FEVER WITH RASH

Dr. Gautam Lahiri

RMO
Dept. of Medicine, MCH

POINTS TO DISCUSS :

Basics
Etiology of fever with rash
Classification by distribution & morphology
Salient features of common conditions
presenting as fever with rash
Approach

BASICS

FEVER
FEVER : a.m. temperature 37.2C ( 98.9F) or p.m.
temperature 37.7C ( 99.9F)
HYPERPYREXIA : A fever of 41.5C ( 106.7F)
HYPERTHERMIA : an uncontrolled se in body
temperature that exceeds body's ability
to loose heat

PRIMARY SKIN LESIONS

PRIMARY SKIN LESIONS

Contd..

PURPURA :
erythematous macule due to extravasation of
RBCs into dermis
nonblanchable on diascopy

Nonpalpable purpura : flat lesions due to

bleeding into the skin
Petechiae : Purpura 3 mm in diameter
Ecchymoses : Purpura 3 mm in diameter
Palpable purpura :
raised lesion due to vasculitis with subsequent
hemorrhage

Etiology
of
fever with rash

ETIOLOGY
FEVER WITH RASH
VIRAL : Measles, rubella, chicken pox, herpes simplex, herpes zoster, dengue,
chikungunya, HIV, EBV, HBV, HCV, parvovirus B-19, coxsackie A16,
BACTERIAL : Gr. A streptococcus, Staphylococcus aureus, Salmonella,
N. meningitidis & N. gonorrhea, mycobacteria
INFECTIVE

PARASITIC : Leishmania, T. cruzi, Schistosoma mansoni & S. japonicum,

A. braziliense, S. stercoralis, Onchocerca volvulus
FUNGAL : Coccidioides immitis, Blastomyces dermatitidis, H. capsulatum,
Cryptococcus neoformans
SPIROCHETE : T. pallidum, Leptospira
RICKETTSIAL : R. akari, R. conori, R. tsutsugamushi
CTDs : SLE, RA, Stills ds

NON - INFECTIVE

Sarcoidosis
Drug rash with fever
Acute rheumatic fever

CLASSIFICATION
BY
DISTRIBUTION & MORPHOLOGY

CLASSIFICATION BY DISTRIBUTION &

MORPHOLOGY
DISTRIBUTION & MORPHOLOGY

Centrally distributed maculopapular eruptions

Peripheral eruptions
Confluent desquamative erythemas

Vesicobullous or pustular eruptions

Urticaria like eruptions

ETIOLOGY
Acute meningococcemia, DIHS / DRESS,
Measles, Rubella, Erythema infectiosum, roseola,
primary HIV infection, IM, exanthematous drugeruptions, scrub typhus, leptospirosis, Lyme ds,
relapsing fever, typhoid fever, dengue fever, rat
bite fever, erythema marginatum (rheumatic
fever), SLE, Stills ds
2 syphilis, chikungunya fever, hand-foot-mouth
ds, erythema multiforme, bacterial endocarditis
Scarlet fever, Kawasaki ds, TSS, SSSS, DIHS /
DRESS, SJS, TEN
Varicella, primary HSV infection, ecthyma
gangrenosum, , hand-foot-mouth ds, TSS, SSSS,
DIHS / DRESS, SJS, TEN
Urticarial vasculitis

CLASSIFICATION BY DISTRIBUTION
& MORPHOLOGY Contd..
DISTRIBUTION & MORPHOLOGY
Nodular eruptions

Purpuric eruptions

Eruptions with ulcers &/or eschars

ETIOLOGY
Disseminated eruptions, erythema nodosum,
Sweets syndrome
Acute meningococcemia, purpura fulminans,
disseminated gonococcal eruptions, viral
hemorrhagic fever, TTP / HUS, cutaneous small
vessel vasculitis, dengue fever, endocarditis,
parvovirus B-19 infection, rat bite fever

Anthrax, Tularemia, scrub typhus, ecthyma

gangrenosum

SALIENT FEATURES
OF
COMMON ETIOLOGIES

MEASLES (Rubeola)
Paramyxo virus
rash starts as discrete erythematous
lesions at hairline 3-4th day of
fever
becomes confluent as rash spreads
down the body
spares palms & sole
rash lasts 3 days
Kopliks spot (buccal mucosa)
cough, coryza, conjunctivitis,
prostation

RUBELLA (German measles)

Toga virus
generalized maculopapular rash spreads from hairline downwards ; lasts
3 days
tends to clear from originally affected areas as it migrates (c.f. measles)
Pruritus
Forchheimer spot (palatal petechiae)
postauricular, suboccipital lymhadenopathy & arthritis / arthralgia : M/c in
females

ERYTHEMA
INFECTIOSUM
(Fifth ds)
Human parvo virus B-19
Children 3-12 yrs
winter & spring : rash follows
resolution of fever
appearance of bright blanchable
erythema on cheeks (slapped cheeks)
with perioral pallor ; f/b diffuse lacy
reticular rash (often pruritic) that may
wax & wane over 3 weeks
adults : arthritis

ERYTHEMA
SUBITUM
(Roseola ; sixth ds)
o
o
o
o
o
o
o
o

HHV 6
children 3 yrs
rash follows resolution of fever
2-3 mm rose pink macules-papules ;
rarely coalesce
trunk, neck, extremities
spares face
rash fades within 2 days
febrile seizure

VARICELLA
(Chickenpox)

Varicella-zoster virus
macules papules vesicles
(sometimes umbilicated) on an
erythematous base ; pustules
pleomorphic eruptions (different
stages) in centripetal distribution
(most profuse on the trunk & less
on face & limbs)
lesions appear in crops ; crusting
may involve scalp, mouth
intensely pruritic

DENGUE

ACUTE
MENINGOCOCCEMI
A
Neisseria meningitidis
pink maculopapular lesions evolving
into numerous petechiae
trunk, extremities M/c involved, may
appear on face, hands, feet

hypotension, shock, meningitis

M/c in children, pt with asplenia,

terminal complement (C5-C8)

deficiency

CHIKUNGUNYA
FEVER
Chikungunya virus ; aedes mosquito
maculopapular / morbiliform eruptions
prominent on upper extremities & face
severe arthralgia : polyarticular,
migratory, small joints (hand, wrist,
ankle)

SCARLET FEVER
(Second ds)
o Gr. A streptococcus
o
o

o
o
o
o

children 2-10 yrs ; usually follows

streptococcal pharyngitis
diffuse blanchable erythema
beginning on face & spreading to
trunk & extremities
accentuated petechiae in body
folds : Pastias lines
circumoral pallor
red strawberry tongue
desquamation in 2nd wk

ERYTHEMA
MULTIFORME

ERYTHEMA
NODOSUM

Infections (HSV, mycoplasma

pneumoniae) ; drugs (sulfa,
phenytoin, penicillin) ; idiopathic
Target lesions (central
erythema surrounded by area of
clearing & another rim of
erythema) : upto 2 cm
symmetric on knee, elbow,
palm, sole ; spreads centripetally
papular, sometimes vesicular
50 pts 20 yrs age

Infections (streptococcal,
fungal, mycobacterial, yersinial)
; drugs (sulfa, penicillin, OCP) ;
sarcoidois ; idiopathic
large, violaceous, nonulcerative subcutaneous nodules
highly tender
usually on lower legs, may be
on upper extremities
common in girls & women
15-30 yrs age
50 arthralgia

ERYTHEMA
MARGINATUM
Gr. A streptococcus
Major diagnostic criteria
of acute rheumatic fever
Erythematous annular
papules & plaques over
trunk, proximal extremities
evolve & resolve within
hours

TOXIC SHOCK
STAPHYLOCOC
SYNDROME (TSS) CAL SCALDED
SKIN
SYNDROME
(SSSS)
Streptococcal TSS :
may occur in the setting of
severe gr. A streptococcal
infection (necrrotizing fascitis,
bacteremia, pneumonia)
rash resembles scarlet fever
hypotension, MOF
30 mortality

Staphylococcal TSS :
Staph. aureus
diffuse erythema involving
palms
erythema of mucosal surface
conjunctivitis
desquamation 7-10th day
fever 102F ; MOF,
hypotension

Staph. aureus, phage gr

II
children 10 yrs
(Ritters ds in neonates) or
adults with renal
dysfunction
diffuse tender erythema,
often with bullae &
desquamation ;
Nikolsky sign

DIHS / DRESS

SJS / TEN

(Drug induced
hypersensitivity syn /
Drug reaction with
eosinophilia &
systemic symptoms )

(Stevens-Johnson syn / Toxic

epidermal necrolysis)

anti convulsant,
sulfonamides,
minocycline
maculopapular
eruptions, sometimes
exfoliation
profound edema,
especially facial
lymphadenopathy,
eosinophilia, atypical
lymphocytes, MOF
(especially hepatic),
mimics sepsis

drugs (80 : allopurinol,

anticonvulsants, antibiotics) ;
infections ; idiopathic
erythematous & purpuric
macules or diffuse erythema
progressing to bulla sloughing
& necrosis of entire epidermis
Nikolskys sign
involves mucosal surface
SJS : 10 epidermal necrosis
SJS/TEN overlap : 10-30
TEN : 30
dehydration , sepsis
~30 mortality

SLE

SWEETS SYNDROME

Autoimmune ds
typically a sharply defined
erythematous eruption in a butterfly
distribution on the cheeks (malar rash)
other lesions : macular & papular
erythema often in sun exposed area ;
discoid lupus lesions (atrophy, scale,
pigmentation) ; periungual telangiectesia ;
vasculitic lesions ; palpable purpura
young to middle aged women
flares ppt by sun exposure
association arthritis, cardiac,
pulmonary, renal, hematologic &
vasculitic ds

Yersinial infection ; IBD ;

lymphoproliferative disorders ;
idiopathic
Tender, red or blue edematous
nodules mimicking vesiculations
usually on face, neck, upper
extremities
when on lower extremities, may
mimic erythema nodosum
common in women 30-60 yrs
20 malignancy (M=F)
often associated with headache,
arthralgia, leucocytosis

STILLS
DISEASE
Autoimmune ds
transient
(evanescent) 2-5 mm
erythematous papules
at the height of fever
over trunk, proximal
extremities
children & young
adults
high spiking fever,
plyarthritis,
splenomegaly,
ESR 100

VIRAL
HEMORRHAGIC
FEVER
Arbovirus (including dengue) ; arena
virus
petechial rash
triad of fever, shock, hemorrhage
from mucosa or GIT
residence in or travel to endemic
areas
common hemorrhagic fevers
(HF) : DHF/DSS ; Marburg or Ebola
HF ; Kyasanur Forest HF ; Yellow
fever ; HF with renal syndrome ;
Lassa fever ; Rift valley fever etc.

HUS/TTP
Idiopathic ; E. coli O157 : H7
(shiga toxin) ; drugs
petechiae
persons with E. coli O157 : H7
gastroenteritis, cancer CT, HIV,
autoimmune ds, pregnant or
postpartum women are prone
fever (not always) ; hemolytic
anemia ; thrombocytopenia ; renal
dysfunction ; neurologic
dysfunction
coagulation studies normal

How
To
Approach
A Case of Fever with Rash ?

HISTORY
I) Age of the patient :
)
)

Primary viral exanthems Children ; changing pattern (immunization)

Acute maculopapular rashes :
Children viral infections
Adults drug reactions

II)

Sex of the patient :

Erythema nodosum & SLE females

III) Season of the year :

)
)
)
)
)

Parvovirus B-19 infection winter / spring

Rubella infection M/c in spring ; anytime
Dengue fever around the arrival of monsoon
Enteroviruses (Echovirus, Coxsackie) summer & autumn months
Scrub typhus
Hilly areas of north eastern states (endemic areas) : rainy seasons
South India : winter

HISTORY Contd..
IV) Geographical settings :
)
)
)

Dengue fever classically urban ds (population density & short flying

distance of Aedes aegypti) ; rural outbreaks in Asia, Latin America
Scrub typhus outbreaks reported from sub-Himalayan belt, from Jammu
to Nagaland ; also from south India recently
Chikungunia recent outbreak started in southern & spread to Western &
Eastern states

V) Prodromal symptoms :
)
)

Present in many cases of viral fever with rash

Absent in varicella in children

HISTORY Contd..
VI) Characters of the rash :
1.

Morphology of the rash :

MORPHOLOGY

CAUSES

Maculopapular

Meaasles, Rubella, Roseola infantum, Kawasaki ds, Scarlet

fever, Erythema infectiosum, HIV seroconversion, acute
HBV or HCV infection

Vesicular

Varicella

Vesicobullous

SJS / TEN, drugs

Haemorrhagic

Meningococcal septicemia, ITP, HSP, Acute leukemia,

Bleeding disorders

Erythematous

Urticaria due to hypersensitivity, Scarlet fever, SSSS, TSS,

early stage of SJS, rheumatic fever, SLE, Sarcoidosis, Lyme
ds

Eschar

Scrub typhus

HISTORY Contd..
2. Where the rash 1st appeared & how it progressed :
Vasculitic rashes
Viral fever

peripheral-to-central pattern
central-to-peripheral pattern

3. Time interval between fever onset & appearance of rash :

) 1st day Varicella (chicken pox)

) 2nd day Scarlet fever

) 4th-5th day Measles
) 6th-7th day Dengue, typhoid

4. Rashes painful or not :

) Most generalised rashes are painless

) Exceptions : Sweet syndrome, Kawasaki ds, SJS

HISTORY Contd..

5. Associated pruritus :
Commonly present

Variably present

Absent / rare

Varicella
Urticarial

Drug eruption
Erythema multiforme
Kawasaki ds
TEN
TSS

HIV seroconversion
Erythema infectiosum
Meningococcaemia
Roseola
Rubella
Scarlet fever
2 syphilis
SSSS
SJS

6. Rash involving palm & sole :

Common

Absent

Rubella
Erythema multiforme
SSSS
SJS / TEN
TSS
Kawasaki ds
Hand-foot-mouth ds

Scarlet fever
Roseola
Varicella
Erythema infectiosim

HISTORY Contd..
7. Associated arthritis / arthralgia :
CTD

Infections

SLE

Chikungunya
Dengue
Lyme ds
Disseminated gonococcal infection
Ac. Rheumatic fever
Parvovirus B-19
Rubella
Roseola

VII) Past history :

) Patients with artificial heart valve, valvular ht ds, IV drug abuse IE
) Previous H/o rash (recurs in the same pt) :
Herpes zoster associated with HIV
Recurrent erythema multiforme after HSV or mycoplasma infection
) Prior H/o drug &/or antibiotic allergies

HISTORY Contd..
VIII) Recent medications
IX) Immunization
X) Risk factors for HIV infection (homosexual orientation, IV drug
abuse, unprotected casual sex etc.)
XI) Immunologic status (malignancy, CT, corticosteroid,
splenectomy)
XII) Exposure to febrile or ill individuals in the recent past
XIII) Exposure to wild animals, pets
XIV) Travel history

PHYSICAL EXAMINATION
COMPONENTS OF PHYSICAL EXAMINATION
Vital signs

Pulse / Respiration / BP / Temperature

General appearance

Alert / acutely ill / chronically ill / toxic

Lymphadenopathy

Generalised

Local

Retroauricular &
sub-occipital

IM (EBV)
HIV
Sarcoidosis
2 syphilis

Cat-scratch ds
Tularemia
Rubella
1 syphilis

Rubella in
children

Conjunctival / mucosal / genital lesions

Hepatosplenomegaly
Arthritis / arthralgia
Features of the rash

Type / discrete or uniform / desquamation ? / configuration of

individual lesion / arrangement of lesions / distribution pattern :
centripetal or centrifugal

Pulmonary involvement

Mycobacteria, Endemic fungal infection, Varicella zoster, Sarcoidosis

Cardiac involvement
CNS dysfunction including meningeal signs

INVESTIGATIONS :

Guided by clinical data

CBC, Serum Biochemical studies, Urinalysis
Blood cultures bacteremia, systemic fungal infections
Culture of other body sites : CSF, oropharynx, throat, rectum
Microscopic exam. of buffy coat smear N. meningitidis, S. pneumoniae
bacteremia
Gram stain & culture of aspirates from pustules / petechiae N. meningitidis
in ac. meningococcemia
Wright-Giemsa stain of the basal exudate from unroofed vesicles
multinucleated giant cells in HSV or varicella zoster infection
Serological sudies (often requires both acute & convalescent titres) : HIV,
dengue, HBV, HCV, chikungunya, typhoid, syphilis, leptospirosis,
toxoplasmosis
Skin Bx materials
Culture bacteria/fungus/mycobacteria/virus
IF studies SLE, HSP, pemphigoid

DENGUE

EPIDEMIOLOGY

IP : 7-10 days
Flavi virus ssRNA virus ; 4 serotypes : 1, 2, 3, 4
Virus carried by female Aedes aegypti mosquito
Prevalent in urban & semiurban areas of tropical & subtropical countries
globally ;
Endemic in south-east Asia, the Pacific, east & west Africa, the Caribbian & the
America
50-100 millions dengue infection / yr
5 lakhs DHF / yr
20,000 deaths / yr : children
During & after monsoon
Transmission : bite of infected mosquito nosocomial transmission / vertical
Primary infection : 1st time by any of the 4 serotypes : self limiting
Secondary infection : 2nd time infection by any of the other 3 serotypes
chance of DHF / DSS

CLINICAL FEATURES

Any of the 4 presentations :

Asymptomatic
Undifferentiated fever or viral syndrome (infants & children)
Classical dengue fever (older children & adults)
DHF / DSS

CLINICAL FEATURES Contd..

CLASSICAL DENDUE FEVER :
Biphasic fever : sudden onset high (39-40C) fever with chill, severe headache
severe muscle, bone & joint pain (break-bone fever) : FEBRILE PHASE
Fever lasts for 4-7 days afebrile for variable time period (few hrs days) :
CRITICAL PHASE ; f/y a 2nd febrile phase for 1-2 days

CLINICAL FEATURES Contd..

Retro-orbital pain : particularly on eye movement or pressure ;
congestion & sub-conjunctival hge.
Skin rash : May be biphasic :
evanescent diffuse erythematous flushing (blanches with
pressure) during febrile phase ; 50 cases, replaced by appearance
of maculopapular rash around 3rd/4th day at the time of
defervescence of fever
Rash spreads in centrifugal pattern ; spares palm & sole
Generalized lymphadenopathy 50
Hepatitis : enlarged, soft, tender liver ; jaundice rare
Cardiac involvement - 25 cases

PICTURE OF CLASSICAL DENGUE RASH

CLINICAL FEATURES Contd..

DHF :
4 cardinal features (WHO) :
1. Fever lasting for 2-7 days
2. Plasma leakage due to ed
vascular permeability
) Hemoconcentration (20 se in
Hct above base line
) Pleural effusion
) Ascites
3. Marked ed platelets
4. Hemorrhagic tendency
) +ve tourniquet test
) Spontaneous bleeding : petechiae,
epistaxis, GI bleed

DSS :
All 4 criteria of DHF + evidence of
circulatory failure :
Rapid thready pulse
Narrow pulse pressure ( 20
mmHg)
Hypothermia for age
cold & clammy skin

LABORATORY DIAGNOSIS

5 DAYS POST ONSET OF SYMPTOMS :

Virus culture
Detection of viral RNA by RT-PCR
Detection of viral antigen (NS1) by ELISA /rapid test kits

5 DAYS POST ONSET OF SYMPTOMS :

Detection of specific antibody :
MAC-ELISA : IgM antibody capture ELISA : M/c used
IgG ELISA : if +ve, reflects a past dengue infection
Samples with a ve IgG in Acute phase & +ve IgG in convalescent phase
PRIMARY DENGUE INFECTION
Samples with a +ve IgG in Acute phase & a 4 fold rise in IgG titre in convalescent
phase phase SECONDARY DENGUE INFECTION

LABORATORY DIAGNOSIS
Contd..
HEMATOLOGY :
Thrombocytopenia : develops within 3-8 days after illness
ed Hct : se 20 of the basal value ( ed vascular permebility &
Plasma leak into serosal cavities)
Leukopenia : reaches a nadir at the end of febrile period & beginning of
critical phase
Low ESR : due to hemoconcentration : differentiates DHF/DSS from septic
shock
CxR / USG pleural effusion

DF-DHF Distinction & severity of DHF

TREATMENT

Admission Criteria :
refuses food/water
protracted vomiting
acute abdominal pain
thirsty / oliguric
worsening of general condition
when temperature drops
bleeding

Febrile phase :
Home management if no...
Plenty of fluid, fruit juoice, electrolytes
Paracetamol
NSAIDs CONTRAINDICATED

Critical phase :
(immediate post febrile 2-3 days -- ed
complications)
supportive therapy

TREATMENT Contd..
RATIONAL FLUID THERAPY IN DENGUE :
1. Group 1 : rising / persistently high Hct ; stable hemodynamics, adequate
UOP ( 0.5 ml/kg/hr) :
Crystalloid @ 6 ml / kg / hr for 1-2 hr se to 3 ml / kg / hr for 1-2 hr
maintenance
2.

Group 2 : rising / persistently high Hct ; narrow PP

more intensive fluid therapy :
Crystalloid @ 20 ml / kg / hr IV bolus se to 10 ml / kg / hr for 1-2 hr
5 ml / kg / hr 3 ml /kg / hr for 1-2 hrs maintenance ; fluid continued for 48
hrs

3.

Group 3 : sing Hct + unstable vitals (narrow PP, tachy, metabolic acidosis,
ed UOP) major active bleeding :
Urgent blood transfusion ; colloids

THANK YOU