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48 year old male complains of an acute onset of fever with accompanying…
48 year old male complains of an acute onset of fever with accompanying rash for 2 days.
Macule: Circumscribed area of change in normal skin color, with no skin elevation or depression; may be any size
Rubeola (measles)
Macularpapular rash that may become confluent; begins on face, neck and shoulders and spreads centrifugally and inferiorly; fades in 4 to 6 days
Most common in children 5 to 9 years of age, nonimmune persons
Prodrome consisting of symptoms of upper respiratory tract infection, coryza, barklike cough, malaise, photophobia and fever; Koplik's spots (prodromal stage); development of exanthem on fourth febrile day; late winter through early spring
Rubella
Pink macules and papules that develop on forehead and spread inferiorly and to extremities within one day; fading of macules and papules in reverse order by third day
Young adults, nonimmune persons
Prodrome uncommon, especially in children; petechiae on soft palate (Forschheimer's spots); in adults: anorexia, malaise, conjunctivitis, headache and symptoms of mild upper respiratory infection
Roseola (HHV-6)
Diffuse maculopapular eruption, usually sparing face
Children 6 months to 3 years of age
Fever lasting 3 to 4 days, followed within 2 to 3 days by the rash, which resolves spontaneously in several days; almost always a selflimited benign disease; temporal relationship of fever followed by rash is helpful in making the diagnosis
Lyme disease (Borrelia burgdorferi)
Macule or papule at site of tick bite, progressing to pathognomonic erythema migrans
All ages at risk for tick exposure in endemic areas
History of tick exposure; secondary erythematous, macular lesions; Borrelia lymphocytoma; highest incidence: May through September
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
Pustule
Circumscribed elevation of skin containing purulent fluid of variable character (i.e., fluid may be white, yellow, greenish or hemorrhagic)
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
Multiple
Erythema multiforme (Idiopathic in 50 percent of cases)
Dullred macules developing into papules with central vesicles or bullae; common on dorsa of hands, palms, soles, arms, knees, penis and vulva; often bilateral and symmetric
Adults 20 to 30 years of age; men affected more often than women
Major and minor forms; major form always with mucous membrane involvement and usually the result of drug reaction; minor form often associated with herpes simplex outbreak; rarely lifethreatening
Secondary syphilis (Treponema pallidum)
Various presentations; brownishred or pink macules and papules; generalized eruption or localized eruption on head, neck, palms or soles; condyloma lata common
Adolescents and adults 15 to 49 years of age; females affected more often than males
Develops 2 to 10 weeks after primary chancre; presents with or without fever; may have generalized lymphadenopathy and splenomegaly; may have recurrent eruptions with symptomfree periods
Meningococcemia (acute) Neisseria meningitidis
Variety of lesions but, characteristically, petechial lesions distributed on the trunk and extremities (although the lesions can be located anywhere); petechiae on mucous membranes
Highest incidence in children 6 months to 1 year of age
Acutely ill patient; high fever, tachypnea, tachycardia, mild hypotension; leukocytosis; meningitis develops in more than 50 percent of patients. headache, fever, neck stiffness
Gram negative diplococcus Neisseria meningitides
myalgia are generally more painful than myalgias seen in viral influenza.
Meningococcemia (chronic)
Intermittent maculopapular lesions, often on a painful joint or pressure point; may have nodules on calves
Fever, myalgias, arthralgias, headache, anorexia; may recur for weeks or months, with average duration of 8 weeks; may progress to acute meningococcemia, meningitis or endocarditis
Scarlet fever - Betahemolytic
Streptococcus pyogenes
Children
Punctate erythema beginning on trunk and spreading to extremities, becoming confluent; flushed face with perioral pallor; rash fading in 4 to 5 days and followed by desquamation
Acute infection of tonsils or skin; linear petechiae in antecubital and axillary folds (Pastia's sign); rash appearing 2 to 3 days after infection; initially, “white strawberry tongue” but by fourth or fifth day, “red strawberry tongue”
Toxic shock syndrome - S. aureus
Diffuse “sunburn“ rash that desquamates over 1 to 2 weeks
All ages, but most common in menstruating females
High fever, hypotension and involvement of three or more organ systems; about 50 percent of cases occurring in menstruating women around onset of menses; postoperative patients at increased risk; condition out of proportion to wound appearance
petechial rashes or skin necrosis on the nose, ears, and extremities, caused by endocarditis due to staphylococcal infection, or severe blood infection
acute HIV
The rash has an acute onset 1 to 6 weeks after infection and is usually accompanied by fever, malaise, myalgias, arthralgias, and lymphadenopathy. It is a symmetric exanthematous rash that involves the face, palms, and soles. Oral and genital aphthous-type ulcers may occur.
Necrotizing fasciitis
common causes
Postoperatively, TSS, surgical scarlet fever, and cholesterol emboli syndrome
ICU: most common - meningococcemia or meningoencephalitis, other causes include TSS, SLE, bacterial sepsis (pneumococcal, staphylococcal, vibrio, etc.), and severe viral diseases (hemorrhagic fever, measles, dengue fever, etc.
central venous catheter or pacemaker, fever and rash due to bacteremia must be considered.
However, the most common cause of fever and rash in patients admitted to the intensive care unit is adverse reactions to drugs [36].
ADR
SJS
Temperature >38.5°C, malaise, sore throat, dysphagia, dysuria, or photophobia initially
Fever, sore throat, and fatigue. Ulcers and other lesions begin to appear in the mucous membranes, almost always in the mouth and lips, but also in the genital and anal regions. Those in the mouth are usually extremely painful and reduce the patient's ability to eat or drink. Conjunctivitis - 30% of children who develop SJS. A rash of round lesions about an inch across arises on the face, trunk, arms and legs, and soles of the feet, but usually not the scalp
medications
(antibiotics, sulfa), viral infections and malignancies
Onset 4 to 21 days after first dose of drug
Severe, acute blistering; initially, rash may be macular erythema or exanthematous eruption and trunk lesions predominate; individual lesions may include “spots” and flat, atypical target le- sions but not true target lesions characteristic of erythema multiforme, which is not usually drug-related; Nikolsky’s sign (ready removal of the epidermis with slight tangential pressure); body-surface area:
10 to 30% in SJS–TEN versus less than 10% in SJS and more than 30% in TEN
DRESS - drug eruption with eosinophilia and systemic symptoms
Temperature >38.5°C, malaise, lymphadenopathy, involvement of at least one internal organ: liver (in >80% of cases), kidney, muscle, lung, heart, pancreas
long latency (two to eight weeks) between drug exposure and disease onset, a prolonged course with frequent relapses despite the discontinuation of the culprit drug, and frequent association with the reactivation of latent human herpesvirus infections
Widespread rash (involving >50% of body-surface area), often exanthematous, and very inflamed;
may have other morphologic features, includ- ing erythroderma; facial edema and erythema; exanthematous eruption may become purpu- ric, especially on lower legs
lab findings:
Eosinophilia (≥700×106 per liter or ≥10% if white- cell count <4000×106 per liter) and lymphocy- tosis or lymphopenia, atypical lymphocytes, thrombocytopenia; simultaneous activation of latent or new infection with human herpesvi- rus 6 common (not a routine test)
AGEP acute generalized exanthematous pustulosis
Leukocytosis with neutrophilia (absolute count, >7000×106 per liter)
Rapid evolution (over a period of hours) of sterile, nonfollicular pustules on erythematous swol- len skin; accentuation of rash in body folds; facial edema
Initial onset (<3 days) after first dose of an antibi- drug, especially in the case of antiepileptic otic but slower onset with other drugs
Papule
Solid, raised lesion up to 0.5 cm in greatest diameter
eczema herpeticum (kaposi's varicelliform eruption
Widespread eruption - serious complication of atopic eczema or less commonly other skin conditions
● Herpes simplex virus
● Extensive crusted papules, blisters and erosions
● Systemically unwell with fever and malaise