FEVER WITH RASH
Introduction
•Overview:
Fever with rash can be a diagnostic challenge but often provides clues to
systemic illnesses Recognizing patterns aids in prompt diagnosis and critical interventions.
•Importance:
The appearance and distribution of a rash alongside symptoms such as fever can signal
life-threatening conditions or guide infection control measures.
Classification of Rashes
•Basis of Classification:
Rashes are categorized by lesion morphology and distribution. Key types include maculopapular,
vesiculobullous, urticarial, nodular, purpuric, desquamative erythema, and others.
•Evolution and Variability:
Morphology may change as rashes evolve (e.g., Rocky Mountain spotted fever starts as
blanchable macules but becomes petechial).
Centrally Distributed Maculopapular
Eruptions
• Common Causes:Measles: Begins at the hairline, spreads downward;
Koplik’s spots are pathognomonic.
• Rubella: Rash clears from previously affected areas, often pruritic;
Forchheimer spots may appear.
• Erythema Infectiosum (Fifth Disease): "Slapped cheeks" rash caused
by parvovirus B19, often accompanied by arthritis in adults.
• Roseola: Caused by HHV-6/7, rash appears after fever resolves.
Peripheral Rashes
• Prominent Examples:Rocky Mountain Spotted Fever: Starts on
wrists and ankles, progresses centripetally, involves palms and soles
later.
• Secondary Syphilis: Rash prominent on palms and soles, can be
confused with pityriasis rosea.
• Hand-Foot-and-Mouth Disease: Tender vesicles on hands, feet,
and oral mucosa caused by coxsackieviruses.
Vesiculobullous or Pustular
Eruptions
• Varicella (Chickenpox): Pruritic lesions in various stages of
development, primarily on the trunk.
• Smallpox (Variola): Lesions uniform in stage, prominent on the face
and extremities.
• Herpes Simplex Virus: Grouped vesicles on an erythematous base,
associated with fever during primary infection.
Confluent Desquamative Erythemas
•Characteristics:
Diffuse erythema often followed by desquamation.
•Examples:
•Scarlet Fever: Strawberry tongue, Pastia’s lines, and desquamation post-pharyngitis.
•Kawasaki Disease: Fissured lips, conjunctivitis, and cardiac involvement in children.
•Toxic Epidermal Necrolysis (TEN): Full-thickness epidermal sloughing, high
mortality.
Urticarial and Nodular Eruptions
•Urticarial Eruptions:
•Classic Urticaria: Hypersensitivity reaction, not always febrile.
•Urticarial Vasculitis: Lesions last >24 hours, associated with systemic disease (e.g., lupus).
•Nodular Rashes:
•Disseminated Fungal Infections: Candida or Cryptococcus often in immunocompromised hosts.
•Erythema Nodosum: Painful nodules on the lower extremities, linked to infections or autoimmunity.
Purpuric Eruptions
• Meningococcemia: Petechial rash progressing to purpura fulminans,
indicative of DIC.
• Rocky Mountain Spotted Fever: Initially maculopapular, then petechial,
involving extremities.
• Disseminated Gonococcemia: Purpuric or necrotic lesions in sexually
active individuals.
Diagnostic Challenges and
Considerations
•Overlap of Features:
Viral exanthems vs. drug reactions (e.g., ampicillin rash in mononucleosis).
•Key Factors:
•Medication history.
•Travel or exposure risks.
•Timing of rash onset relative to fever.
•Critical Syndromes:
•Streptococcal toxic shock.
•DRESS syndrome (Drug Reaction with Eosinophilia and Systemic Symptoms).
Summary and Approach to Management
•Stepwise Approach:
•History and physical examination.
•Rash morphology and distribution.
•Associated systemic features (e.g., lymphadenopathy, arthritis)
•Management Principles:
•Treat underlying infection.
•Supportive care for systemic symptoms.
•Avoidance of triggers (e.g., drugs causing hypersensitivity).
