ involvement.

54. • Localised: seen in flexures. Erythematous eruption which
progresses to blister formation. Heals classically with
leaving wrinkled desquamating skin, with
hyperpigmentation
• Generalised: accentuated in flexures, nikolsky +, tender
skin, raw areas.

56. • Children< 2 years of age
• M>F
• Fever with generalized exanthem and lymphadenitis.
• Strawberry tongue, widespread exanthem on limbs and
trunk which then become localized over distal
extremities, hands and feet.

58. • aGVHD- blanching macules on palms and soles.
Photoaggravated in distribution. Severe cases-
erythroderma, bullae, nikolsky +.
• cGVHD- LP like lesions on skin or in oral cavity. Sclerotic,
morphoeform lesions, poikiloderma. Nail dystrophy.

60. WITH FEVER

61. BACTERIAL NON BACTERIAL NON INFECTIOUS
Staphylococcemia Varicella Allergy
Impetigo Herpes zoster Eczema vaccinatum
Gonococcemia Parvovirus b 19 Erythema multiforme
Hand, foot, mouth
disease

62. • Can occur at any age but common in children
• Most common over face around nose and mouth
• Non bullous impetigo-Initially very thin walled vesicle on
erythematous base, multiple lesions which coalesce,
without central healing.
• Bullous impetigo- lesions rapidly ruptured and covered
with crust.

64. • Epidemiology: 50% before 5 years of age and 85%
before puberty.
• Infective agent: VZV
• Incubation period: 14-17 days.
• History- fever and malaise for day or two.
• Morphology- characteristic presence of lesions at
different stages. Centripetal in distribution. Pleomorphic.
DEW DROPS ON ROSE PETALS
• Infective period- 1-2 days before the rash appears until
all lesions have crusted.

66. • Infective agent- coxsackie A16, A10 and the echo virus.
• History- children< 10 years of age. 12- 36 hour of
prodrome of fever, malaise, abdominal pain, URTI
• Morphology: painful ulcerative lesions in oral cavity.
Maculopapular rash- vesicle- ulcer with erythematous
halo. Hands and feet- 2-3 mm erythematous macules or
papules with a central grey vesicle. Hands > feet.
• Highly infectious.

68. • VZV.
• Not common in children
• History: severe pain, fever.
• Grouped vesicles over erythematous base in dermatomal
distribution.
• Infectivity: vesicular fluid can cause chicken pox in non
immunised person.

70. • HSV1
• History of recurrent similar episodes
• Can occur on any part of skin but perioral area most
common.
• Macules- papules - painful vesicles.

72. WITH FEVER

73. BACTERIAL NON BACTERIAL NON INFECTIOUS
Mycoplasma infection Enteroviral infection Vasculitis
EBV Malignancy
Hepatitis Idiopathic
HIV

74. • 5TH decade. F>M
• History of infection or drug intake. Fatigue, malaise and
fever.
• Recurrent painful wheals lasting for more than 24 hours.
Livedo retucularis, raynaud`s phenomenon

76. WITH FEVER

77. BACTERIAL NON BACTERIAL NON INFECTIOUS
Meningococcemia Enteroviral Acute allergic eruptions
Endocarditis EBV Allergic purpura
Bacteremia Hepatitis b Acute thrombocytopenia
Septicemia Rubella Hematologic malignancy
CMV Acute rheumatic fever
Influenza Sle
Ebola Amyloidosis
TTP
Cutaneous small vessel
vasculitis

78. • MENINGOCOCCEMIA- MC . hemorrhagic rash ranging
from patechiae to ecchymoses.
• CMV- blueberry muffin spots. Petechial or purpuriform
exanthem. Hepatosplenomegaly, deafness,
microcephalus, intracereberal calcificatios.

80. WITH FEVER

81. INFECTIOUS NON INFECTIUOS
Disseminated infection Sweet syndrome
Erythema nodosum Kaposi sarcoma

82. • Idiopathic- 40%
• Infectious causes
beta hemolytic streptococci
yersinia pestis
hepatitis c
mycobacterium species
chlamydia trachomatis
• Non infectious
medications-sulfonamides, OCP
• SLE
• Ulcerative colitis
• Behcets syndrome
• Pregnancy
Ref: Fitz[atrick

83. • History-fever or infectiuous disease.
current or previous malignant disease
new drug administration
• Tender red papules, nodules and eventually plaques.
Pseudo vesicles or pseudo pustules

85. • KSHV/ HHV8
• Present in saliva, spreads by oral sexual contact.
• Violaceous macules, papules, nodules or plaques.
Palpable and non purpuric. Discrete or confluent. Linear ,
symmetrical distribution.
• Cough , dyspnoea, fever.

87. WITH RASH

88. RASHES AND CONCOMITTANT
FEATURES
SUSPECTED DISEASES
Rash & shock TSS,sepsis, haemorrhagic fever
Rash & conjuctivitis Kawasaki disease, measles, TSS,PLEVA
Rash &abdominal pain Typhoid fever, scarlet fever, SLE
Rash & diarrhea Vibrio vulnifius, gas gangrene, TSS, PLEVA
Rash & mental changes SLE, typhoid, ABE
Rash & pulmonary infiltrates SLE, atypical measles
Rash & bullous lesions Vibrio vulnificans, gas gangrene
Rash & purpura hypersensitivity vasculitis
Rash & adenopathy SLE, rubella, scarlet fever, kawasaki disease
Rash & splenomegaly Typhoif fever, rubella, SLE

89. 1ST Disease Measles Koplik spots
2nd Disease Scarlet fever Pastia`s sign
3rd Disease Rubella Forscheimer`s spots
4th Disease SSSS Nikolsky
5th Disease Erythema infectiosum Slapped cheek
6th Disease Exanthem subitum Rainbow after storm
Chikungunya Chik sign
Pityriasis rosea Christmas tree
Scarlet fever Pastia`s lines, strawberry
tongue
RMSF Rash starting on wrist
Rheumatic fever Erythema marginatum
Varicella Dewdrops on rose petals

90. • Day 1-varicella
• Day 2- scarlet fever
• Day 3- pox
• Day 4- measles
• Day 5-typhus
• Day 6- dengue
• Day 7- enteric fever

92. THANK YOU
FOR YOUR
ATTENTION