Fever and Rash
The coexistence of fever and rash suggests a relatively wide spectrum
of pathologic entities for diagnostic consideration. This spectrum
includes local or systemic infection with a wide range of microbial
pathogens; toxin-mediated disorders, including those associated with
bacterial superantigen production; inflammatory conditions including
vasculitides and rheumatologic diseases; and hypersensitivity
disorders.
While most conditions causing fever and rash are benign and self-
limited, a thorough clinical evaluation is crucial to identify those
caused by life-threatening diseases or those requiring specific
treatment.
History
Ask about the features of the rash including when it occurred in
relation to the fever, its evolution or progression, its anatomic
distribution, and whether it is pruritic or painful.
History
Essential Elements of the History in the Clinical Assessment of Fever and Rash
Demographic Data
• Age
• Sex
• Ethnicity
• Season
• Geographic area; resident or travel to endemic areas
• Diet history (raw meats, shellfish; unpasteurized dairy, etc.)
• Ill contacts (home, daycare, school, workplace)
• Pets (dogs, cats, reptiles, turtles, rodents, birds), wildlife, insects (especially ticks)
• Medications and drugs
• Transfusions
• Immunizations
• Occupational
History
Essential Elements of the History in the Clinical Assessment of Fever and Rash
Features of Rash
• Temporal associations (onset relative to fever)
• Progression and evolution
• Location and distribution
• Pain or pruritus
• Timing and pattern of desquamation
Associated Symptoms
• Focal (suggesting organ-specific illness)
• Systemic (suggesting generalized or multisystem illness)
Prior Health Status
• Medical and surgical history
• Growth and development
• Recurrent infectious illnesses
Family History
Examination
The physical examination is used to refine the probability of
underlying serious illness, to identify rashes typical of a specific
diagnosis, to look for non-cutaneous disease manifestations, and to
identify if further testing or treatment is indicated.
Examination
Essential Elements of the Physical Examination in the Clinical Assessment of Fever
and Rash
Degree of Toxicity
Vital Signs
• Fever pattern
• Tachycardia or bradycardia
• Tachypnea
• Hypotension or hypertension
Examination
Essential Elements of the Physical Examination in the Clinical Assessment of Fever
and Rash
Characteristics of Rash
• Macular
• Papular
• Maculopapular
• Petechiae or purpura
• Accentuation in flexural creases
• Painful
• Urticarial
• Vesicles, pustules, bullae
• Nodules
• Ulcers
Examination
Essential Elements of the Physical Examination in the Clinical Assessment of Fever
and Rash
Distribution and Localization of Rash
• Generalized or localized
• Symmetric or asymmetric
• Centripetal or centrifugal
Associated Enanthem
• Buccal mucosa
• Palate
• Pharynx and tonsils
• Genitals
Examination
Essential Elements of the Physical Examination in the Clinical Assessment of Fever
and Rash
Associated Findings (Isolated or in Clusters)
• Ocular
• Cardiac
• Pulmonary
• Gastrointestinal
• Musculoskeletal; myalgia
• Neurologic
• Lymphadenopathy
• Hepatosplenomegaly
• Arthritis/arthralgia
Specific Skin Lesions
An exanthema is defined as a skin eruption occurring as a sign of a
generalized disease. An enanthem is an eruption on the mucous
membranes that occurs in the context of generalized disease. Exanthems
and enanthems may be macular, maculopapular, vesicular, urticarial,
petechial, or diffusely erythematous.
Specific Skin Lesions
Specific Skin Lesions
Specific Skin Lesions
Specific Skin Lesions
Specific Skin Lesions
Purpuric lesion can be differentiated from an erythematous lesion by diascopy test.
Diascopy (glass test): Press the lesion with a glass slide.
If redness disappears, it is due to vascular dilatation.
If redness persists, it is due to extravasation of red blood cells.
Differential Diagnosis
Maculopapular or Macular Rash
Viruses
Measles (confluent), rubella (discrete), roseola (human herpesvirus 6), fifth disease
(parvovirus), EBV, enteroviruses
Bacteria
Rheumatic fever (group A streptococcus), scarlet fever, erysipelas,, meningococcal
infection (early), Mycoplasma pneumoniae
Other
Kawasaki disease, drug reactions, SJIA, hereditary fever syndromes, HLH, toxoplasmosis,
MIS-C
Differential Diagnosis
Vesicular, Bullous, Pustular
Viruses
Herpes simplex, varicella-zoster, coxsackieviruses
Bacteria
Staphylococcal scalded skin syndrome, staphylococcal bullous impetigo, group A
streptococcal crusted impetigo
Other
Toxic epidermal necrolysis, Stevens-Johnson syndrome
Differential Diagnosis
Petechial-Purpuric
Viruses
Atypical measles, congenital rubella, cytomegalovirus, enterovirus, HIV, hemorrhagic
fever viruses, hemorrhagic varicella, EBV, hepatitis B, adenovirus, yellow fever,
parvovirus
Bacteria
Sepsis (meningococcal, gonococcal, pneumococcal, S. aureus), endocarditis,
Pseudomonas aeruginosa, group A streptococcus
Other
Vasculitis, thrombocytopenia, Henoch-Schönlein purpura, malaria
Differential Diagnosis
Distinctive Rashes
Koplik spots Measles
Erythema marginatum Acute rheumatic fever (group A streptococcus)
Erysipelas Group A streptococcus
Common Viral Exanthema
Measles (rubeola):
Prodrome: High fever, cough, coryza, conjunctivitis, 2–4 days
Rash: Maculopapular (confluent), begins on face, spreads to
trunk; lasts 3-6 days
Enanthem: Koplik spots on buccal mucosa before rash
Common Viral Exanthema
Rubella (German measles):
Prodrome: Malaise, fever, posterior auricular, cervical,
occipital adenopathy, 0–4 days
Rash: Discrete, non-confluent, rose-colored macules and
papules, begins on face and spreads downward; lasts 1–3 days
Enanthem: Variable erythematous macules on soft palate
Common Viral Exanthema
Roseola (exanthema subitum):
Prodrome: Irritability, high fever 3–7 days, cervical, occipital
adenopathy
Rash: Discrete macules on trunk, neck; sudden-onset rash with
defervescence; lasts 0.5–2 days; some patients have no rash
Enanthem: Variable erythematous macules on soft palate
Common Viral Exanthema
Fifth disease (erythema infectiosum):
Prodrome: Headache, malaise, myalgia; often afebrile
Rash: Local erythema of cheeks (slapped cheek appearance);
lacy pink-red erythema of trunk and extremities, ± pruritus;
rash may lag prodrome by 3–7 days; lasts 2–4 days, may recur
2–3wk later
Enanthem: Rare, ill-described, on buccal mucosa
Common Viral Exanthema
Chickenpox (varicella) :
Prodrome: Fever
Rash: Pruritic papules, vesicles in various stages, 2–4 crops and
then crusts; distributed on trunk and then face, extremities;
lasts 7–10 days; recurs years later in dermatomal distribution
(zoster, shingles)
Enanthem: Oral mucosa, tongue
Common Viral Exanthema
Infectious Mononucleosis:
Prodrome: Fever, adenopathy, eyelid edema, sore throat,
hepatosplenomegaly, malaise; atypical lymphocytosis
Rash: Maculopapular or morbilliform (measles-like) on trunk,
extremities; may be confluent; often elicited by simultaneous
administration of ampicillin, lasts 2–7 days
Enanthem: Variable
Common Viral Exanthema
Enteroviruses (non-Polio):
Prodrome: irritable, fever, sore throat, myalgias, headache
Rash:
Hand-foot-and-mouth: vesicles in those locations.
others: nonspecific, usually fine non-confluent, macular or
maculopapular rash, rarely petechial, urticarial, or vesicular;
lasts 3–7 days
Enanthem: Variable
Common Bacterial Exanthema
Scarlet fever:
Prodrome: Sore throat, headache, abdominal pain, cervical
lymphadenopathy, fever, 0–2 days, acute onset
Rash: Diffuse erythema with “sandpaper” feel; accentuation of
erythema in flexural creases (Pastia lines); circumoral pallor,
lasts 2–7 days; may exfoliate
Enanthem: Palatal petechiae, strawberry tongue
Common Bacterial Exanthema
Staphylococcal scalded skin syndrome (SSSS):
Prodrome: None
Rash: Sudden onset, tender erythroderma progressing to
diffuse flaccid bullae; significant perioral, perinasal peeling;
eventual diffuse exfoliation (positive Nikolsky sign), possibly
conjunctivitis, purulent rhinorrhea
Enanthem: Unusual
Common Bacterial Exanthema
Toxic shock syndrome (TSS):
Prodrome: Myalgias, fevers, and gastrointestinal symptoms
Rash: Diffuse sunburn-like erythroderma; hypotension,
diarrhea, emesis, mental status changes; late desquamation
Enanthem: Conjunctivitis
Common Bacterial Exanthema
Meningococcemia:
Prodrome: Fever, malaise, myalgia, 1–10 days
Rash: Erythematous, non-confluent, discrete papules (early);
petechiae, purpura present on trunk, extremities, palms, soles
Enanthem: Petechiae
