Evaluating the Febrile Patient with a Rash

TABLE 2
Diseases Presenting with Fever and Rash

DESCRIPTION DIAGNOSTIC BASIS FOR

DISEASE ETIOLOGY EPIDEMIOLOGY
OF RASH CLUES DIAGNOSIS

Rubeola Measles virus Macular-papular Most common in Prodrome Serology

rash that may children 5 to 9 consisting of
become years of age, symptoms of
confluent; begins nonimmune upper respiratory
on face, neck persons tract infection,
and shoulders coryza, bark-like
and spreads cough, malaise,
centrifugally and photophobia and
inferiorly; fades fever; Koplik's
in 4 to 6 days spots (prodromal
stage);
development of
exanthem on
fourth febrile day;
late winter through
early spring

Rubella Rubella virus Pink macules Young adults, Prodrome Serology

and papules that nonimmune uncommon,
develop on persons especially in
forehead and children;
spread inferiorly petechiae on soft
and to palate
extremities (Forschheimer's
within one day; spots); in adults:
fading of anorexia, malaise,
macules and conjunctivitis,
papules in headache and
reverse order by symptoms of mild
third day upper respiratory
infection
 DESCRIPTION DIAGNOSTIC BASIS FOR
DISEASE ETIOLOGY EPIDEMIOLOGY
OF RASH CLUES DIAGNOSIS

Erythema Human Begins as Children 3 to 12 Can present as Serology

infectiosum (fifth parvovirus B19 classic bright-red years of age rheumatic
disease) facial rash syndrome in
(“slapped adults; prodrome
cheek“) and of fever, anorexia,
progresses to rash typically
lacy reticular beginning after
rash; may wax resolution of fever
and wane for 6 [ corrected]
to 8 weeks

Roseola Human herpes- Diffuse Children 6 months Fever lasting 3 to Clinical

virus 6 maculopapular to 3 years of age 4 days, followed findings,
eruption, usually within 2 to 3 days serology
sparing face by the rash, which
resolves
spontaneously in
several days;
almost always a
self-limited benign
disease; temporal
relationship of
fever followed by
rash is helpful in
making the
diagnosis

Lyme disease Borrelia Macule or All ages at risk for History of tick Clinical
burgdorferi papule at site of tick exposure in exposure; findings,
tick bite, endemic areas secondary serology,
progressing to erythematous, polymerase
pathognomonic macular lesions; chain reaction
erythema Borrelia test
migrans lymphocytoma;
highest incidence:
May through
September
 DESCRIPTION DIAGNOSTIC BASIS FOR
DISEASE ETIOLOGY EPIDEMIOLOGY
OF RASH CLUES DIAGNOSIS

Erythema Idiopathic in 50 Dull-red macules Adults 20 to 30 Major and minor Clinical

multiforme percent of developing into years of age; men forms; major form findings
cases (see papules with affected more often always with
Table 3) central vesicles than women mucous
or bullae; membrane
common on involvement and
dorsa of hands, usually the result
palms, soles, of drug reaction;
arms, knees, minor form often
penis and vulva; associated with
often bilateral herpes simplex
and symmetric outbreak; rarely
life-threatening

Secondary Treponema Various Adolescents and Develops 2 to 10 Dark-field

syphilis pallidum presentations; adults 15 to 49 weeks after examination,
brownish-red or years of age; primary chancre; serology
pink macules females affected presents with or
and papules; more often than without fever; may
generalized males have generalized
eruption or lymphadenopathy
localized and
eruption on splenomegaly;
head, neck, may have
palms or soles; recurrent
condyloma lata eruptions with
common symptom-free
periods

Meningococcemia Neisseria Variety of lesions Highest incidence in Acutely ill patient; Often, clinical
(acute) meningitidis but, children 6 months high fever, findings; blood
characteristically, to 1 year of age tachypnea, cultures
petechial lesions tachycardia, mild
distributed on hypotension;
the trunk and leukocytosis;
extremities meningitis
(although the develops in more
lesions can be than 50 percent of
located patients
anywhere);
petechiae on
mucous
membranes
 DESCRIPTION DIAGNOSTIC BASIS FOR
DISEASE ETIOLOGY EPIDEMIOLOGY
OF RASH CLUES DIAGNOSIS

Meningococcemia N. meningitidis Intermittent Same as for acute Fever, myalgias, Blood cultures
(chronic) maculopapular form arthralgias,
lesions, often on headache,
a painful joint or anorexia; may
pressure point; recur for weeks or
may have months, with
nodules on average duration
calves of 8 weeks; may
progress to acute
meningococcemia,
meningitis or
endocarditis

Rocky Mountain Rickettsia Rash evolving Young adults with Onset typically Clinical
spotted fever rickettsii from pink tick exposure; men abrupt; fever, findings,
macules to red affected more often severe headache serology
papules and than women and myalgias are
finally to prominent; rash
petechiae; rash appearing around
beginning on fourth day of
wrists and illness; may have
ankles and relative
spreading bradycardia and
centripetally; leukopenia
involvement of
palms and soles
late in disease

Scarlet fever Beta-hemolytic Punctate Children Acute infection of Rapid strep

Streptococcus erythema tonsils or skin; test, wound or
pyogenes beginning on linear petechiae in throat culture,
trunk and antecubital and antistreptolysin
spreading to axillary folds O titers
extremities, (Pastia's sign);
becoming rash appearing 2
confluent; to 3 days after
flushed face with infection; initially,
perioral pallor; “white strawberry
rash fading in 4 tongue” but by
to 5 days and fourth or fifth day,
followed by “red strawberry
desquamation tongue”
 DESCRIPTION DIAGNOSTIC BASIS FOR
DISEASE ETIOLOGY EPIDEMIOLOGY
OF RASH CLUES DIAGNOSIS

Toxic shock Staphylococcus Diffuse All ages, but most High fever, Clinical
syndrome aureus “sunburn“ rash common in hypotension and criteria,
that menstruating involvement of vaginal and
desquamates females three or more wound
over 1 to 2 organ systems; cultures
weeks 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

Kawasaki's Idiopathic Erythematous Children less than 8 Winter and spring; Specific
disease rash on hands years of age, with high fevers, clinical criteria
and feet; peak incidence at 1 cervical
morbilliform, year; boys affected lymphadenopathy,
scarlatiniform more often than arthritis,
rash on trunk girls arthralgias,
and perineum; cardiac
hyperemic lips involvement,
mucous
membrane
involvement; can
be complicated by
coronary artery
abnormalities in
20 to 25 percent of
cases
 DESCRIPTION DIAGNOSTIC BASIS FOR
DISEASE ETIOLOGY EPIDEMIOLOGY
OF RASH CLUES DIAGNOSIS

Chickenpox Varicella-zoster Initially, papules, 90 percent of cases Prodrome Clinical

virus which evolve into in children less than consisting of findings,
vesicles 10 years of age; 5 headache, general confirmed by
(“dewdrops on a percent of cases in aches, backache Tzanck test
rose petal”) and persons older than and malaise is
eventually into 15 years typically absent in
pustules and children; exposure
crusts; rash history; may have
beginning on all forms of lesions
face and at the same time;
spreading vesicles evolving
inferiorly to trunk to shallow
and extremities erosions common
on mucous
membranes of
palate; may also
have vesicles on
nasal,
conjunctival,
gastrointestinal
tract and genital
mucosa

Herpes zoster Varicella-zoster Begins as All ages, but Prodrome of Clinical

(shingles) virus erythematous incidence increases unusual skin findings,
maculopapular with age and sensations; confirmed by
eruption, rapidly immunosuppression dermatomal Tzanck test
evolves to pattern, with
vesicles lesions rarely
crossing midline;
pain often severe;
more common in
thoracic and facial
dermatomes
 DESCRIPTION DIAGNOSTIC BASIS FOR
DISEASE ETIOLOGY EPIDEMIOLOGY
OF RASH CLUES DIAGNOSIS

Rickettsialpox Rickettsia akari Generalized All ages; urban Transmitted from Serology
maculopapular- settings mice to humans
vesicular via mites;
exanthem; formation of
possible papules 7 to 10
involvement of days after initial
mucous bite; typically,
membranes; no formation of a
involvement of black eschar over
palms or soles healing lesion;
febrile phase
occurring 3 to 7
days after initial
lesion and lasting
up to a week; self-
limited, usually
mild course

Erythema Various causes Bright-red Adolescents and Thorough history Clinical

nodosum (see Table 4) nodules (3 to 20 young adults 15 to and physical findings
cm in diameter) 30 years of age; examination to
scattered females affected identify known
bilaterally but not more often than causes; throat
symmetric; most males culture for group A
frequently on beta-hemolytic
lower legs but streptococci; chest
also found on radiograph to rule
knees and arms; out sarcoidosis;
rarely found on arthralgias present
face and neck; in 50 percent of
lesions often cases; fever and
tender and malaise common
indurated

Adapted with permission from Kaye ET, Kaye KM. Fever and rash. In: Fauci AS, et al., eds. Harrison's Principles of internal
medicine. 14th ed. New York: McGraw-Hill, Health Professions Division, 1998:90–7, with additional information from Fitzpatrick
TB, et al. Color atlas and synopsis of clinical dermatology: common and serious diseases. 3d ed. New York: McGraw-Hill,
Health Professions Division, 1997.

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