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AN OVERVIEW OF • Streptococcus pyogenes – Scarlet fever

MUCOCUTANEOUS SYMPTOM COMPLEX • Salmonella typhe – Typhoid fever
ANTONIO E. CHAN, M.D. • Leptospira spp. - Leptospirosis
• N. meningitidis – Meningococcemia early
(Module 4 Lecture date: June 29, 2006) • N. gonorrhea – disseminated
• Bartonella henselae – Cat Scratch Disease
DEFINITION • Streptobacillus moniliformis – Rat bite fever

A febrile illness in children associated with skin manifestation OTHER CAUSES OF MACULOPAPULAR ERUPTIONS
(exanthem) and mucous membrane involvement (conjunctiva, • Kawasaki disease
throat, respiratory or gastrointestinal tract) • Drug eruption

CLASSIFICATION
• Maculopapular eruption ESSENTIAL ELEMENTS OF HISTORY
• Vesiculobullous or vesiculopustular (Pertinent questions to ask)
• Petechial or purpuric eruption
• Demographic data
– Age
MACULES are circumscribed, flat, discolored lesions that are not palpable – Season
and less than 1 cm in diameter – Geographic area
• Exposure
PAPULES are circumscribed, solid, elevated lesions, less than 1 cm. in – Ill contacts
diameter – Sexual contacts
– Travel
DESCRIPTIVE DERMATOLOGIC TERMS – Pets, wildlife, insects (esp. ticks)
– Medications and drugs
Lesions Description Example – Transfusions
Discrete Lesions remain separate Childhood exanthems – Immunizations
(Rubelliform) • Features of the rash
Confluent Lesions run together Childhood exanthems – Temporal associations (onset of rash relative to
(Morbilliform) fever)
Reticulated Lace-like network Erythema infectiosum – Progression and evolution
– Location and distribution
Multiform More than one type of Erythema multiforme
– Pain or pruritus
(Polymorphous) shape or lesion
• Associated signs & symptoms
Iris Circle within a circle; Erythema multiforme
– Focal (suggesting organ specific illness)
A bull’s eye lesion
– Systemic (suggesting generalized or multi-system
Grouped Lesions clustered Herpes simplex
illness)
together
• History of previous illness (infectious)
Generalized Widespread
Zosteriform Linear arrangement Hesrpes zoster
along a nerve
distribution

GENERAL STATEMENTS

• Many different types of viruses, treponemes, chlamydia,

rickettsiae, mycoplasma, bacteria, fungi, protozoan and
metazoan agents cause illness with associated cutaneous
manifestations
• Many possible etiologic agents; hence, no unified epidemiology
exist.
• Erythematous macules and papules are the most common
primary lesions seen during acute febrile illness in children
• Occurring in association with mild, febrile upper respiratory or
gastrointestinal tract illness
• In the recent era, enteroviruses are the leading cause of
infection-related exanthematous diseases
• Most exanthematous illnesses in children are benign, their
differential diagnoses is critical because the early
manifestations of potentially fatal bacterial and rickettsial
diseases frequently have cutaneous findings.
• Many conditions that will ultimately manifest purpuric, vesicular,
urticarial or ulcerative cutaneous lesions may first appear as
erythematous macules or papules
• Maculopapular rashes are non-specific, a review of
epidemiologic and physical findings is most helpful in
establishing a diagnosis

PATHOGENESIS

1. Dissemination of infectious agents by blood (viremia,

bactermia) which results in secondary infection at the
cutaneous site

a. Direct result of infectious agents in the epidermis,

dermis or dermal capillary endothelium
b. An immune response between the organism and
antibody or cellular factors in the cutaneous
location.
2. Dissemination of known specific toxins of infectious agents

3. A combination of these mechanisms

VIRAL CAUSES OF MACULOPAPULAR ERUPTIONS
• Rubeola – Typical, Modified, Atypical & Hemorrhagic Measles
• Rubella virus - German measles
• HHV 6 & 7 – Roseola infantum (Exanthem Subitum)
• Parvovirus B19 – Erythema infectiosum
• Enteroviral infection
– Enterovirus 71
– Coxsackievirus – A2, A4, A5, A7, A9, A10, A16, B1-
B5
– Echovirus – 1-7, 11-14, 16-19, 22, 24, 25, 30, 38
• Epstein Barr Virus – Infectious mononucleosis
• Hepatitis B virus – Papular Acrodermatitis in Childhood
• HIV

BACTERIAL CAUSES OF MACULOPAPULAR ERUPTIONS

• Staphylococcus aureus – SSSS, TEN
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ACUTE FEBRILE ILLNESS WITH MACULOPAPULAR ERUPTIONS

DISEASE OR INFECTIOUS INCUBATION CLINICAL CHARACTERISTICS LESIONS DISTRIBUTION

SYNDROME AGENT PERIOD (DAYS)
RUBEOLA Onset with fever, cough, coryza, and conjunctivitis. Erythematous, maculopapular, and confluent. Develop Starts behind ears and on forehead.
(Measles) Infants, 8 – 12 About 2 days after onset, appearance of enanthem a brownish appearance, and fine desquamation Spreads downward over body. Confluence
Adolescents (Koplik spots), and 2 days later, onset of exanthem occurs most prominent on face, trunk, and proximal
end of extremities
Mild symptoms with onset 1-5 days before rash. Fever usually Erythematous, maculopapular, discrete Starts on face and spreads downward to
Infants,
RUBELLA 15 – 21 <38.50C. Headache, malaise, and suboccipital and postauricular trunk and extremities
young adults
(German Measles) lymphadenopathy

ROSEOLA INFANTUM Fever 3-5 days in duration, rapid defervescence, and then the Erythematous, macular or maculopapular Most prominent of neck and trunk. Face and
HHV-6 & 7 6 mos – 2 yrs
(Exanthem Subitum) appearance of rash. No prodromal period extremities may be affected
Coxsackieviruses Fever and mild to moderate pharyngitis. Occasionally, herpangina, Most commonly erythematous, maculopapular, and Usually starts on face and spreads
A2, A4, A5, A7, A9, meningitis, and other manifestations of systemic viral infection. discrete. May have macular, petechial, vesicular, and downward to trunk and extremitities. May
Infants &
A10, A16, B1-B5; Exanthem occurs in 5-50% of infections, depending on virus type. urticarial components. Rarely erythema multiforme have peripheral distribution (hand, foot, and
ENTEROVIRAL young 4–7
Echoviruses 1-7, Rash may occur during fever or after defervescence. Hand, foot, mouth syndrome)
INFECTION children
11-14, 16-19, 22, and mouth syndrome
24, 25, 30, 38;
Enterovirus 71
Biphasic illness with mild prodromal period with headache and Three stage exanthem: Initially, rash on cheeks Starts on face. More prominent on extensor
Prepubertal
ERYTHEMA Parvovirus B19 malise for 2-3 days, then 7-day symptom-free period, followed by (slapped-cheek appearance) and then erythematous surfaces of extremities.
children & 7-17
INFECTIOSUM typical exanthem maculopapular rash on trunk and limbs. Finally rash
Adults
develops a reticular pattern
Fever, pharyngitis, and lymphadenopathy. Most commonly erythematous, macular, Mainly on trunk and proximal end of
Exanthem occurs in 3-13% of cases. If ampicillin maculopapular, and discrete (rubelliform). In extremities
INFECTIOUS Epstein-Barr Virus Children & 28-49
administered, then exanthem in 50% of cases association with ampicillin administration, the rash
MONONUCLEOSIS Adolescents
may be more vivid. Erythema multiforme and urticaria
may occur
PAPULAR Insidious onset with arthralgia, arthritis, and rash occurring before Maculopapular, macular, and/or urticarial. In young Generalized
ACRODERMATITIS Hepatitis B 1 – 6 yr 50 – 180 jaundice children, papular (Gianotti-Crosti syndrome). Rarely,
OF CHILDHOOD erythema multiforme
HUMAN Fever, pharyngitis, myalgia, arthralgias, adenopathy, and rash Macular Mainly chest and abdomen
14 - 60
IMMUNEDEFICIENY
VIRUS
STAPHYLOCOCCAL Usually occurs in infants and children 1 month - 5 years of age. Scarlatiniform eruption with exfoliation. Positive Generalized. Most marked on trunk
Staphylococcus
SCARLATINIFORM Mucopurulent nasal and eye discharge. Nikolsky sign. Crusty appearance around eyes and
aureus Neonates &
ERUPTION Fever and staphylococcal infection in throat, but no evidence of under nose. Scarlet fever-like rash with desquamation.
SSSS, TEN (exfoliative toxin- infants
pharyngitis Pastia lines present.
(Ritter or Lyell’s Syndrome) producing)
Fever, pharyngitis, and cervical lymphadenitis. Rash onset within 2 Diffuse erythematous and fine maculopapular (looks Circumoral pallor. Generalized rash, with
Streptococcus
SCARLET FEVER School age days of first symptoms. Incubation period 3-4 days and feels like red sandpaper). Rash darker in skin trunk and proximal end ofextremities being
pyogenes
folds (Pastia lines). Desquamation occurs. most involved.
Older Malaise, headache, and marked fever. Rash onset 10 days after Rose spots. 2-4 mm macular lesions Discrete lesion on abdomen
TYPHOID FEVER Salmonella typhi children & onset of fever
adults
Fever and pharyngitis, Sudden onset of rash Characteristic rash is petechial or purpuric. Generalized
Early lesions may be erythematous, maculopapular, or
MENINGOCOCCEMIA N. Meningitidis Any (<5 yr)
urticarial

LEPTOSPIROSIS Leptospira spp. Fever, conjunctivitis, and anorexia. Rash rarely noted Erythematous maculopapular rash Mainly on trunk
5 days or more of high fever, sore throat, cervical Maculopapular rash Generalized
Unknown lymphadenopathy, mucosal erythema, conjunctivitis without
KAWASAKI DISEASE
exudates, skin rash, and desquamation of the skin on the fingers
and toes
/3na/secB’08
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CLINICAL COURSE RASHES OTHER SYMPTOMS

Measles

Conjuctivitis with photophobia

Koplik’s spots

Rubella

“Blueberry Muffin” Lesion

Roseola
infantum

Scarlet
fever

Typhoid
Rose Spots

Stepladder Appearance

Kawasaki
Disease