Fever and skin rash.ppt

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FEVER AND SKIN RASH

• DR M. YOUSRY ABDEL-MAWLAMD.
• Zagazig Faculty of Medicine

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INTRODUCTION

• The differential diagnosis for febrile patients
  with a rash is extensive.
• Diseases that present with fever and rash are
  usually classified according to the morphology of
  the primary lesion.

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MORPHOLOGIC CLASSIFICATION of RASH

• Maculopapular .
• Petechial.
• Diffusely erythematous with desquamation.
• Vesiculobullouspustular .
• Nodular.

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AETIOLOGICAL CLASSIFICATION

• Viruses.
• Bacteria.
• Spirochetes.
• Rickettsiae.
• Medications
• IMMUNOLOGIC-MEDIATED DISORDERS

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HISTORY

• A detailed history can be quite helpful in
  identifying the cause of fever and a rash.
• A history of recent travel.
• Animal exposure and inscet bites.
• Drug ingestion
• Contact with ill persons should be noted.
• The time of year can be a clue to certain
  diagnoses
• Any rash that is sudden in onset and covers a
  large part of the body
• Any rash that starts either shortly after a
  flu-like illness begins or a rash that starts
  after a flu-like illness goes away

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Some disorders among travellers

• Lyme disease.
• Strongyloides stercoralis.
• HIV/AIDS.
• Rocky Mountain spotted fever.
• Leishmaniasis.
• Leprosy
• STDs

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Animal Insect Contact Disorders

• Animal contact Q fever.Anthrax.Viral hemorrhagic
  fevers.Cat scratch disease
• Insect exposure
• MosquitoesMalaria.Dengue.
• FilariasisYellow fever.
• Ticks Tick typhus . Rocky Mountain spotted
  fever
• Lyme disease .
• Sand flies LeishmaniasisSandfly fever
• Black flies Onchocerciasis

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Speacial care to the following

• Conditions associated with valvular heart
  disease
• Sexually transmitted diseases or
• Immunosuppression from chemotherapy.
• Immune status is particularly important because
  many of the diseases that result in fever and a
  rash present differently in immunocompromised
  patients.

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Details about the rash

• Site of onset
• Rate .
• Direction of spread
• Presence or absence of pruritus.
• Temporal relationship of rash and fever.
• It is also important to know whether any topical
  or oral therapies have been attempted.

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Identification of Primary Skin Lesions
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MACULE

• Circumscribed area of change in normal skin
  color with no skin elevation or depression may
  be any size

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PAPULE

• Solid raised lesion up to 0.5 cm in greatest
  diameter

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NODULE

• Similar to papule but located deeper in the
  dermis or subcutaneous tissue differentiated
  from papule by palpability and depth rather than
  size

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PLAQUE

• Elevation of skin occupying a relatively large
  area in relation to height often formed by
  confluence of papules

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VESICLE

• Circumscribed elevated fluid-containing lesion
  less than 0.5 cm in greatest diameter may be
  intraepidermal or subepidermal in origin

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BULLA

• Same as vesicle except lesion is more than 0.5
  cm in greatest diameter

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LOOK FOR

• The patients vital signs and general appearance.
• Signs of toxicity.
• Adenopathy.
• Oral genital or conjunctival lesions.
• Hepatosplenomegaly.
• Evidence of excoriations or tenderness.
• Signs of neck rigidity or neurologic dysfunction.

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LABORATORY DATA

• The complete blood count with differential an
  erythrocyte sedimentation rate
• A chemistry panel liver function tests.
• Blood and urine cultures
• Aspirates scrapings and pustular fluid may be
  obtained for Gram staining and culture.
• Tzanck test may unroofing a lesion and taking a
  scraping of the lesion base.
• Biopsy samples from nonhealing or persistent
  purpuric lesions.
• Biopsy of inflammatory dermal nodules and ulcers

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Specific diagnoses that may be confirmed
histologically

• Rocky Mountain spotted fever herpetic
  infections systemic lupus erythematosus
  erythema multiforme allergic vasculitis
  secondary syphilis and deep fungal infections

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Serologic tests

• Systemic lupus erythematosus.
• Other collagen vascular disorders
• Syphilis.
• Rheumatoid arthritis .
• Human immunodeficiency virus infection.

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Maculopapular Rash.

• Viral illnesses rubeola rubella erythema
  infectiosum and roseola
• Immune-mediated syndromesErythema Multiforme
• Drug reactions penicillins or cephalosporins
• Bacterial infections Lyme Disease Secondary
  Syphilis
• - Others early stages of meningococcemia Rocky
  Mountain spotted fever and Dengue fever

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The exanthem of rubeola

• begins around the fourth febrile day with
  discrete lesions spreading from the hairline
  downward sparing the palms and soles.
• The exanthema lasting four to six days fading
  gradually in order of appearance leaving a
  residual faint desquamation.
• Rubeola Kopliks spots in the oral mucosa.

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The exanthem of rubeola
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Erythema infectiosum fifth disease

• Caused by human parvovirus B19.
• In children between three and 12 years of age
  although it can present as a rheumatic syndrome
  in adults.
• The prodrome fever anorexia sore throat and
  abdominal pain.
• Once the fever resolves the classic bright-red
  facial rash (slapped cheek) appears.
• Exanthem progresses to a diffuse lacy reticular
  rash that may wax and wane for six to eight weeks
  .

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Erythema infectiosum
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Lyme DiseaseErythema Migrans

• Borrelia burgdorferi which is transmitted by the
  bite of a tick (Ixodes species).
• Erythema migrans the pathognomonic rash
  develops in about 80 percent of patients with
  Lyme disease.
• Systemic symptoms fever chills myalgias
  headaches and arthralgias.
• The rash on the proximal extremities in body
  creases and on the chest. It enlarges over a
  period of days to weeks.
• Complicationscarditis arthritis and
  acrodermatitis chronica atrophicans

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Lyme disease
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Lyme disease
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Erythema Multiforme

• The dull-red lesions advance from macules to
  papules with prominence of characteristic
  target-shaped lesions.
• Vesicles and bullae develop in the center of the
  papule .
• The systemic symptoms fever and prostration.

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Secondary Syphilis

• The rash of secondary syphilis can be diffuse
  with localized eruptions often occurring on the
  head neck palms and soles.
• The lesions brownish-red or pink macules and
  papules papulosquamous pustular or acneiform.
• Macules papules (mucous patches )

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Secondary Syphilis
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Adult-onset Stills disease (AOSD)

• Major Criteria
• Fever gt 39CArthritis/arthralgias gt 2
  weeksStills maculopapular red rashand
  blanching eruption of the proximal upper and
  lower extremities Neutrophilic leukocytosis

• Minor Criteria
• Sore throatLymphadenopathy or
  splenomegalyLiver dysfunctionNegative
  Rheumatoid factor and ANA testing

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Rash in Adult-onset Stills disease (AOSD)
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Maculopapular rash in collagen vascular disorders
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Petechial Purpric Eruptions

• MENINGOCOCCEMIA
• ROCKY MOUNTAIN SPOTTED FEVER
• Viral illnesses causing petechial rashes
  coxsackievirus A9 echovirus 9 Epstein-Barr
  virus and cytomegalovirus infections atypical
  measles and viral hemorrhagic fevers caused by
  arboviruses and arenaviruses.

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Differential diagnosis of petechial rash

• Disseminated gonococcal infections.
• Bacteremia.
• Staphylococcemia
• Thromboticthrombocytopenic

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MENINGOCOCCEMIA

• Seeding of Neisseria meningitidis from the
  nasopharynx acute meningococcal septicemia
  meningococcal meningitis or chronic
  meningococcemia.
• Petechial rash a high spiking fever tachypnea
  tachycardia and mild hypotension

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ROCKY MOUNTAIN SPOTTED FEVER

• Caused by Rickettsia rickettsii.
• The prodrome malaise chills a feverish
  feeling anorexia and irritability photophobia
  prostration and nausea.
• Rash on fourth day of illness.starting as pink
  macules located on the wrists forearms
  ankles palms and soles.
• Within 6 - 18 hours the rash spreads centrally
  to involve the arms thighs trunk and face
  evolving into deep-red papulesthen into
  petechiae

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Diffuse Erythema with Desquamation

• SCARLET FEVER
• TOXIC SHOCK SYNDROME SCALDED SKIN SYNDROME
• KAWASAKIS DISEASE
• Other causes a)Enteroviral infections .b) Toxic
  epidermal necrolysisGraft-versus-host reaction.
  C) Erythroderma generalized pustular psoriasis
  

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SCARLET FEVER

• An acute infection by group A beta-hemolytic
  streptococci that produce an erythrogenic
  exotoxin.
• The rash finely punctate erythema on the
  superior trunk and face two to three days after
  the onset of illness spreading to the
  extremities.
• White with red swollen papillae (white
  strawberry tongue). By the fourth or fifth day
  it becomes bright red (red strawberry tongue).

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KAWASAKIS DISEASE

• An acute febrile illness that affects infants and
  young children (mean age 2.6 years). Fever
  temperature is typically higher than 40C
  lasting five to 30 days and not responding to
  antibiotics nor antipyretics.
• Rash(within three days of the onset of fever )
  scarlatiniform on the trunk erythematous on the
  palms and soles with subsequent distal
  desquamation.
• Mucous membrane hyperemic bulbar conjunctiva
  injected oropharynx dry cracked lips and a
  strawberry tongue.
• Non-suppurative cervical lymphadenopathy .
  Coronary artery abnormalities develop in 20 to 25
  percent of patients

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TOXIC SHOCK SYNDROME AND SCALDED SKIN SYNDROME

• Staphylococcus aureus exotoxins responsible for
  classic toxic shock syndrome and scalded skin
  syndrome.
• Presention hypotension erythema fever and
  multisystem dysfunction.
• The rash diffuse and can present as bullous
  impetigo scarlatiniform lesions or diffuse
  erythema.
• The mucous membranes spared

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Vesiculobullous-Pustular Eruptions

• VARICELLA-ZOSTER VIRUS INFECTIONS
• Coxsackie viruses and other entero viruses
• Noninfectious neutrophilic dermatoses pustular
  psoriasisReiter diseasePustular
  vasculitis
• Bowel-associated dermatosis-arthritis
  syndromeRheumatoid neutrophilic
  dermatosisPyostomatitis vegetansFami
  lial Mediterranean fever

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Varicella.

• Primary infection with varicella-zoster virus
  results in chickenpoxA mild prodrome lasting one
  to two days before appearance of the rash is not
  uncommon. The rash typically begins on the face
  scalp or trunk and then spreads to the
  extremities.
• The lesions erythematous macules and progress
  to papules with an edematous base evolving into
  vesicles into pustules which become umbilicated
  and subsequently crust over in eight to 12 hours.
  

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Herpes Zoster

• it affects a single dermatome and rarely crosses
  the midline .
• The common locations the chest and the face
• A prodrome unusual skin sensations may evolve
  into pain burning and paresthesias which
  precede the rash by two to three days.
• The rash erythematous maculopapular eruption
  evolveing to a vesicular rash. Drying of the
  lesions with crust formation in seven to 10
  days
• Resolve in 14 to 21 days.

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Coxsackie viruses and other enteroviruses

• Hand-foot-and-mouth disease the children develop
  fever and rash. The rash includes blisters to the
  mouth and tongue to the hands and the feet.
• Herpangina causes a fever sore throat and
  painful blisters or ulcers to the back of the
  mouth.

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Nodular Eruptions

• Erythema nodosum acute intlammatory immunologic
  process involving the panniculus adiposus.
• Presenting features fever malaise and
  arthralgias.
• The nodules painful and tender.
• The lesions on the lower legs knees and arms

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Aetiology

• Idiopathic.
• Infectious causes
• Beta-hemolytic streptococci . Nocardia
  PseudomonasHepatitis C virus
• Mycobacterium species
• Noninfectious causes
• Medications sulphonamides
• Systemic lupus erythematosus
• Sarcoidosis Ulcerative colitis
• Behcets syndrome Pregnancy

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THANK YOU